Pain Management – Why Doctors Don’t Get It
In this blog, we have written often about pain management because so many patients come to us desperate for help. Pain seems to be one of the most misunderstood aspects of patient care. A recent New York Times article sparked a lively debate among fellow advocates about the failure of most doctors to understand pain and to treat it appropriately. I invited Ken Schueler to share his thoughts as guest editor today.
“I had the privilege of participating some years ago in Dr. Russell Portenoy’s successful initiatives in making “pain” the fifth vital sign. Dr. Portenoy is considered the father of the Pain Management movement in the U.S. He is at Beth Israel Hospital in New York.
There are multiple problems with regard to pain management in the United States. First, we have a puritanical history that has contempt for suffering which can’t be measured scientifically or associated with an organic disease (e.g., Reflex Sympathetic Dystrophy, also known as Complex Regional Pain Syndrome).
In other words, with the exception of some investigational functional MRI’s, doctors can’t verify a patient’s subjective report of pain. So they begin by under-dosing a patient’s baseline pain, allowing continual breakthrough pain. Gradually they will dose to effect unless they dismiss the patient and refer them to the psychiatric service believing the patient is malingering or that “it’s all in your head.”
Second, for many years, pain management physicians had no Board Certification; they were composed of neurologists and anesthesiologists. Now, there is the American Board of Pain Medicine which is fostering education among all physicians.
Third, there is an enormous misunderstanding and lack of knowledge about addiction and three characteristics of pain management:
1) Dependency – if you suddenly stop taking an opioid you’ll go into withdrawal. Note: one wouldn’t say that a diabetic is addicted to insulin, one would say a diabetic is dependent on insulin. Therefore, dependency is NOT addiction;
2) Tolerance – needing a higher dose to achieve the same effect, as often happens in advanced cancer: that is NOT addiction;
3) Addiction is properly defined as “drug craving behavior where a patient is obsessively seeking to score opioid drugs through doctor shopping (paying cash) and even forging prescriptions.”
For many years I was on a list service with Dr. Russell Portenoy, and the stories of suicides by pain patients unable to receive adequate treatment were/are heart-breaking. The Drug Enforcement Agency’s witch hunt tactics contributed to these suicides. There is an irony that the most widely used addictive substance in the U.S., tobacco, is not even FDA regulated.
Many patients are not sufficiently educated to know that once there is breakthrough of their baseline pain(managed with long-acting opioids), it make take considerable time to get the plasma concentration high enough with a short acting opioid to get the pain under control. Often, good pain management Nurse Practitioners are the best educators for pain patients.
Chronic pain requiring an opioid cannot be managed solely with acupuncture, but we know from research that acupuncture stimulates the body’s own endogenous opioid system, such that it may be possible to reduce the dose levels of opioids. One problem here is that insurance companies limit the number of acupuncture sessions, just as they do with physical therapy sessions. Fortunately, a number of compassionate acupuncturists have lowered their prices for pain patients.
I’ve often said that if all medical services were run like hospice we would have a much more humane health care system, notwithstanding the abhorrent insurance system we have. You never see the DEA harass a hospice physician over their opioid prescriptions because admission to hospice requires the primary physician’s certification that the patient has less than six months to live.
Many years ago I did a study of “physicians who became patients.” Several observations: if the physicians experienced pain they become much more sensitive to their patient’s pleas for better pain management. Second, if they had a serious illness or surgery, their colleagues were less likely to refer new patients to them, in other words, once you’re seriously ill, you diminish in value and the institutionalized impact of this on patients is seen when a doctor making rounds with residents says, “that’s the pancreatic”- NOT SEEING THE WHOLE PERSON.
For other posts on pain, please visit:
Back Pain Help Comes in Many Forms
Guest Editor: Ken Schueler
Thank you for that much needed article on pain. While physicians “don’t get it” I’ve seen many nurses who don’t get it either, and have no concept of chronic vs. acute pain, and addiction vs. dependency. There was an excellent article/CE module on cancer pain in the October 11, 2010 issue of Nursing Spectrum. You can also visit Nurse.com/ for more info. I refer nurses to this article as an information/education piece, so they can educate themselves on this important issue.
