A rant on pain management, in this country.

[geauxtohell]

Look up the DSM-IV criteria for Somatoform Pain Disorder.

I know what it is. I don't think that is the issue for most people with FM.

Not for MS. But the symptoms of FM sound a lot like it. It is a neurosis.

I am not a big proponent of FM, but I just don't believe that it's somatoform. For one thing, there isn't always sexual and multi-internal organ dysfunction.

I really think it's people with a low pain tolerance who, because we know have tricked people into thinking we can treat it, demand treatment.

 

[Sunshine]

While I don’t have an exact statistic on this, I can say that most of us are sensitive to the heat. In fact, for many years, the "hot bath test” was used to diagnose MS. A person suspected of having MS was immersed in a hot tub of water, and watched to see if neurologic symptoms appeared or got worse, which would earn them a diagnosis of MS. (This practice was stopped when MRIs came on the scene, but is still practiced in some countries where MRIs are not readily accessible.)

Heat Intolerance and Multiple Sclerosis - Heat and MS - Pseudoexacerbations in MS

you are such a fucking dumb bitch at times

And hysterectomies were used to treat ill behaved (read: "women who don't want to have sex with their husbands) at one time.

The link between latitude and MS incidence (sun/heat exposure) has been disproven.

I really think a hot bath is a wives tale. It's a hell of a lot cheaper than an MRI w/ T2 Flair, and if it were at all accurate, would be a better test.

Exactly. You know they USED to diagnose mumps by having the kid eat a pickle. If the parotid gland hurt then he/she had the mumps. Well this Remodulin I'm on causes that to happen every time I take a bite of anything. According to the wives tale, I will have mumps until the day I die. Think I can get disability? LOL

 

[Sunshine]

I know what it is. I don't think that is the issue for most people with FM.

Not for MS. But the symptoms of FM sound a lot like it. It is a neurosis.

I am not a big proponent of FM, but I just don't believe that it's somatoform. For one thing, there isn't always sexual and multi-internal organ dysfunction.

I really think it's people with a low pain tolerance who, because we know have tricked people into thinking we can treat it, demand treatment.

Well, it's a money maker for rheumatologists! That's for sure.

 

[Quantum Windbag]

I think "Pain Management" is the last thing I need to go into, LMAO. Though, my mentor doctor, who I have worked with weekly and then on a daily basis for one month out of each year, is board certified in Pain Management. So I have encountered a lot of patients who are pain management issues and know how things need to be charted to be kosher with the DEA. So I am not completely ignorant of this issue.

Showing an indication and then the name, number, and amount of refills for a narcotic is not asking too much of a doctor.

Physicians that do pain management full time should understand that the DEA is going to be watching them as the potential for fraud and abuse is highest there.

Do you think filing a report on all abortions which included the name and phone number would be too much for a doctor? Or do you think that might violate doctor/patient confidentiality? My point is the government should not be in doctor/patient relationships at all, you seem to think it is justifiable as long as your personal morality agrees with it.

I take exception to you claiming that your opinion is the rule. This is a cause and effect issue. We both understand the effect. We disagree on the cause. You think doctors are stringent about prescribing narcs because they fear the DEA. I think they are stringent because over prescribing narcs is bad medicine that leads to universally bad outcomes.

You are free to do so. My position is consistent, and based on giving all patients privacy from government interference. I therefore see the DEA as the problem. Your is based on the psotion that some government interference in patient privacy is justifiable because, as you have pointed out to me, a small number of patients are addicts.

Frankly, if most people who tried to get pain meds were addicts you might have an argument, which is why I was giving you the benefit of the doubt earlier before you insisted that was not your position. I would still disagree with you, but I could see the basis of an argument based on the fact that more addicts try to get meds than people who actually need them.

*sigh*. I haven't demanded anything. This is, at heart, an academic issue. If you don't want to treat it as such, then fine. However, don't lambaste me for trying to elevate it from a matter of opinion to a matter of science.

To me pain is personal, just like it is to anyone who has really experienced it. I have had both shingles and kidney stones, and have neuralgia and paralysis from the shingles. You can talk about science all you want, just remember that patients are people, not case studies.

For the most part, the DEA is out of what is and is not proper treatment. Though, if you feel that prescribing narcotics to prevent someone from getting them on the street is a proper indication for their use, then perhaps you would get some heat from the DEA.

As you should. That's just boneheaded.

I did not say I agree with it, I just think that if a doctor and patient decide that, the government should not have a voice in the decision.

No it's not. You have no clue what my "moral position" is, thank you very much.

My position is that physicians should not contribute to harming their patients if they have the opportunity.

