The new forums will be named Coin Return (based on the most recent vote)! You can check on the status and timeline of the transition to the new forums here.
The Guiding Principles and New Rules document is now in effect.
Pain Mismanagement
Ludious
I just wanted a sandwich A temporally dislocated QuiznosRegistered User regular
I just wanted a sandwich A temporally dislocated QuiznosRegistered User regular
Pain Management.
We all know someone who suffers from chronic pain. Unfortunately most of us probably know someone who has become addicted to prescription medications (specifically opioids) or moved onto heroin.
The story is usually the same. A severe injury or major surgery leads to the prescribed usage of opioid medications for pain management.
Eventually, the prescriptions stop, and far too often Doctors fail to practice due diligence in explaining to the patients that it is best to ween them off these medications. Some doctors flat out don't. They just cut the patient off. A patient who is now suffering from not only injury related pain, but opioid withdrawal pain.
One thing leads to another and suddenly you have an addict who begins seeking drugs by any means necessary. It's not long before they wind up in the criminal justice system. They begin participating in petty crime, major crime, and even violent crime to fuel their addiction. Ultimately they are incarcerated. This far too often leads to relapse and death by overdose upon release.
Opioid drugs being handed out like candy and not properly managed has lead to some very strict laws across the country. Many states do not allow refills on narcotic painkillers, even if it is for a sufferer of long-term chronic pain by a doctor following all the necessary steps.
Now you have a two fold problem:
Addicts who become part of the system, contribute to crime, and ultimately overdose
Patients with legitimate long-term pain management treatment that includes use of these drugs being subjected to random pill counts, monthly doctor's appointments, and random drug tests. This sounds great and all, but the cost of healthcare in this country being what it is, makes all of these extra appointments and tests add up. Many disabled patients simply can't afford this.
This can force a responsible patient down a dangerous path of drug seeking, leading to unmonitored use, and eventual addiction. Leading to more people in the criminal justice system, ultimately, for being in pain and given the shaft one way or the other which lead them down a preventable dark road.
So what's the answer? Decriminalize these drugs? Establish some sort of official exemption/slackening of requirements for long term chronic pain patients who are under a good doctor's care?
I don't know the answer. But all I see are a bunch of people winding up in jail or without proper medical care because the system has become far too strict and punitive.
Discuss!
We all know someone who suffers from chronic pain. Unfortunately most of us probably know someone who has become addicted to prescription medications (specifically opioids) or moved onto heroin.
The story is usually the same. A severe injury or major surgery leads to the prescribed usage of opioid medications for pain management.
Eventually, the prescriptions stop, and far too often Doctors fail to practice due diligence in explaining to the patients that it is best to ween them off these medications. Some doctors flat out don't. They just cut the patient off. A patient who is now suffering from not only injury related pain, but opioid withdrawal pain.
One thing leads to another and suddenly you have an addict who begins seeking drugs by any means necessary. It's not long before they wind up in the criminal justice system. They begin participating in petty crime, major crime, and even violent crime to fuel their addiction. Ultimately they are incarcerated. This far too often leads to relapse and death by overdose upon release.
Opioid drugs being handed out like candy and not properly managed has lead to some very strict laws across the country. Many states do not allow refills on narcotic painkillers, even if it is for a sufferer of long-term chronic pain by a doctor following all the necessary steps.
Now you have a two fold problem:
Addicts who become part of the system, contribute to crime, and ultimately overdose
Patients with legitimate long-term pain management treatment that includes use of these drugs being subjected to random pill counts, monthly doctor's appointments, and random drug tests. This sounds great and all, but the cost of healthcare in this country being what it is, makes all of these extra appointments and tests add up. Many disabled patients simply can't afford this.
This can force a responsible patient down a dangerous path of drug seeking, leading to unmonitored use, and eventual addiction. Leading to more people in the criminal justice system, ultimately, for being in pain and given the shaft one way or the other which lead them down a preventable dark road.
So what's the answer? Decriminalize these drugs? Establish some sort of official exemption/slackening of requirements for long term chronic pain patients who are under a good doctor's care?
I don't know the answer. But all I see are a bunch of people winding up in jail or without proper medical care because the system has become far too strict and punitive.
Discuss!
