Tuesday, December 13, 2011

Pt. 2: Tales From the Trenches in the War on Pain

Guest Author Correspondent: Thomas Sachy, MD, MSc

As mentioned in my first installment in this series [here], I will continue to comment on my personal experiences and knowledge regarding the continuing war on pain. Of course the Internet has made monitoring this conflict infinitely easier; similar to the general who, while safely removed from harm, is able to monitor the pitched battles taking place a world away with an all-seeing eye while perched high above the fray.

However, in my case, I am no armchair general. I am clearly in the fight, struggling against the enemy called “chronic pain.” This battle has its host of dangers, including the possibility of so-called “friendly fire” from the very “weapons” used to fight pain.

For example, I recently read a December 10, 2011 article from a media outlet in New-Zealand [here] detailing the accidental overdose death of a 49-year-old woman. She was paralyzed from the neck down due to an accident and had suffered from excruciating pain, so the woman had been prescribed transdermal fentanyl. It was reported that she had been using a space heater in her bedroom and it was speculated that the increased heat from that caused excessive dumping of fentanyl from the patch into her body, resulting in the fatal overdose.

The patient’s mother commented, “If it's as bad as that, [the drug] should have very strong warnings. If it's that strong, [patients] should know about it. I wasn't aware until I read the coroner's report that heating could have an adverse effect on those patches."

The mother also stated that she “had not been aware of fentanyl's risks and her daughter had never mentioned them.” Furthermore, "She [the daughter] was sort of constantly in pain and I don't think she could get enough of anything to stop it.” But the woman added, “Her [daughter’s] life wasn't all doom and gloom. She still got out and did things.”

Several points stand out in the mother’s comments, which anti-opioid pundits might gloat over, but need more clarification:

  1. “If it's as bad as that…” — Actually, in my opinion, fentanyl is not bad. It is not evil. Still, it is a medication that, if improperly administered, can be harmful if not fatal. So are coumadin and insulin — the list of “dangerous” medications is endless. But for various reasons, the potentially harmful or fatal non-opioid medications are seldom labeled as “bad.” Why? In 2005 the number of unintentional overdose deaths in the U.S. involving prescription opioids was 8,541 [data here]. Also in 2005, 45,520 deaths in the U.S. were related to motor vehicles [data here]. So, why are we not trying to ban automobiles?!

  2. “It must be a pretty potent drug.” — Yes, fentanyl is potent [Rx info here]. In fact, I consider ALL opioid analgesics to be extremely potent, and potent analgesics are just as much a medical necessity as are potent antibiotics. They all have risks, and managing risk is what physicians are supposedly trained to do.

    However, words like “potent” and “bad” in this context imply something sinister — like “dirty bombs” or “weapons of mass destruction.” And, to a family member who is grieving the loss of a loved one due to the legitimate use (or illegitimate abuse) of pain medications, opioids and those who prescribe them may seem like the enemy and absolutely malevolent. But, from the bottom of my heart, and the depths of my medical and scientific knowledge, I know that opioid pain medications are inherently good and I am not being malevolent by prescribing them.

  3. She “had not been aware of fentanyl's risks and her daughter had never mentioned them.” — So, the mother was not aware of the risks of fentanyl; well, perhaps she should have attended some of her daughter’s pain management appointments and then she would have known of the risks, benefits, and alternatives to fentanyl. Perhaps the daughter was given appropriate warnings about transdermal fentanyl and she chose to disregard them? Sadly, then, she is responsible for her purported overdose death. Or, perhaps the prescribing physician was unaware of the relevant side effects of transdermal fentanyl, or he was aware but failed to administer informed consent [info here] to the patient? Then he bears a significant proportion of responsibility for the patient’s passing. Without further information, we cannot know what really transpired.

On the other hand, several additional points stand out in this story that are important. The mother said “[the daughter’s] life wasn't all doom and gloom. She still got out and did things," but also added, "She was sort of constantly in pain and I don't think she could get enough of anything to stop it.” Here’s the common problem we pain physicians see every day: this patient was in constant pain, and she was suffering, and her pain levels were so bad that she could not get adequate relief no matter what she did or took.

So, was she an addict, displaying aberrant behavior and/or a pattern of abuse outside the therapeutic setting? Was she a smoker? Did she have mental illness or past problems with substance abuse? These are common obstacles to effective pain management [article here]. The mother hints at pseudoaddiction — “could not get enough of anything... [or] adequate relief no matter what she took” — but what patient with chronic pain who is suffering does not experience and/or demonstrate this behavior at one time or another?

The mother says something else of importance that legitimate pain practitioners all know very well. She says of her daughter, “Her life wasn't all doom and gloom. She still got out and did things.” So her daughter did have some functionality, some life and enjoyment of it — some relief. And all of this was most likely due to the beneficial effects of her opioid pain medication, which made her constant pain bearable.

The reality of this woman’s story is that, yes, it is likely that her opioid pain medication caused her death, but her death was accidental. And, judging from the article, it was not due to some greedy over-prescribing physician, corrupt practices by pharmaceutical companies, or pain medication abuse. It was just bad luck, like dying in a car accident, probably combined with a lack of knowledge about her medication. Sadly, it happened to a woman alone, suffering from chronic pain and trying to keep warm in her bedroom.

In view of the above discussion, I strongly recommend the following to all healthcare providers:

  • Counsel all your patients prescribed opioids that the diversion of their medications, even sharing them with friends or relatives, is a felony.

  • If other practitioners prescribe opioids for them, even a small amount after a dental procedure, they must let you know immediately.

  • Assure your patients with chronic pain that you are not out to harm them by prescribing opioids or to get them addicted to drugs.

  • And always tell patients about all the important risks of their pain medications, including the relatively small risk of addiction. Remind them that just taking a few extra doses could be fatal; tell them that they can always take less of their medication if its effects seem too strong, but they can only take more of the medication with your permission.

  • Tell your patients, and their accompanying loved ones, that they MUST contact you at the first sign of any side effects that they experience. Tell them that they must not continue taking prescribed medications that are causing side effects and, if necessary, they must get emergency care if the adverse effects continue.

Most of all, tell your patients with chronic pain that there is always hope, and that the right mix of opioid and/or non-opioid medications can be found to bring them some relief of their suffering. And, this is the case, even though other treatments might have been tried and failed, such as: surgery, physical therapy, epidural/trigger point injections, nerve stimulators, Botox, and others. Patients especially need comforting encouragement if they’ve been subjected to humiliating browbeating from callous physicians or pharmacists, or even insensitive loved ones, who really should “walk a few steps in the shoes” of those suffering from chronic pain to better understand their concerns and needs.

Sachy About the Author: Thomas Sachy has Bachelor’s Degrees in electrical engineering and in general studies, and graduate degrees in medicine [MD] and biology [MSc]. His post-graduate medical training was in psychiatry, forensic psychiatry, and behavioral neurology. Dr. Sachy practices in the state of Georgia and has completed numerous ongoing continuing medical education activities in the field of pain management and the neurosciences, and has been featured on national TV on several occasions. He is a Diplomate of the American Board of Psychiatry and Neurology.

Proviso: All observations, opinions, advice, or facts expressed above are those of the guest author, and do not necessarily reflect the positions of Pain Treatment Topics, our staff and advisors, or our educational supporters.