A national Pain Crisis Protocol is imperative

There should be a pain crisis protocol for dealing with patients who present to the ER or urgent care with significant pain that is not related, or is disproportionate, to obvious pain causes (such as trauma, fractures, infections, heart attacks, organ disease, etc. — the issues that ERs are used to handling.)

The main function of the ER is to identify and stabilize conditions which pose an immediate or proximate threat to life or function. Ongoing conditions are referred to primary or specialist care for follow up.

Crises in ongoing conditions are clearly outside this realm. No wonder patients with pain flares get called drug seekers. Of course they’re seeking drugs. Their condition causes terrible pain crises at random times, often outside office hours, and their only option at those times is to go to the ER seeking the medication they genuinely need.

It puts both the ER staff and the patient in crisis into an intolerable position. A Pain Crisis Protocol, generated at the national level, could eliminate that problem almost completely.

It would provide guidance for further investigation and appropriate treatments (including patient-specific treatments) for the many pain crises that are not traumatic or otherwise obvious, such as flares of CRPS, fibromyalgia, lupus, RA, certain forms of blood dyscrasia; arthritis exacerbation; unexamined or ill-examined organ or CNS compromise; and so on — all things that do require ongoing specialist treatment and thus tend to leave ER staff ill-equipped to deal with, but which occasionally require immediate care for episodes of crisis.

It would also provide ways to move past the “you must be a drug seeker” mindset, which is prejudicial and unhelpful to all concerned. It would create useful ways to move patients out of the blame-the-patient path and into a constructive treatment path where pain gets treated as pain, addiction gets treated (not bullied or abused, but treated) as addiction, and physicians’ appropriate treatment decisions are protected from the political hysteria around the use of pain medications.

Many of these painful diseases require customized crisis management, because response to pharmaceuticals can vary so widely from one patient to another in these already fragile, destabilized systems.

Rationally, then, this would require specialists who treat people with these conditions to provide crisis-management protocols for each patient to the patient’s home ER in advance.

Since many specialists resist planning for such crises, specific guidance on this matter would lift a needlessly vicious burden from patients who suffer from diseases for which flares are an inevitable, if unpredictable, feature.

Moreover, if a patient must be admitted to an ER outside their home area, the admitting ER can retrieve the necessary patient-specific protocol from the home ER at any hour via phone and fax. Again, this would provide appropriate treatment without imperiling the patient with false, undefended, and prejudicial diagnoses or potentially criminalizing the treating physicians for using politically sensitive medication.

The Centers for Disease Control (CDC) is going through another round of tortured logic around narcotic medications and pain treatment. Never in modern history has federal policy driven so much of medical protocol. (Informed dissent would be welcome. Looking forward to being wrong about this.)

The fallout in terms of patient care has been horrific, while addicts remain less treated than ever before and doctors are so hemmed in by inappropriate limitations on care that they can be criminalized for being responsive physicians.

It’s very odd.

Nobody wins — except the professional dealers, who don’t need to follow legal processes to access their product and have a growing pool of potential customers, many with a legitimate un-met need.

So, since the CDC is now so ready to get involved in the physician-patient relationship, it may be time to do so in a constructive manner. Creating a coherent protocol for pain crisis management, which provides forward guidance for ER staff past the fatality-eliminating process, safety for patients with a legitimate need, and appropriate diagnosis with rational intervention for addicts, would be wise. The money and lives saved would pay for it in the first year, if not sooner.

Relevant links

The current CDC proposed guidelines for narcotic use in the outpatient setting: http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0001

CDC guidelines for public comment: http://www.cdc.gov/other/public-comments.html

Selection of CDC articles on narcotic policy (opens new tab): CDC search for ‘narcotic policy’

How to contact your elected officials in the U.S. government (opens new tab): Contact your elected US officials

In politics as in medicine… Speak up, because there is no guarantee that they are paying attention to your reality.

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Good findings and bad conclusions on post-op pain treatment

Today’s “egg in your face” article from the American Academy of Orthopaedic Surgeons (via Science Daily) says:
One out of five adult orthopaedic trauma patients sought additional providers for narcotic prescriptions

http://www.sciencedaily.com/releases/2014/08/140811125114.htm

Link to the original JBJS article: http://jbjs.org/content/96/15/1257.long

Overview

Sadly, the orthopedic industry is still blaming the patients:

“Many suspect that orthopaedic trauma patients may be at a higher risk for pre-injury narcotic use and ‘doctor shopping.’”

The underlying accusation of addiction in that prejudicial statement is wholly unsupported in the information provided.

Moreover, that prejudicial opening statement opposes their own findings about the psychosocial context of these people:

“The “doctor shopping” patients had an average age of 39.6 ±12.2 years, and were primarily white (89 percent) and male (63 percent). Forty-four percent were uninsured. There were no differences between the single-provider and multiple-provider groups with regard to age, sex, race, injury type, distance between the patient’s home and treating hospital, tobacco use, psychiatric history (depression, anxiety, attention deficit hyperactivity disorder, or bipolar disorder), or comorbidities.