Ludious on
0
Posts
I don't think I would phrase it as pain as the virtue but the stoicism in the face of pain is definitely something we treat as a virtue. Which isn't really a good thing as it leads people to just suffer through pain they find "manageable" instead of seeking treatment.
It was very much a thing of the Puritans, whose fucked up values and beliefs we still live with and suffer for, that pain and illness were signs that the person had angered The Devil and so must have been doing something righteous. It's a major part of Christianity going back to at least the 2nd century.
edit: to be clear I mean the glorification of suffering goes back that far. The early proto-orthodox would have shunned Puritans and their modern protestant descendants as Manichean since they essentially elevate The Devil into a co-equal power with god. Prior to the 4th century the glorification of blood focused on martyrdom (in terms of what we would call the Political) and the insistence on the physical nature of Jesus (in terms of what we would call the theological, though of course theology is political and vice versa). During the 4th century a form of Christianity became the dominant religion of Empire (and far more christians who chose the wrong sect were persecuted than the pagans had ever managed) and so new outlets had to be found for the continued glorification of blood.
But I do have some.
And pain is it. If I'm not dying, I put myself into "it's not a problem" mode. I don't take painkillers (typically).
It's one of the worse things that I do to myself.
"We believe in the people and their 'wisdom' as if there was some special secret entrance to knowledge that barred to anyone who had ever learned anything." - Friedrich Nietzsche
As for opioid use, it should be monitored and controlled, and only practiced under the care of a physician. They shouldn't be unreasonable restrictions on opioid use - it shouldn't be treated any differently than any other prescriptions, but doctors should also have more practical knowledge about addiction and pain management rather than just throwing drugs at it. Overprescription should be handled at the doctor level, not at the patient level.
On another note, there is a lot of promising research on different methods to treat chronic pain. My wife worked on a study that used gene therapy to successfully treat patients chronic pain. I can only imagine how much of a relief it will be for chronic pain sufferers when they can receive an annual / biannual injection of a viral vector that eliminates their chronic pain without impairing function or the ability to feel acute pain.
I'm also a big fan of making treatment plans widely available for addicts (regardless of their addiction) rather than forcing them to deal with an addiction on their own. Essentially criminalizing addiction doesn't do anyone any good.
I'd caution against reinforcing the stereotype that "opioid addict" is just the evolved-Pokemon version of "opioid patient." I don't think you believe that, based on prior conversations, but I think that your post could be misinterpreted that way.
Some opioid addicts started out with opioids when they were prescribed by a doctor. Others started out buying diverted prescription painkillers (from a patient who was illicitly selling pills that they got through a valid prescription from a domestic doctor, sometimes through other means like theft or importing them from a country with weaker controls). And yet others are heroin addicts who found it easier to obtain prescription opioids than heroin. (There's a pendulum of conversion from heroin to prescription opioids and back again depending on the relative supply of both drugs. Some studies find that more people convert one way; others find the opposite; the difference seems to be when and where the study was performed.)
There isn't really enough good data on how addicts become addicts. One study found that 1 in 4 people prescribed opioids for acute pain (such as a broken arm) ended up staying on them for over 90 days:
http://www.huffingtonpost.com/entry/doctors-opioid-addiction_us_55e8e486e4b093be51bb10f2
On the one hand, this is evidence that, yes, a significant number of patients end up addicts.
On the other hand, the number of patients who end up receiving 120 days worth of pills or more than 10 separate prescriptions was roughly 1 in 16. The vast majority of opioid patients do not end up addicted.
Furthermore, people who do end up with opioid addiction are more likely to have a prior history of addiction:
Of course, it's difficult for a doctor to pre-screen for prior addiction. If a patient knows that saying "Yes, I smoke" means he's less likely to get a pain prescription, he's not going to admit it.
There's been some success limiting opioid dispensing from emergency departments, thereby forcing patients to go back to a doctor they have a long-term relationship with (either a general practitioner or a pain management specialist) but this is complicated by the misuse of emergency departments as primary healthcare facilities - and that's it's own can of worms.
the "no true scotch man" fallacy.
Global Tel-Link, Corso, and Corizon might disagree with you.