I started my own advocacy business in November of 2009, however in my heart it started after my sweet mother passed in 2002. In retrospect, her severe pain of a broken hip from CA mets was so mismanaged. I decided in 2002 shortly after her death to become a hospice nurse vowing that anyone committed to my care would NEVER be left in pain. After many years of hospice, I started my own advocacy business. I have 23 years of nursing experience and know that I can help many, many people understand pain management and assist them as they navigate the ever changing and challenging healthcare landscape. Unfortunately, the rest of the world is just slowly catching on to the whole “ADVOCACY” field. I hope we can continue to get the word out: that there are real people out there that TRULY CARE! Kudos to all of you who want to make a difference. One can certainly go to school to learn medicine, nursing, advocacy, etc. but one cannot be taught to be compassionate, empathetic and deeply dedicated. Those are true virtues and although there are alot of healthcare providers who have them, many still do not. For those of us who care, we can start to change the world, starting with ourselves, one person at a time.
Sincerely,
Margie
During the AIDS epidemic in San Francisco during the 1980s, San Francisco General Hospital and the UCSF Medical School established a Pain Committee because of the inconsistencies of the pain management for their inpatients. This committee could and did overrule the attending physician whenever the patient’s pain was not being relieved. Included in the committee’s membership was a pharmacist, a voice I have found missing in too many discussions about pain. In the home care situation, patients leary of addiction or have difficulty with side effects of pain medication, often use alcohol to find relief from chronic pain. Unless the patient is forthcoming about drinking alcohol while receiving treatment, the home care clinical team may miss the fact that they are treating an alcoholic (or a drug addict) or that pain management is inadequate, is being ignored by the patient or the patient may have issues about complaining or about asking for more help with pain.
Doctors dont get it because they dont want to get it and government has failed to ensure the best interests of people in pain are being served by a medical profession that is trained and determined to ‘alleviate pain and suffering” The issues with opioids are a red herring-the real problem is doctors- 80% in a survey cant diagnose pain-becuase they are not interested in learning how. Furthermore they arent trained to offer dry needling, eswt, hypnosis,low level lasers, idet- to name a few treatments for pain. The IOM says 116 million Americans suffer chronic pain-and at a cost of over $600 billion/year- one would think thats a 400 pound Gorilla thAT COULDNT BE IGNORED-BuT IT LASGELY STILL IS IGNORED
I am one of the unfortunate statistics in the catigory of undertreated chronic pain. In short, I have a seizure disorder that causes serious physical bodily harm when I have them. They have caused multiple dislocations of both shoulders as well as torn rotator cuffs, comperssion fractures of the spine to name a few. My seizure disorder started on january 6,2008, and has only gotten worse since then. After four years, many different attempts to decrease the seizures with medications and ever increasing dammage, broken bones and pain with no end in sight, I have given up. I honestly feel as if I have been left behind and I was completely unprepaired for the total lack of compassion and humanity that I have been experiencing. Before my personal experience with this type of pain, I believed that people were mostly under general circumstances good and would do the right thing most of the time. I have always lived a life of trying to give the best of myself to others, to be as honest and caring as I possibly can, and always give the benifit of the doubt until such a time that I was given a valid reason to believe otherwise.
I think I have greatly overestimated people after recent events, and I now believe the rest of my days will be lived in increasing pain and seizures (of which I don’t know when they are going to happen), And I hope that someday that there will be more compassion and a greater understanding of pain and it’s appropriate treatment!
I am in chronic pain all of the time, and the doctor’s don’t care.
It’s really hard to keep going sometimes. I have so much to be happy for, but I hurt constantly and sometimes I wonder if it wouldn’t be better just not to wake up to the agony.
I love my family so much, I just wish there was a Doctor who would care, and actually help me, and not look at me like I’m some pillseeker.
I wish I had a compassion ray, in which any time someone assumed I wasn’t really in pain or exaggerating that I could make them feel this for one moment. Pretty sure thy’d write me a prescription then.
I’ve been in pain for the past 6 years. At the best of times it’s a 3-4 (depends on the spot), at the worst I’m wondering why I can’t pass out. I’ve seen several doctors and a couple pain clinics. I have 4 pinched nerves and fibromyalgia. At the moment I was told to use hot or cold compresses to ease the pain. I was told by the pain clinic that I’m not even supposed to use over-the-counter medication for it.