[Emphasis mine.]

Findings vs. conclusions

Let’s address these points in order:

  1. Men handle pain worse than women. They’re not well-designed that way. White men of mature years feel entitled to be treated. (Note that people of color are more likely to avoid conventional care, for good historical reasons. Women feel greater pain for the same injury, but are used to being undertreated and ignored, also for good historical reasons.) If adult white men are restricted by pain, they’re going to get pain meds, because they must function, and they cannot function past a certain limit of pain.
  2. The uninsured (who were counted) and underinsured (who weren’t) who’ve had a recent trauma requiring hospitalization are going to be under geometrically more stress than they were before: issues of money, mortality, and function can be overwhelming; work may be hard or impossible because of the injury, so ongoing survival is at risk; and recovery may be threatened because of the interplay of stress, undertreatment, and lack of rehabilitative care due to insurance and financial issues… all of which exacerbate post-operative issues and grind in stress levels. Any guesses about what significantly higher stress levels do to pain and pain tolerance over time, not to mention healing speed and nutritional needs? Right. More pain meds are needed.
  3. Most importantly, there are NO CORRELATIONS with the biggest addiction of our age, tobacco, nor with psychiatric history or logistical issues; these folks aren’t out for an easy fix, they’re doing what it takes to get what they need. (It’s important to reiterate that these scientists discovered those points themselves, but ignored them.)

This last issue, alone, is a big fat hairy clue that postoperative orthopedic pain is undertreated nearly 20% of the time — not that 20% of these ordinary folks are suddenly mainlining narcotics or flogging them for a few bucks a tab.

Two more points deserve critical attention:

Patients with a high school education or less were 3.2 times more likely to seek multiple providers (p = 0.02), and patients with a history of preoperative narcotic use were 4.5 times more likely to seek multiple providers (p < 0.001).

People with higher education have better command of information, can generally get their hands on better nutrition, and can more easily seek modes of self-care other than, and in addition to, conventional medicine. Assuming that, just because people are poorly educated, they must be seeking drugs for recreational use rather than because they don’t have access to good alternatives for pain management (including less physically demanding work), is a straw-man argument with contemptibly classist roots. I suspect I’m a lot closer to a lot more poorly educated people, and have made a much closer study of the data around their decision-making processes, than these orthopedic surgeons.

As for the second point in that quote, there was no assessment as to why people were taking narcotics pre-injury, and the assumption that doing so is necessarily wrong is blatantly daft.

People who are already being treated for pain, and then go through something as brutal as orthopedic surgery, know full well what’s going to happen if they ask one doctor for all the pain control medication that they need. Because their physiologic margins are already being stressed, it is perfectly reasonable to expect their medication rates to be higher, but the guidelines for narcotic administration don’t allow for that outside of late-stage cancer treatment, because cancer patients are presumed innocent where other pain patients are not.

Moreover, people who live with pain tend to have a harder time moving and are physically slower to react, so they are more likely to get injured. I speak from bitter experience. It doesn’t mean the pre-op narcotic use is inappropriate, but instead follows logically from the nature of living in pain.

The echoing silence on that issue alone pollutes all the rest of the study.

Consider the source

This prejudicial article would need to look elsewhere for data to support the idea that ~1/12th of pre-op and 1/5th of post-op orthopedic patients are users or pushers or both, but it consummately fails to do so.

As a sometime RN in homecare and emergency care, as well as a longtime pain patient with an orthopedic-surgery-triggered iatrogenic disease and a wide network, I find it far more believable that orthopedic pain is hideously undertreated. On top of the usual issues around invisible problems and pain conditions, orthopedic surgeons really don’t get it about how deep and hard that pain is.

They trivialize pain and recovery time because they don’t see the patient through to 100% recovery, only to the point where they aren’t likely to have acute complications. Thus, they really don’t understand the impact it has on real life. Far too few orthopedic surgeons have undergone major injuries, let alone orthopedic surgery, and fewer still have had complicated recoveries.

Basically, in orthopedics, the blind are treating the lame.

The real issue: narcotic abuse is on the rise

I’m not dismissing the anxiety in the article. Diverting narcotics is a real problem with ghastly consequences, including a tragic death toll and wholesale disruption of families and communities. Dealing with that as an addiction issue from a public health standpoint and a community-engaged model is the useful approach. Demonizing patients is not.

The useful approach requires social spending, which is currently unfashionable despite the rate of savings (~$1:$3 to ~$1:$1000 annually, depending on issue being addressed, depth and efficiency) which it provides. Demonizing patients comes for free, but the downstream costs in health, productivity, long-term care, and ultimately police and court costs, is horrific, but rarely calculated.

It’s indefensible to continue to condemn patients to needless pain and debility, the misery and humiliation that accompanies it, and the outstandingly hateful and contemptuous treatment they get from “care” providers if they’re suspected of being drug seekers.

Repeating: I was an ER nurse; I get it about drug seekers. Criminalizing pain patients does not address that issue.