This impacts people who are legitimately in pain because a lot of the protocols used to weed up drug seekers, will also weed out someone with something like fibromyalgia. The quicker we get to decriminalizing drug use, the better off everyone will be.
I don't think it has anything to do with any macho bullshit in regards to no pain, no gain. Everyone knows there's a difference between muscle pain from working out, and nerve pain from a disease. If they don't, well, they should try to see how long they can last when that red hot pain tears through their body and makes them crumple to the floor.
Skeptical cat is skeptical.
There have been a lot of drugs that promised to be more effective and/or less addictive than classic opioids: Darvon, Ultram, and Oxycontin were each initially marketed as safer and less addictive than existing opioids.
Darvon and Oxycodone turned out to be so addictive that the former has been pulled off of the market and the patent-holder for the latter (Purdue) had to pay out hundreds of millions in lawsuit settlements. Ultram has a narrower therapeutic window, more interactions with other drugs, and isn't as effective as true opioids.
The best developments have been in drugs that work on specific types of pain. Lyrica or off-label venlafaxine (Effexor) for neuropathic pain; Toradol for kidney pain, etc. A non-opioid drug that can substitute for opioids in the general case is the holy grail of pharma research.
the "no true scotch man" fallacy.
A blue flower; a present for my friends.
the "no true scotch man" fallacy.
the short version is, "pain control" is often conflated with "successful medical outcome" regardless of the underlying injury or illness
If a meaningful percentage of pain is perceived/psychological, then isn't some sort of "be more stoic" counseling is part of the solution? Rather than just "Here have another stronger Oxy-script".
I think the jump from the realization that pain is all subjective and we can never truly know the level of another's pain accurately to "Toughen up" is not really justified.
Bullshit is the short of what I have to say here. I am a chronic pain patient so forgive my bluntness but this is the crap I have heard for far too long. Hand wringing and attempts to up my pain tolerance have worked to an extent, but that just means I am now ok with debilitating pain that leaves me unable to move. That's just normal life. Thankfully I eventually got some kind of pain killers, and have got a good regiment now that works mostly. This still took years where being bed ridden for days at a time was normal for me because pain is subjective, and doctors wanted to worry about whether or not I was a drug seeker because apparently that is more important than being able to live my life.
THC
QFT
Is this actually true though? The US isn't particularly reserved with regards to prescribing medication, and it seems weird to attribute specifically the increase in prescribed medication abuse to a reluctance to treat chronic pain as serious. Though I suppose you could argue that just giving out a lot of heavy pain medication is not treating the issue very seriously, it doesn't square with the pain as a virtue thesis.
Nothing currently available to medical practitioners.
Most tests of pain in animals involve looking for a behavioral response. You can also look for biochemical markers of pain, but many of these methods are post-mortem or otherwise highly invasive.
There's been some promise with brain imaging, but there's a major confound here. Opioids don't just dull the perception of pain, but also the emotional response to pain. It's going to be hard to figure out how much of imaged brain activity is associated with direct perception of physical stimulus and how much is associated with emotional response to that stimulus... and, more importantly, how much the latter is controllable with non-opioid strategies.
Talk therapy and behavioral therapy dedicated towards managing the emotional response to pain can be helpful. (Example: http://ptjournal.apta.org/content/91/5/700.full)
Managing pain shouldn't be confused with stoicism, though. Brute stoicism can itself be a problem - if you ignore pain, you may be at risk of re-injuring yourself, putting yourself under unnecessary stress, ignoring signs that the underlying condition is worsening, etc. "Be more stoic" is too simplistic.
the "no true scotch man" fallacy.
Well, for one, we don't treat pain as a medical condition, but as a symptom. Hence the overreliance on pain medication, as well as the difficulty chronic pain suffers have getting good pain management. Two, there's a racial and class aspect as well, where members of the underclass dealing with chronic pain are routinely seen as "pill seeking", even when they aren't (and may, in fact, be looking to avoid medication!)
There are biological racial disparities in pain management which doesn't help
Doc: That's right, twenty five years into the future. I've always dreamed on seeing the future, looking beyond my years, seeing the progress of mankind. I'll also be able to see who wins the next twenty-five world series.