That means avoiding giving them addictive and potentially lethal medications if their are better alternatives.

I could give a shit less if someone wants to smoke pot for whatever reason (to include simply getting high). I resent medical providers being drug into the issue under the guise of "medical need" simply because people want to get high. Marijuania for anxiety? Give me a frigging break. Marijuania for cancer patients on Chemo or HIV patients on HAART to reduce nausea and stimulate appetite? I am all for that.

However, to avoid the stupidity of the people that want to simply get high and will invent new and fabulous indications that only marijuania can treat (in their opinion), I think they should just legalize it.

I can't argue with that. I will point out that, addiction is more a matter of the person than the drug. I have been in the hospital twice for pain management, the last time was for over a week. I got narcotics the entire time on both occasions, and left without a trace of withdrawal. I also took Vicodin 4 times a day every day for almost a month when I had shingles, I have a friend who got addicted after three days and not only had to go through withdrawal, he attends NA meetings to make sure he stays away from temptation. I hope he never needs treatment for acute pain again.

I am aware of the potential for addiction, I just think I am more typical than my friend.

That's your opinion. The issue of "who needs narcotics" is the obvious sticking point and if that was clear, there would be no need for debate.

The issue should be decided by a doctor, not the government.

No. At the same time, I would be negligent if I simply gave people what they wanted without consideration for the pros and cons of the issue.

Just a basic tenant of treatment.

If I present to you with kidney stones and you start examining my fingers for pinpricks I am going to demand a doctor that knows that my kidneys have nothing to do with my fingers.

Just saying.

 

[geauxtohell]

Not for MS. But the symptoms of FM sound a lot like it. It is a neurosis.

I am not a big proponent of FM, but I just don't believe that it's somatoform. For one thing, there isn't always sexual and multi-internal organ dysfunction.

I really think it's people with a low pain tolerance who, because we know have tricked people into thinking we can treat it, demand treatment.

Well, it's a money maker for rheumatologists! That's for sure.

I hate just dismissing potential pathology. I know FM has a terrible rap as a condition that "lawyers invented" to rack up damages, but at the same time I think it's a real thing.

It's just frustrating to treat. One of the reasons I am glad I am going into EM is that I won't have to deal with it.

 

[Sunshine]

I am not a big proponent of FM, but I just don't believe that it's somatoform. For one thing, there isn't always sexual and multi-internal organ dysfunction.

I really think it's people with a low pain tolerance who, because we know have tricked people into thinking we can treat it, demand treatment.

Well, it's a money maker for rheumatologists! That's for sure.

I hate just dismissing potential pathology. I know FM has a terrible rap as a condition that "lawyers invented" to rack up damages, but at the same time I think it's a real thing.

It's just frustrating to treat. One of the reasons I am glad I am going into EM is that I won't have to deal with it.

Famous last words! LOL

 

[geauxtohell]

Well, it's a money maker for rheumatologists! That's for sure.

I hate just dismissing potential pathology. I know FM has a terrible rap as a condition that "lawyers invented" to rack up damages, but at the same time I think it's a real thing.

It's just frustrating to treat. One of the reasons I am glad I am going into EM is that I won't have to deal with it.

Famous last words! LOL

Well.... Other than telling FM patients that they aren't getting narcotics or long term management of their condition and they need to establish care with a PCP.

 

[Montrovant]

Did it ever occur to you that the reason triage exists so that people that have actual emergent medical conditions go straight back and jump over the people who are just there for pain control and other trivial complaints that clog up the system? (I once saw someone wait for 8 hours to be seen for "insomnia".

Why is the word emergent used that way by the medical community? My understanding of the definition was that it would be describing something as emerging, and that you should say 'people that have actual emergency medical conditions'. The couple I live with both work in hospitals (he on the clerical side, she as an ER nurse) and their use of the word was the first I had heard it used in such a way. It just seems so unnecessary to me.

/end unrelated rant

 

[Montrovant]

To speak to the point of the thread, as I stated in my previous post, I live with a couple who both work in/around hospital ER's. Both of them have told me stories of the many people who come to the ER just hoping to score some pills, without any real medical condition. Obviously this is hearsay, and equally obviously the few hospitals they have worked in are not necessarily indicative of conditions everywhere in the country. That said, based on what I have heard from them (and through them, what they have heard from other nurses and doctors) abuse of the ER to obtain narcotics either for recreational use or to sell is pretty widespread.

Whether that is more an issue of unneeded government intrusion or what constitutes sound medical treatment I could not say.