Related issue: addiction does not bar treatment

In my view, it is never acceptable to withhold appropriate treatment. People with addictions may develop pain syndromes; this doesn’t mean they shouldn’t be treated with them. It requires more and better communication from both doctor and patient, and the patient’s physical needs have to be met within the context of their behavioral needs.

If I were treating someone with addiction and pain, and found that narcotics were the best option for handling the pain, then yes, there’d be more monitoring, because that’s a practical form of support for their sobriety. Focused counseling and CBT would be appropriate, because they may need help with redefining sobriety to mean, “taking meds as prescribed,” especially as that involves the sobriety skills of honest information communication with care providers — a big step.

The current fashion for dehumanizing addicts is predictable, given the divide-confuse-and-suborn political environment, but it remains utterly unethical. The road to sobriety must be a feasible challenge before anyone can be expected to rise to it. This does not mean abandoning them with untreated or under-treated pain.

Outcomes

When the scientific establishment ignores its own findings to perseverate on an outdated, counterproductive, fiscally and intellectually indefensible meme that penalizes and further harms patients, nothing improves.

This is a problem — and because legislators and the public tend to listen to these organizations, in defiance of the hard data and common sense, it’s one that breeds lots of other problems, each one as unattractive, expensive, and useless as its parent.

Clinical takeaways

It’s important to distinguish between real needs and artificial worries. The clinical takeaways are threefold, in order to take that into account:

  • Orthopedic pain is undertreated roughly 1/5 of the time. Current treatment parameters do not account for a significant proportion of outliers, and should be used with appropriate flexibility.
  • Postoperative treatment is more problematic than ever. With nearly half the population still uninsured and many of the rest underinsured, and simultaneously pain treatment being examined more narrowly every day, then recovery, rehabilitation, and patient education around these issues is more important than ever. Every patient should go home with printed, illustrated aftercare instructions which include the following:
    • Expected timeline for stages of recovery to 100%, with instructions on how to track and record stages, and what to do for complications or setbacks before, up to, and including calling the doctor. No surprises, unless both you and your patient are surprised.
    • General, practical, ADL and work-task focused guidelines for gradually progressed activity, day by day or week by week as appropriate, until 100% recovery is expected — with instructions on how to handle variances and setbacks. No surprises, unless both you and your patient are surprised. These should ideally be written jointly by orthopedists, occupational therapists and physiotherapists.
    • Nutritional guidelines for healing. These are absolutely basic but doctors, especially surgeons, consider it beneath them. A bit like breathing is beneath them, really. Let’s focus on the facts, and the fact is that vitamins and minerals in appropriate forms and quantities yield enormous benefits (vitamin C, 500 mg BID, prevents 80% of CRPS conversions, for instance) and deficiencies in calcium, magnesium, phosphorus, B vitamins, D vitamins, protein, EFAs and antioxidants result in more complications, slower bone and soft-tissue healing, and greater post-op needs.

    Posting those instructions online in generic form, perhaps under a Creative Commons license to facilitate collaboration, could be very useful to countless patients and care providers. If you have such instructions online, please post a link to them in the comments here and share them wherever appropriate. People need that.

  • The data from the American Academy of Orthopaedic Surgeons seems good, but their stated findings are highly political, not logical or practical. Go to the data and use your own intelligence to draw conclusions, because politics change but the principles of good practice do not. We all need to be reminded of that periodically…

Postscript

Highly attentive readers will notice that the study mentioned no correlation with comorbidities. I can’t access the full text of the study, and in the outer material, there was no description of what they considered comorbid. It might imply prior illnesses or conditions, or it might not. Given the gaping holes in the work otherwise, it doesn’t make sense to weight this statement at all. There is no indication, on the basis of the available information, that prior pain or musculoskeletal issues were assessed or accounted for at all.

Links

Science Daily article, with quotes from the study authors: One out of five adult orthopaedic trauma patients sought additional providers for narcotic prescriptions

JBJS posting of the study’s outer material (full article only available with subscription; this free material is what the authors chose to show): Narcotic Use and Postoperative Doctor Shopping in the Orthopaedic Trauma Population

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Warning: Starvation and alcoholism don’t mix

The latest candidate for Dept. of the Blitheringly Obv.: Young people eating too little and drinking too much is worse than doing either alone. No, really??

Lasting damage to memory and thinking, more bad choices, and increased likelihood of developing chronic conditions later in life, are far more likely because the damage from each form of fashionable self-abuse compounds the other.

This idea is certainly high on the head-desk quotient, but the article is mostly clear and sensible:

http://www.sciencedaily.com/releases/2011/10/111017171506.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain+%28ScienceDaily%3A+Mind+%26+Brain+News%29

They mention that the risks to women are higher ounce per ounce, but don’t say why; that vagueness is annoying and wrong, and science is far enough along to know better.

The idea that real food might be good for you is kind of a shocking idea, to some. Encourage them to get used to it. Fresh salad, berries, roast chicken, apples, baked potatoes, butternut squash … There are worse things. Like brain damage, cirrhosis, kidney failure, strokes, chronic fatigue, and HIV.

And looking really bad by 30.

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