Sure, but that doesn't seem to have anything to do with pain as a virtue? Aside from it making no sense to treat pain as a medical condition instead of as a symptom*, the relation between what you say here and what you said earlier is not at all clear. Like, the weird american focus on trying to root out pill seekers doesn't seem to have anything to do with attitudes about pain as a virtue. And at any rate you would expect these problems to still exist in societies with less fucked up attitudes about drugs/less fucked up medical systems with comparable attitudes towards pain, but it doesn't really seem to be much of a problem in the rest of the world.
*what does this even mean?
Its an odd reality. Basically you have a lot of sketchy doctors who will dump out opiates if you can find them. At the same time those doctors often get sanctions as a result. So your average doctor gets reluctant and scared of prescribing to addicts or creating an addict. Addicts are also much more clever about getting the drugs where as pain patients stupidly just state they are in pain. It is a really shitty set of circumstances that put those in need in the worst way.
Pain can be a medical condition in of itself, which needs to be treated differently from pain as symptom.
And again, class plays a large role in our pursuit of pill seekers:
Just restating what you said doesn't clear anything up. I don't care that class plays a large role in everything in American society, since it seems besides the point. And just saying "pain as a medical condition" does not tell me what you actually mean by that.
I'm asking you what this has to do with your "pain as a virtue" thesis, and how such an attitude explains American over prescribing of pain medication.
Pain is a side effect of another illness basically. You don't treat it you treat what is causing it. This is largely true in my experience as no doctor wanted to treat the pain as a means of ending the problem so much as something I endured while they found a way to treat an underlying condition that never surfaced. This leaves the patient in a lot of pain, without much hope, and generally miserable while the doctor works on what may be an impossible problem.
Sometimes pain management is the game, and it is possible though hard to find a doctor willing to work with you on that. Typically changing doctors to find one who will is seen as bad an potentially criminal (doctor shopping). At best it makes other doctors less likely to prescribe because it looks like addict behavior.
Doc: That's right, twenty five years into the future. I've always dreamed on seeing the future, looking beyond my years, seeing the progress of mankind. I'll also be able to see who wins the next twenty-five world series.
I would be skeptical as fuuuuuuuuck of brain imaging for this reason and others. I suspect that, at best, you're going to end up reducing the subjective 1-10 chart with a smeared 1-3 chart. Assuming, of course, that there aren't confounds (and that the relevant areas are even areas that fMRI works well in!)
We need time for the science to develop. It still seems like we're flailing around in the dark in a lot of areas of pain management and addiction. Just as a small anecdote, after I dislocated my shoulder I was put on morphine both during the resetting procedure and for a while afterwards. I can't tell you the exact duration anymore because just about everything from that time is fuzzy. But what isn't fuzzy, what I remember in very vivid detail, was that the morphine did not work. I still felt the pain, but the drugs put me so out of it that I would forget about it moment to moment. Probably not too surprisingly, this made me very irritable and hard to be around. Certainly I didn't feel much or any of the euphoria that opiates are supposed to confer.
And that's a long winded to say that it's extremely difficult to have a one-size-fits-all answer, when everything to do with this is affecting people in wildly different ways we have trouble quantifying.
But it goes further than that. Do you know why oxycodone is referred to as "hillbilly heroin"? It's because it became identified mainly with rural areas where the extraction industries were predominant, because it was seen as a solution to the chronic pain those workers would be in from the heavy labor they performed. And the reason those workers were seen to "deserve" their pain was because of social class.
We, as a culture, have a fucked up view on pain. Athletes are often encouraged to "play through" pain, many times winding up risking their own bodies. Pain is seen as a necessary part of manual labor, and attempts to combat it have been thwarted, such as Bush repealing OSHA ergonomic regulations signed by Clinton. Culturally, we have many phrases and idioms that view pain in a positive light. As such, this results in a culture that does not take pain seriously. And because we don't take pain seriously, we don't deal with it well, medically. Chronic pain sufferers are routinely considered to be liars, and management quite often just devolves to throwing a pill at it.
the "no true scotch man" fallacy.
Several people in the thread have discussed chronic pain management in the thread better than I can, which is a good example of when pain needs to be viewed in the context of a condition of its own, as opposed to solely a symptom.