 

[Gagafritz]

Honestly, i don't get the hysteria over pain medication and opioids. Yeah, some people will become addicts. If they dont' medicate themselves with that they will use alcohol or whatever. Not every pain syndrome is inflammation. Some pain is simply pain. Chronic use of NSAIDs can cause GI problems, GI bleeding and kidney failure. And, for some reason there seems to be a notion that chronic pain isn't worthy of being treated with opioids. Opioids are the gold standard of pain relief. And, toradol and motrin are helpful adjuncts but often do not really treat the pain. Opioids target specific mu receptors that are not targeted by nsaids and tylenol. To withhold pain medication out of irrational fears of addiction is cruel and inhumane.

 

[Sunshine]

I hate just dismissing potential pathology. I know FM has a terrible rap as a condition that "lawyers invented" to rack up damages, but at the same time I think it's a real thing.

It's just frustrating to treat. One of the reasons I am glad I am going into EM is that I won't have to deal with it.

Famous last words! LOL

Well.... Other than telling FM patients that they aren't getting narcotics or long term management of their condition and they need to establish care with a PCP.

I went to a pain management seminar a few years back before pain was the '5th vital sign.' The guy who taught it was an oncologist. He was gung ho for giving cancer patients everything they needed, but didn't consisder spinal injuries a source of pain. I spoke to him after the seminary and he commented 'those people have something mentally wrong to start with.' There ARE others out there who discount legitimate pain people are having.

I've had degenerative arthritis in my spine for 33 years. Early on I took a little Baclofen, but after about 5 years stopped that and have managed it with therapeutic massage, good work chairs, and a super duper expensive mattress to sleep on. I still have a little pain and in reality it really mimics the compaints that FM patients have. But I've never considered that AND I like working and want something out of life other than narcotics. So, I just deal with it. But when I do have pain from some other source, I think it looks exaggerated and it may be simply because after dealing with constant pain all the time, any more on top of it puts me over the limit.

Last knee replacement was so bad the surgeon said I would have plenty of pain medicine and he kept his word. I took 4 Lortabs a day for 8 weeks. At the end I tapered myself off, but still had horrible cramps when I stopped it. Death from opiate withdrawal is unlikely, but you may WISH to die. I can't even imagine what it would be like for someone who had a genuine addiction with all the psychological craving along with the physical.

Obviously there ARE a lot of doctors and pharmacists too who basically deal in drugs. Over the years just seeing so many addicted patients, I have come to understand how much is available on the streets. Sure, some comes from other countries, but I really believe most of the problems are from prescribers.

The people who do this are dangerous clinicians. Oversight IS needed and the decisions should definitely NOT be left between the provider and the patient, and that is in the interest of patient safety.

I dig what you mean about the cannabis as well. When it was up for a vote in California, I had patients throwing that in my face every day. My response to them was 'move to California, I'll be happy to transfer your care to someone there.' But it quieted down when that referendum didn't pass. It makes you weary. When I was in law school, I was still practicing and Tenncare became 'concerned' about how much benzodiazepine was available on the street. So they mandated that everyone on a benzo had to get it through a mental health clinic. I had sweet little old ladies shaking their fists at me over xanax. After about 8 months of that, I quit practice and went into academia for about 4 years. Only those of us who have had to deal with the realities of the drug culture in this country really have a clue the extent to which it exists.

 

[Sunshine]

Honestly, i don't get the hysteria over pain medication and opioids. Yeah, some people will become addicts. If they dont' medicate themselves with that they will use alcohol or whatever. Not every pain syndrome is inflammation. Some pain is simply pain. Chronic use of NSAIDs can cause GI problems, GI bleeding and kidney failure. And, for some reason there seems to be a notion that chronic pain isn't worthy of being treated with opioids. Opioids are the gold standard of pain relief. And, toradol and motrin are helpful adjuncts but often do not really treat the pain. Opioids target specific mu receptors that are not targeted by nsaids and tylenol. To withhold pain medication out of irrational fears of addiction is cruel and inhumane.

The problem with treating chronic pain with opiates is the tolerance to the drug that is built up over time. Eventually the person is on such mega doses that at some point it will become lethal. Reputable providers prefer not to kill their patients.

 

[Sunshine]

Did it ever occur to you that the reason triage exists so that people that have actual emergent medical conditions go straight back and jump over the people who are just there for pain control and other trivial complaints that clog up the system? (I once saw someone wait for 8 hours to be seen for "insomnia".

Why is the word emergent used that way by the medical community? My understanding of the definition was that it would be describing something as emerging, and that you should say 'people that have actual emergency medical conditions'. The couple I live with both work in hospitals (he on the clerical side, she as an ER nurse) and their use of the word was the first I had heard it used in such a way. It just seems so unnecessary to me.

