In the late 80’s some brilliant (sarcasm in use here people) doctor, who I assume later took a position with one of the companies who manufacture hard core narcotic pain medications, or at least was paid a significant ‘renumeration’ by them, decided that “pain is whatever the patient SAYS it is” and if patients were in pain, then medical and nursing staff were not doing their jobs properly. This, regardless of whether the patient got better, or even had a medical problem that necessitated pain medication.
Once upon a time, drugs like oxycontin were reserved for patients who were dying of cancer, or in some other profound end-of-life type of pain. Never used for maintenance.
And now, 30 years later, we have a positive epidemic of patients who are in chronic pain – it even has official diagnosis codes: 338.2 – chronic pain (can’t get paid for diagnosing this one though), 338.4 – chronic pain Syndrome ( whoo baby you can get paid for this one!), 338.29 – other chronic pain (you can get paid for this one too). Whenever medical ‘science’ (I use this term loosely because a lot of the science is based on getting paid by someone for something) defines a syndrome, what that actually means is a cluster of symptoms that usually go together. They are NOT a disease. They are just a bunch of symptoms that go together.
A good example of a syndrome that can be covered under “other chronic pain” or “chronic pain syndrome” is fibromyalgia. This is a syndrome, not a disease. It probably has an ICD 9 code of its own, but I don’t plan to ever diagnose this so I don’t have any interest in learning it. Fibromyalgia means literally pain in fibers – muscle fibers. People who have fibromyalgia are usually (but not always) overweight, sedentary, eat a lot of simple carbohydrates, watch a lot of TV, are depressed, don’t get out much, and don’t sleep well though they usually spend a lot of day time napping and feel fatigued most of the time. Because of their fatigue and depression, they often feel mentally cloudy. They hurt all over, even when there is no obvious medical pathology. This is the cluster of symptoms. The treatment consists of: 1. Education on what the problem(s) are and why they are affecting the patient. 2. NSAIDs – ibuprofen, naproxen, toradol. 3. Exercise – the muscles hurt because the human body was designed to MOVE and if you don’t move, they not only waste away, they hurt while doing so. 4. A combination drug that both helps with pain and depression such as Cymbalta or Lyrica. 5. Cognitive Behavior Therapy – you have to come to grips with why you are doing this to yourself in order to make changes to how you avoid or do things. CBT can be very helpful with this. It has nothing to do with your childhood or that sort of therapy. It’s purely to help you change your responses to situations in order to help you take control of your own life. Note that I didn’t include narcotics AT ALL. Yet I see people all the time whose only diagnosis is fibromyalgia and they are on MASSIVE quantities of oxycontin, oxycodone, or even morphine pills which they take multiple times a day. Why? It does absolutely nothing to help the patient, and isn’t even recommended as an effective treatment. So why are so many patients prescribed narcotics for this?
The place where I am doing clinicals has a lot of patients who come there for nothing but narcotics, because the provider will prescribe for them. Many if not most of them have been discharged from one or multiple pain management centers for non-compliance: they also smoked pot, or they have alcohol in their system while taking narcotics, or they don’t have any narcotics in their system at all – every pain management patient gets urine drug screens every time they go in for an appointment to get their drugs. Why you would be STUPID enough to smoke pot right before going to get your drugs I don’t know. I guess you can’t cure stupid. Why you would drink while taking sedatives I also don’t know. Perhaps in addition to being stupid you have a death wish. Can’t cure that either. And those that sell their narcotics while pretending to have a chronic pain problem deserve to go to jail. Have fun there. And good luck with getting narcotics while in there even if you DO happen to need them for a legitimate reason like a tooth extraction.
A patient came in recently who originally complained of low back pain. Yet when the tests were done in the office to assess his pain, they were negative. The patient did not realize these tests were to assess low back pain, I should point out. Otherwise they would have been ragingly positive. And in fact were ragingly positive when repeated on him while telling him they were to assess his pain. He was unable to get disability for his ‘chronic back pain’…wonder why?? This patient now complains of headaches. He was told there was in fact something that showed up on the MRI he was sent for. He states he doesn’t want to see a neurologist for this though, because he’s trying to get disability and if the neurologist can fix it he can’t get disability. That seems to be the mentality of the average pain patient we see. Malingerer. If this guy spent as much time working as he did trying to get disability he would probably be solidly middle class, instead of ‘working’ poor.
Another patient came in with slurred speech and the inability to complete a sentence – she would flit from thought to thought without ever completing an entire thought through to the end point. She said she didn’t want to go back to the pain management center she had been going to. She was in the office to get Valium, a sedative. She said she had gotten a month’s supply of oxycontin, oxycodone, and morphine from the pain management center and didn’t need any of those. As it turns out, she had been discharged from not one, but SIX pain management places. For having alcohol in her urine. And for consistently running out of her pain medications well before the time for renewal. Unbelievably, the doctor actually gave her a prescription for a 60 day supply of Valium.
Third patient: came into the office complaining of low back pain, a ‘chronic’ problem. Got a prescription for 30 days worth of Percocet with 2 refills. Her room mate called the office later that day to say that he just wanted the office staff to know that she sold the entire bottle to a drug dealer named Don as soon as she got home.
These are entirely typical. I am very frustrated and I refuse to bother doing any more assessments on these people because I don’t learn anything and I have no patience for these sorts of ‘patients.’
I hurt my back when I was still fighting fire. At my original emergency room visit, I was asked if I wanted narcotics and I refused. I did ask for a muscle relaxant that wouldn’t make me sleepy so I could function at work and at home. The xray didn’t show anything (which it wouldn’t if it was a herniated disc). And, while I have had some level of pain nearly every day since then yoga keeps it under control. That injury though, and the pain it brought with it, was the impetus to change careers. I was entirely too young to become an invalid, and it scared me to think of becoming one. I have never pursued further testing because even if I did have a herniated disc I would not consider surgery. I cannot imagine being unable to walk when I want, to run, to stretch, to garden. I also have a torn rotator cuff, suffered while working as a firefighter. That actually causes me more pain on a regular basis than my back, and eventually I WILL have to have surgery, but until then I continue to do strengthening exercises and keep it as mobile as possible. I cannot IMAGINE living my life under the cloud of narcotics and being in the twilight of consciousness every day of my life. What a horrible way to live. I think the fact that I’ve suffered injuries that caused permanent pain in myself makes me even less sympathetic to those who come in wanting, not physical therapy, not surgery, but disability and a lifetime of narcotics. As my parents used to tell me, if you’re not puking or dying you get up and go to work/school. I would add to that list also if you don’t have explosive diarrhea. Everybody hurts. Deal with it and move on.
The largest group of users of narcotic prescriptions, if I remember correctly, are Medicaid patients. Meaning they don’t pay, we the taxpayers do. If even a small portion of the people who receive disability are anything like those I have seen in the ER when I was working there, or in clinicals, we could probably halve the national debt simply by kicking them off and making them work. Maybe being a brick layer isn’t a good career choice for them, but surely they could answer phones, or sit at a cashier stand, or walk dogs or something. Once again, it comes down to ‘sick care’ versus health care. And lining the pockets of the pharmaceutical companies instead of investing in the real health of our population. Of course, we have no economy to speak of anymore, so I guess disability takes the place of unemployment. The irony is that those with real issues, with real medical problems, get overlooked because the system is overwhelmed with those who don’t pay for their access and so use a lot more of it.
Pain tells us we are alive. Pain tells us something is wrong which we need to address. Using narcotics to mask pain, unless it’s for an end of life issue, prevents us from making changes to improve our lives. Why would you want to do that?