Apparently, in the world of trauma orthopedics, it was a slow weekend.  Which, for me, means that we finished both our cases by 9:30, I got coffee with my attending, and have time to write a blog post I have been avoiding for a long time.  So, here it comes!  We are about to delve into the world of chronic pain...

Chronic pain, and the narcotic use and abuse that comes along with it, is one of the most difficult things to manage in medicine (according to me).  Patients with chronic pain don't fit into one box, although I think a lot of times we try to put them all into the same one.  These patients are as varied as patients without chronic pain in all of the things that we tend to label patients for: noncompliance, motivation, obesity, comorbidities, disability, job status, tobacco and alcohol use.  When someone comes in complaining of chronic pain who works a white color job, has never smoked, exercises regularly, has followed all the recommendations doctors have given them, and has never lost a prescription for vicodin, we tend to trust them.  When someone comes in complaining of chronic pain who is on disability for back pain, smokes a pack and a half a day, eats cheeseburgers, and calls in the middle of every month for a refill of oxycodone, we tend not to trust them.  Right or wrong, good or bad, that's how it tends to be.

Taking care of a patient with chronic pain means you are trying to accomplish a number of things in an undoubtedly frustrated person.  You're trying to treat their pain, prevent addiction to narcotic medications, give them as much of a functional lift as possible, treat their other medical problems, set out clear expectations and boundaries, and identify treatable sources of pain (ie treatable by means other than pain meds). 

The problem with treating pain is that there is no way to monitor how well the treatment is working, or how much pain a person is "really" in.  The end goal, one would hope, would be to control pain enough that a person could function normally, without being too zonked by pain meds, and without being in too much pain to do the things they need to.  This is a difficult balance that is dictated by the amount of pain, a person's pain tollerance, their motivation to do normal function, the kinds of pain medications they are on, their dependance to the medication, and any secondary gain that is always a concern with narcotic medications.

As I see it, these are the major complicating issues in pain treatment:

People have different pain tollerances.
People have different motivations.
Some pain medications are controlled.
We can't measure effectiveness by anything other than patient report.

These are the questions I ask myself when considering treating someone with chronic pain:

Who am I to judge how much pain they are in?
What kind of meds are they on, and what have they tried?
What is the source of their pain?
Is what we're doing helping?
Is there an end in sight?

And these are the tough questions that make me think I will be very conservative with pain medicine when I actually can prescribe it.

If narcotics aren't working, why keep prescribing more?
Is it my responsibility to refill their meds if they keep "losing" them?
If their functional status doesn't change with pain control, what's the point (ie why are they on disability)??

I realize that some of this makes me sound jaded, or mean, or whatever.  That's part of learning the balance, I think.  Patients have real pain, and need real treatment.  But it's important to give them realistic expectations of how much you can help them.  For the most part, patients with chronic pain will never be pain free.  There are lots of people in the world who live in pain every day and live normal, productive lives.  I think that is my major hang up with the whole pain thing.  If you're going to be in pain doing stuff, or not doing stuff, why can't you do stuff?

That's what it boils down to for me.  But that is coming from a person who likes to do stuff.

So, will I treat chronic pain, prescribe narcotics to patients when I'm actually a doctor?  Sure.  But I imagine I will lean on the more conservative side than some people.  This very well may change as my time in medicine moves on.  But I think setting boundaries and sticking to them from the start is important for both the physician and the patient.  That way, if/when a situation progresses to the point that the physician is concerned that there may be dependance, abuse, ineffectiveness, or secondary gain, there are established rules to fall back on. 

How do the medical and the non-medical people of the world feel about this issue?  Should doctors give pain medications freely without question to patients who request them, or should they be restricted?

Weigh in!