/end unrelated rant

Maybe because it's the correct word to use at the time:

e·mer·gent (-mûrjnt)
adj.
1.
a. Coming into view, existence, or notice: emergent spring shoots; an emergent political leader.
b. Emerging: emergent nations.
2. Rising above a surrounding medium, especially a fluid.
3.
a. Arising or occurring unexpectedly: money laid aside for emergent contingencies.
b. Demanding prompt action; urgent.4. Occurring as a consequence; resultant: economic problems emergent from the restriction of credit.
n.
One that is coming into view or existence: "The giant redwoods . . . outstrip the emergents of the rain forest, which rarely reach two hundred feet" (Catherine Caulfield).

emergent - definition of emergent by the Free Online Dictionary, Thesaurus and Encyclopedia.

 

[Gagafritz]

Honestly, i don't get the hysteria over pain medication and opioids. Yeah, some people will become addicts. If they dont' medicate themselves with that they will use alcohol or whatever. Not every pain syndrome is inflammation. Some pain is simply pain. Chronic use of NSAIDs can cause GI problems, GI bleeding and kidney failure. And, for some reason there seems to be a notion that chronic pain isn't worthy of being treated with opioids. Opioids are the gold standard of pain relief. And, toradol and motrin are helpful adjuncts but often do not really treat the pain. Opioids target specific mu receptors that are not targeted by nsaids and tylenol. To withhold pain medication out of irrational fears of addiction is cruel and inhumane.

The problem with treating chronic pain with opiates is the tolerance to the drug that is built up over time. Eventually the person is on such mega doses that at some point it will become lethal. Reputable providers prefer not to kill their patients.

Reputable providers know how to manage and use these medications correctly, not just put a black box label on them and disregard them.

 

[Gagafritz]

What is wrong with the word "emergent" ? It is used correctly .

 

[Sunshine]

Honestly, i don't get the hysteria over pain medication and opioids. Yeah, some people will become addicts. If they dont' medicate themselves with that they will use alcohol or whatever. Not every pain syndrome is inflammation. Some pain is simply pain. Chronic use of NSAIDs can cause GI problems, GI bleeding and kidney failure. And, for some reason there seems to be a notion that chronic pain isn't worthy of being treated with opioids. Opioids are the gold standard of pain relief. And, toradol and motrin are helpful adjuncts but often do not really treat the pain. Opioids target specific mu receptors that are not targeted by nsaids and tylenol. To withhold pain medication out of irrational fears of addiction is cruel and inhumane.

The problem with treating chronic pain with opiates is the tolerance to the drug that is built up over time. Eventually the person is on such mega doses that at some point it will become lethal. Reputable providers prefer not to kill their patients.

Reputable providers know how to manage and use these medications correctly, not just put a black box label on them and disregard them.

Giving opiates to patients with chronic pain is not a sound practice, due to increased tolerance over time. As I have already stated. The person who does that is the one who is not reputable and doesn't know how to manage and use the medications correctly.

Sometimes patients just have to learn how to live with their pain. As I have. Distraction is the best intervention for chronic pain. That's one reason I still work. It keeps me busy and I don't think about it. The OP on which this thread started is not having chronic pain. She is having acute exacerbations. Narcotics are appropriate in that situation. However, the question remains if anything has been done to stop/prevent the spasms which cause the pain.

 

[Gagafritz]

Opiates are a reasonable line of treatment and should be included along in a wholistic or total approach to the patient and pain response. There are different pain pathways that are treated my opioids versus NSAIds and tylenol and so forth. In addition to biofeedback, heat/cold therapy and PT and whatever else. To dismiss chronic pain as not amenable to opioids is unfair to the patient in chronic pain.

 

[Sunshine]

Opiates are a reasonable line of treatment and should be included along in a wholistic or total approach to the patient and pain response. There are different pain pathways that are treated my opioids versus NSAIds and tylenol and so forth. In addition to biofeedback, heat/cold therapy and PT and whatever else. To dismiss chronic pain as not amenable to opioids is unfair to the patient in chronic pain.

It is even more unfair to allow a build up of tolerance to opiates such that they die from overdose.

 

[Gagafritz]

I'm sorry. But opioids can be properly managed and used just like any other medication. Just like any other, there are side effects that need to be monitored and managed. There are many people in this country who would be incapicitated but can now live a relatively normal life due to proper treatment with opioids. I really don't understand your fear of that. Pain medication is used safely everyday in this country .

 

[Sunshine]

The picture of the drug seeker emerges.