My latest continuing education CD is titled “Pain Management; Psychiatrists need to get more involved”. I am intrigued to see what this means.
The treatment of chronic pain is one of the most f*cked up fields of Medicine. For a matter that is so common, and for which there is much need, there is so little done about it. I recall very few if any lectures or training in medical school on the topic of chronic pain and its management.
I am not revealing any secret when I tell you very few doctors want to treat chronic pain. General practice doctors turf patients with chronic pain to psychiatrists. They often send such patients as pain is often deemed ‘psychosomatic’. Patients understandably feel insulted viz. their pain is ‘not real’ or judged ‘all in the head’. Psychiatrists understandably balk at this erroneous approach and tell patients to go see a pain specialist. “Pain specialists” are as rare as snowballs in hell. If a patient is lucky enough find one (let alone have it ‘covered by insurance’) they find them disappointing. Pain docs want patients to do anything but take ‘pain killers’: patients are looking for someone to prescribe just that.
A common scenario; a patient sees me and tells me their chief complaint is ‘pain’ and they were sent by their primary care doctor. The PCP sometimes sends the consult question “Is their pain real?” The patient either wants me to prescribe the pain killers their PCP is not willing to prescribe, or they want me to ‘prove’ their pain is real so they can force their doctor to finally deal with it viz. give them pain medication. I screen for co-morbid disorders like depression and anxiety. It is usually there in people with chronic pain. Patients poo-poo this. “Well, you would be depressed too….” They are not interested in treatment for their depression; they want help with the pain. Counseling to help deal with pain is offered (by the way, a very helpful component for pain management) but most people can’t see how ‘talking’ can help with pain. They believe proper treatment = opiate prescription. They often don’t come back to see me; they are now even more upset with the Medical System.
Most doctors distrust pain complaints; sensing pain patients ‘are drug seeking’. Chronic pain patients are not ‘attractive’. They are often miserable, chronic, seldom improve; they are not ‘nice patients’ in the eyes of most doctors.
Doctors fear getting sued for treating chronic pain. First there is the accusation of ‘turning patients into drug addicts’. While there are countless papers and reports showing pain is woefully under-treated, whenever a doctor has the balls to prescribe ‘until pain is alleviated’ they get harassed by State Medical Boards for being ‘pill pushers’. Doctors feel damned if they do and damned if they don’t. And every doctor has a few nasties who turned out to be actual malingerers, drug seekers, or abusers. This causes burn out and distrust of patients. It all thwarts treatment for those who really need it.
Another layer of problem is how pain is treated. Most MDs know opiate analgesics are not the ideal Rx for chronic pain. There are a lot of non-Rx interventions that are better than opiates, but try to get patients to do them – or insurance companies to pay for it. Alas, It is ‘simpler’ and less costly to give nasty Vicodin and Oxycontin.
No one wins.
I have no idea how to improve things but I know some of the elements that are required
- coverage for ‘proper pain treatment’ like counseling, rehab, guided imagery, yoga etc.
- less liability risk for doctors bold enough to treat pain in the ways everyone says they should
- better patient education about chronic pain and its proper treatment
- more patient responsibility to work on pain; not succumb to infantile regression
- everyone’s change in relying on “pills as treatment”.
- clearer boundaries as to who treats what. And more openness by doctors to be part of pain treatment, ‘not just specialists’.
Oh the pain.
9 comments
Comments feed for this article
July 10, 2009 at 3:43 AM
Ultra Dave
I must admit any time a doctor wants to give me a pill, I feel like he is a pusher, but if it is something tangible to me, like a sinus infection, I defer to his judgement that will won’t go away without it. Before my mother retired from nursing, she was a big advocate for patients who needed something for pain. She usually won after talking personally with the doctor. Maybe they just needed a second opinion before prescribing.
July 10, 2009 at 4:24 AM
Doug
That is a very complicated situation. As is common, money has become more of an issue than the actual issue.
July 10, 2009 at 4:56 AM
ElfBear
It sounds like, in many if not most cases, it all comes down to the patient’s word. How can you confirm ‘pain’ if you cannot quantify it, like blood pressure or heart rate? I can understand pain coming from a measurable event (I stubbed my toe, it hurts (I’m oversimplifying)) but how can you reach and treat something that you cannot see, touch or measure. A close friend of mine is going through a battery of tests to determine the cause of chronic pain he has been feeling for almost a year. Pain that came seemingly out of nowhere and treatment that appears to be going nowhere. It pains me (no pun, I swear) to watch him go through this ordeal as it is leading him to question his own sanity. He is a smart, reasonable, calm man who is slowly going batty due to this phantom haunting his body and mind. Thanks for the details, it helps me see this from a new perspective.
July 10, 2009 at 5:24 AM
Shawn
A DVD called “The Secret”.
It can seem far fetched to some, but there is real truth in it. If one can change mindset and perception, life improves, including pain. It is really that simple for most. Focus on the good things and more will come to you!
July 10, 2009 at 6:46 AM
foxystone
All pain is mental in the sense that the brain is responsible for all interpretation of the body’s senses.
July 10, 2009 at 7:06 AM
Nine
About 10 years ago I had a period of several months following an operation where I was in a hell of a lot of pain. It took a year for the pain to completely subside. Initially I took all the painkillers I could get but eventually I stopped. The side-effects (like constipation!) were really getting to me.
When I stopped taking the pills I was forced to ‘accept’ the pain and kind of learned how to tune it out. During bad patches I just told myself that it was just pain and that I would get through it. I just needed to take myself to another place and basically ignore the physical side of things.
There was an upside. These days I can take a lot more nipple-play than I used to be able to!
July 10, 2009 at 11:03 AM
Mark H
You’ve described one of the BIG problems in American Medicine today! Er, should I say “corporate” mediciine….The doctors today are so removed personally from their patients, they’re just numbers to them, and stats that affect how the physician/clinic interacts with the pill company. It’s ALL wrong……. Thanks for discussing it in the open.
July 10, 2009 at 2:03 PM
Bigg
This topic is rather personal to me. As a result of my medical condition, I still experience severe and rather debilitating pain from time to time. When I was in chemo, they gave me painkillers. Now, they act as if I am using my condition as an ‘excuse’ to seek medication when I ask for some relief. As a result, I have learned to suffer through as much pain as I can possibly stand. I personally feel that this is wrong, because suffering that can be alleviated but is not is needless and cruel. Thanks for giving us your thoughts about this.
July 11, 2009 at 7:22 PM
Raybob
As a massage therapist who worked on the staff (weekly!) at a pain management clinic, I can tell you that I got an eyefull and an earfull. And it is a *very* complicated situation. Untenable, IMHO.