Chronic Pain Patients

Chronic Pain is defined by D.C Turk, et al as "pain that extends beyond the expected period of healing". Prior arbitrary definitions of pain lasting 3 months or 6 or 12 months are probably not helpful from a practical standpoint and are too limiting. Whatever the definition, it is certainly a common source of prolonged suffering for millions of people, and is not new to this century.


Challenges in Chronic Pain

Taking care of chronic pain patients is one of the greatest challenges for physicians and nurses within both the inpatient and outpatient setting.

There are multiple reasons for this...

• We often find ourselves at odds with patients. They frequently want more pain medication than we feel comfortable giving.

• Pain is very subjective. There are no truly objective measures of how severe someone’s pain is. The 1-10 scale that we often used is interpreted in different ways by our patients.

• Sometimes it is very difficult to tell the difference between the patients who really have severe pain, the ones who only think they have severe pain due to psychosomatic illness, and the ones who are drug-seeking addicts. Many times there are combinations of these factors all in the same patient.

• It’s medically risky business because many times if we give enough medication to truly control the pain, we may actually harm the patient by suppressing respirations or blood pressure.  Many thousands of deaths have occurred as a result. There is often a fine line between controlling the pain and harming the patient.

• There is also the risk that a depressed or otherwise mentally unstable patient will use the medication you have prescribed to commit suicide.

• It’s legally risky also because it may expose you to malpractice suits, not to mention withdrawal of your license to practice medicine if your prescribing of analgesics is deemed to be inappropriate by state or federal agencies.

• There is often considerable peer pressure by colleagues and associates not to ever prescribe narcotics for nonmalignant pain.

And yet, there are those patients who legitimately have severe chronic pain for which there are no treatments available other than narcotics. What should we do with these people? Should we ignore their suffering, their misery, and their inability to function and live out their lives in peace because of their pain?


Treatment of Chronic Pain Patients

The treatment of chronic pain patients has changed considerably over the years.  The pendulum of tolerance for prescribing physicians has swung from freedom to treat all suffering to now being very restrictive. The proper balance for thoughtful patient care is probably somewhere in the middle.  It is no longer wise for the primary care physician to be the sole prescriber for many of these patients who require high doses of opioids for non-malignant pain. Referral to a pain management specialist is the appropriate thing to do if there is one available. 

Many of the pain management specialists are either anesthesiologists or physical medicine specialists who treat patients with trigger point injections, epidural injections, nerve blocks or other non-medicinal modalities of pain control. Only a few of these clinics will go a step farther and actually care for the chronic pain patients who have failed all other treatments and the only thing left for them is medication. In fact many of these specialists won't even accept any patients who are already on opiates for chronic pain, which makes referral even more difficult.  Most of these types of patients fall back to the primary care doctors who have varying degrees of discomfort caring for these suffering individuals.

The lack of availability of chronic pain management specialists and/or addiction specialists is a major stumbling block to primary care physicians who are trying to do their best for their patients. It is one thing to decide to make a referral and another to actually find a specialist in your area that will accept your patient's insurance or lack thereof and that is accepting new patients.  The waiting list to get in is way too long - sometimes many months. In the meantime, the risk of overdose for your patient is increasing along with your liability.


Exit Strategy 

If the situation becomes unmanageable and too dangerous, you have to have an exit strategy. This may require admission to the hospital, stopping the opiates, controlling the effects of withdrawal and switching to a drug like buprenorphine, which can then be tapered gradually as an outpatient. The details of this treatment strategy is way beyond the scope of this essay, but if you haven't already done so, I would highly recommend learning as much as you can about it by going to meetings that are dedicated to the education of prescribers for chronic pain patients.

I have no reservation about discharging a patient who is abusing opioids or benzodiazepines and has resisted all of your efforts to help them. However, I personally don’t think it’s right to discharge the patients that you really believe are suffering with chronic pain.  This is a serious medical condition, potentially more deadly than diabetes or heart disease.  However, it requires knowledge and training that is different from that required in taking care of other illnesses. Most of us do not get that kind of training in medical school or residency. That is why the availability of a specialist is so important. If one is not available, then you will have to learn as much as you can about how best to manage these patients. Just handing out a prescription is not an adequate treatment regimen for your patient.

If you don’t have the luxury of having any pain specialists in your area then you will probably need to take care of the person yourself. You could discharge the person from the practice, but then where will the patient go? You could say, "Well, that’s not my problem", but maybe it is in a larger sense. You have to decide for yourself. Somebody has to take care of these people. If not you, then someone else. Perhaps you would be able to take care of them more safely than some other doctor who doesn’t know as much about the risks. After all, you are at least interested enough to be reading this article. Your partners may insist that you not take care of any of these patients because they will not feel comfortable seeing them when you're out of town. There are a lot of issues to consider.


Rules in Chronic Pain Management

If you do decide to continue to care for chronic pain patients, make sure you know the guidelines (aka, RULES) for care that have been written by the medical board in your state, by the Center for Disease Control in Atlanta and by pain management specialists. There is no other area in medicine where the rules for care are more important than in the management of chronic pain patients.  Get your pain patients to sign a contract on how their pain will be managed and ensure that they bring in a written report or log of the severity of their pain and how the medication has improved their functionality. Enlist family support whenever possible. Make sure they keep regular appointments so that you can examine them and look for any adverse effects of the medication. You must do urine testing, pill counting and follow the PMP for every patient that uses any controlled substance.  If your patient refuses to comply with your rules after you’ve explained the medical risks of strong analgesic therapy, then you may have good reason to discharge them for noncompliance.

This is a difficult issue for many caring physicians because of our desire to alleviate suffering on one hand versus risk of harm to the patient and indirectly to ourselves if something goes wrong. It is truly a challenge in many situations, but if you follow the proper guidelines, both your patient and you should remain safe. Many of these patients will be very grateful for your help after so many others have turned them away.

References:

- American Academy of Pain Management

- American Pain Society

- American Academy of Pain Medicine


This page was last updated on October 17, 2019.



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