Pain Management is a Pain
Managing pain is difficult for the doctor and terrible for the patient. Postsurgically, patients complain about pain and usually are treated liberally with opioids. However, I can vouch in my own case that sometimes big doses of opioids are not enough. In the hours after my heart valve repair, the residual anesthesia kept most of the pain at bay. However, in the evening as the anesthesia wore off, pain came knocking on the door and the ordered dose of morphine did not arrest it. Additional dosing of hydrocodone and oxycodone also failed to relieve the pain. I was not a happy camper. In the wee hours of the morning, I was complaining to the night crew, and I know that I was irritating the nurse. How would I rate the pain on a scale of 0 to 10? Probably 14, maybe even 20! It was really a joke. I was definitely loaded with opioids and there was not even a modest reduction in the pain. I imagined that the pain was equivalent to a trip to Hades and that there could not be anything more excruciating.

Changing tactics, the nurse suggested that we try a benzodiazepine, since the opioids were not doing anything. Yes! The alprazolam did induce sleep, and for two hours I wasn't aware of the pain. Somehow the next day, morning and afternoon doses of morphine managed to control the pain. However, by nightfall, the pain returned with a vengeance and I got to spend another night with the devil. Once again we tried a benzodiazepine in the wee hours, and that succeeded in cutting down the pain and providing some sleep. By the third day, the hydrocodone was successful in controlling pain and the postsurgical course was then uneventful. After that experience, I have a great deal of respect for individuals suffering in pain.

Of course, the pain that I experienced was acute pain from the trauma of surgery, and the rules for controlling acute pain are not controversial. Everyone agrees that it should be managed with routine strong medication. The controversy and difficulty lie with pain that is no longer acute. When pain extends beyond 30 days, there is the possibility of developing a pain medicine dependency. After 90 days, there can be little doubt that dependency is present, and addiction is also not unlikely.

Avoiding addiction to opioids is the biggest challenge that physicians face in managing chronic pain patients. However, a front-page story in the October 8–9 Wall Street Journal suggests that surgical approaches to treating pain sometimes are even more dangerous than opioid addictions.¹

A 48-year-old obese male with ischemic heart disease and history of colitis requiring multiple abdominal surgical repairs suffered from long-standing lower back pain. He had been evaluated by his primary care physician and had received prescriptions of NSAIDs with little benefit. The patient had been referred for physical therapy and chiropractic, neither of which was successful in managing the pain. He was referred to a neurosurgeon who diagnosed that the pain was secondary to severe lumbar degenerative disc disease, based on MRI evaluation. The neurosurgeon recommended surgical intervention with implantation of mechanical devices to be placed between the vertebrae, fusing the spine. Peculiar to this surgery and the use of these devices, the procedure required opening both from the back as well as the abdomen, enabling a "360-degree" approach to placing the apparatus. Six hours postsurgery, the patient developed a heart event and died.

A later review of the case by two surgeons indicated that this individual was not a suitable candidate for surgery, given his history of ischemic heart disease and multiple abdominal surgeries and weight. (The reason that the Wall Street Journal reported this case was that the neurosurgeon is a part-owner of a company that makes the devices which he implants, and he receives a substantial percentage of the company's profits, thus financially benefiting from doing the surgery as well as using his company's device).

Pain Free 1-2-3
Jacob Teitelbaum, MD, author of From Fatigued to Fantastic! and Pain Free 1-2-3, thinks that we can treat pain effectively without addicting our patients to opioids or subjecting them to unnecessarily risky surgery. Teitelbaum is not against the use of medication, but he prefers that it be combined with other nondrug approaches to support pain. Too many patients suffering with chronic pain depend on medication alone for treatment. Teitelbaum argues that the typical American diet is woefully inadequate in nutrients, and even following a wholesome anti-inflammatory diet does not provide nutrients in adequate quantities to repair the body tissues and to counter adverse effects of medications employed. Preaching here to the choir: B vitamins and magnesium are never sufficient without supplementation. Essential fatty acids, acetyl-carnitine, and CoQ10 are also needful to manage inflammation and pain.

Teitelbaum strongly emphasizes that pain cannot be effectively managed without adequate sleep. He recommends that at least 8 hours of sleep is necessary. If exercise, stress reduction techniques, and wholesome diet are insufficient to sleep adequately, then natural sleep aids should be employed; and when these fail, sleeping medications should be administered. Teitelbaum believes in "titrating" medications to get sufficient control of sleep and pain. Rather than using too high a dose of any single medication, he thinks that medications should be used in doses sufficient to provide adequate benefit but low enough to avoid adverse effects. When one medication is insufficient for sleep control, then two or more may be needed. Additionally, Teitelbaum advocates using nutraceuticals and herbals for sleep control with medication use. He details much of these pharmaceutical, herbal, and nutraceutical approaches in his books as well as on his website, vitality101.com. We are pleased to have Dr. Teitelbaum talk about his approach to fibromyalgia in this issue.

Conventional pain medicine physicians are beginning to warm up to using avant-garde approaches to manage pain more effectively. The Seattle Swedish Hospital pain medicine department is headed by a very open and receptive physician, Gordon Irving, MD. Dr. Irving has organized a one-day education program on pain management annually for the past 15 years. Dr. Irving's department recognizes that some patients may need ongoing opioid prescriptions, but most can function with other prescriptions. Furthermore, whenever possible he integrates nondrug approaches to supporting pain management that greatly emphasize patient psychological control. One particular approach advocated and used by Rahul Gupta, MD, involves "transformational dialogue." This stepwise diagrammatic approach enables strategies to be developed for patients who are stuck in their treatment management. Transformational dialogue enables them to be motivated to take positive steps toward their own well-being. Plans are under way to allow the physician and patient to engage in transformative dialogue online, providing a tool for gauging the progress a patient makes to change. Lectures from the 15th annual pain management symposium, "Taming the Pain" (dated 9/30/11), are available for viewing at swedish.org/cme (limited to physician/health practitioner use).

Jonathan Collin, MD

Notes
1.      Carreyrou J, McGinty T. Taking double cut, surgeons implant their own devices.
         Wall Street Journal. Oct 8, 2011.