Nobody cares about this except people who read progress notes
Doc: That's right, twenty five years into the future. I've always dreamed on seeing the future, looking beyond my years, seeing the progress of mankind. I'll also be able to see who wins the next twenty-five world series.
Oh yeah I understand that. I went through several months of increasingly painful inflammations of many tissues before I got a diagnosis, and all I had was paracetamol and ibuprofen I bought at the pharmacy. It's not that I don't understand that sometimes management is the main thing, I just don't understand how this makes pain not a symptom. It's just symptom management, it's a big thing for many medical conditions.
Wrong
Sometimes people have problems completely unrelated to any known diseases or injury.
I am confused? Where am I wrong? Are you just going off my first statement which was less a statement of fact an more a framing of how pain management is dealt with?
"Be more stoic" fixes the problem for everyone but the person with the pain. It's basically telling them to not complain or slow down, not to experience less pain. Useful in rare circumstances, questionable in many.
I'm pretty skeptical of overly anti-opioid approaches to pain management. If you undertreat pain, you're literally torturing someone (and considering pain meds are legally controlled, regardless of what caused the pain, moral responsibility falls on both medical professionals and society in general. It's not merely doing anything, it's threatening violence against people who disagree), so I'm not a fan of not focusing on giving the patient the information they need to give informed consent to treatment that they believe meets their criteria.
Honestly, I think people in general vastly overrate what conditions can be resolved 100%. A lot of people I served with got moderately injured in not especially treatable ways. There's no "as good as a spring chicken!" treatment to someone in their 30's who was blown up 3 times in one day at one point. There's simply no way to not result in a long term pain management need there with current medical technology.
I've seen people routinely get IV Fentanyl in doses that would stop a normal persons breathing and require an advanced airway, all while screaming they were in agony. I've worked in an ED where someone who was actively seeking Dilaudid and Ativan would show up every Monday and sit quietly in the waiting room poking at their phone and smiling, and then when staff would walk out into the area he would start trying to wretch and scream as loudly as he could. There are people who get intrathecal pumps full of narcotics that would drop an elephant but now need just to get through their days.
Here's the thing. Pain is like art, it's subjective. Pain is whatever the patient says it is. If you say you hurt, as a member of the hospital staff, I have to believe you. Once you're on long term pain management you typically have to sign a pain management contract. They're usually worded in such a way that you must meet certain conditions in order to keep getting your drugs. They will drug test you when you come to the office, do random pill/patch counts, verify with other hospital/treatment systems that you are not collecting multiple prescriptions, etc etc. If you've signed a PMC and decide to violate it and get a little extra by checking yourself into an ER and lying very bad things happen. Not least of which is you will stop getting your pain meds. This is usually terrifying enough that people who are true sufferers of chronic pain don't really want to increase their dosage unless they absolutely have to in order to stay functional and they don't want to risk their pain management contract on selling their drugs. When they test your urine at a pain clinic (if it's legit) they're actually making sure you're taking your drugs and not selling them.
That all being said, lots of folks abuse the system but it actually works pretty well at weeding those people out. You're going to have problems with shady doctors who run clinics that aren't really interested in anything but turning a profit... which last I heard there was a tremendous crack down on. You're also going to have a problem with people stealing prescriptions to sell them, especially from family members with chronic pain.
We sell our healthcare system as perfect and able to fix anything. Honestly we're not all that advanced. We can staple things, take things out, maybe wire things together and put in some screws or a bit of metal to try to mimic what you were born with... but uh it's still pretty much like putting together Ikea furniture that keeps bleeding. Plenty of stuff we can only fix in so much as we can make it mostly functional again, and that's if we can figure out what's actually wrong in the first place. Until we can repair nerve tissue and such, pain management is going to be super important in maintaining a quality of life.
I take Tylenol 4, Tramadol, Celebrex, and Amitryptiline as pain management medication.
I have opinions on this subject, I tell ya what.
Less jargon: Pain is a symptom of disease, some diseases are just pain.
I'd love to hear em actually.
Edit: I have friends who take anti-depressants to help with the actual mood changes that can be caused by pain. Pain is a crazy thing that does all sorts of awful stuff to your body independent of whatever ailment is causing it. It is literally impossible to just "ignore pain" and man up 24/7 for years on end. The notion is ridiculous and I wish it would go away.