My dearest wish is that the people who are supposed to help and refuse to could feel the pain I feel, just while I’m in their office. I think they would help then. And if I complain I’m told it’s “not that bad or I’d be on pain meds”, LMAO. In my experience when dealing with pain the medical field is a joke.
I found a miracle cure for chronic pain, I found a doctor who has created a new way to treat chronic pain and it works !!! I have had chronic pain for over 10 years. I had been diagnosed with fibromyalgia and a disc in my spine. When the surgeon went to operate on my disc the surgery was complicated by surgery longer than they thought and the pain was worse after the surgery. To make matters worse, the fibromyalgia flared so badly that I could no longer hold my job in computer data entry which was not even physically demanding. Long story short, I was with pain and no work for years, going in for another failed surgery to try to fix the first. Then going to chiropractic, physical therapy. I tried chiropractic and epidural injections. I had a neurologist, a physical therapist, a rheumatologist, a naturopath, and I even went to acupuncture. Nothing worked. My surgeon wanted me to see a psychiatrist because I was so depressed and a pain management doctor. I tried two psychiatrists and four pain management physicians before I found myself on the couch taking 20 pills a day with no relief. Then I found about this pain doctor in California in Newport Beach, his name was Scott Stoney, MD. The doctor has published articles about pain treatment and he has so many certifications on his website. I called and did my research about him on line and it looked good. When I went to his office, patients were traveling from across the country to see him. Some even taking airplane rides to get there. Others were from Los Angeles who had heard about him. Even though I went all this way to see him I was nervous. After listening to my story, looking at my MRI’s and talking to me he told me about a treatment for chronic pain that he invented. Dr. Stoney was a Chemical Engineer before becoming a physician. He developed and injection that breaks up the pain. He explained the injection to me and luckily I was a candidate for the injection. Well long story short, I began the injections from Dr. Stoney. I was able to get off the couch and I could tolerate sitting within two months. I was even looking for work in six months !!! With this economy finding a job after an injury is nearly impossible but my network was still there and my friend was working for Netflix and they were hiring so she got me right to see the right person for a job. I was back to work. Dr. Stoney is really a man of miracles. He was trustworthy, kind, helpful, he listened, he was there for me the whole way. He has the god like touch were he was able to find the spots to inject right away. He has been practicing since 1987 in California. If you have the means to see him, he has created a cure for chronic pain. I still have to take some medication for pain but no crazy doses of medications that other doctors put me on. I see Dr. Stoney on a maintenance basis to keep bolstering my health. There is nothing in his injection that hurts the stomach or liver or kidney or lungs or anything else in my body. I found a Miracle, his name is Scott Stoney, MD in Newport Beach California.
I seem to have the opposite problem of most pain patients — I’ve made it clear that I don’t want to have to rely on medications if it’s not absolutely necessary, yet that’s all they push on me. No attempts to figure out what’s wrong other than the most surface blood tests, no creativity in what they recommend, just drugs and physical therapy (PT has actually caused me more pain in the past, yet I’ve just been prescribed it AGAIN). The hospital where I go used to have a therapy pool that worked miracles for everyone who went there (as long as we went on a regular basis) but because it doesn’t make enough money, the hospital closed. Because in America the goal of medicine is to make money, not make patients better.
Just a caution, there is still no Board Certification for Pain Management. Please see link to attached slide show of pain management qualifications and training. Any pain management program that you attend should be comprised of both alternative and medical treatments so that the best results are achieved as each person’s pain is unique and what one person responds to, another may not.
http://fhs.mcmaster.ca/anesthesiaeducation/documents/StatusofPainManagementCredentialing-Sept2011-Dr.E.Tunks.pdf
I’m so disappointed… The wonderful Dr. Lester Scott Stoney M.D. of Newport Beach, CA is retiring from practice and closing his clinic California Rehabilitation Inc. This was a great physician that was truly helpful to many and will be truly missed. My understanding is that the current health care reform is “eliminating pain management”, according to Dr. Stoney. My question is has anyone else heard of this policy change or the status of L. Scott Stoney MD’s retirement from practice? If you know anyone good enough to replace him, please post. Goodbye and enjoy retirement Dr. Stoney, many patients will miss your kind demeanor and care for their ailments.
Dr. Don F Mills in Irvine is awesome. Very friendly from the doctor and Physician’s Assistant, to the office personnel. Very happy with treatment. Caring and always smiling.