Friday, May 8, 2015

A delicate balance

Surgeons deal with patients who have pain on a daily basis. But pain is not a simple issue. It begins with nociception: the sensation of tissue being damaged. It causes us to recoil from whatever is causing the damage, whether it is a thorn in the foot or the heat of a fire. It is something that is designed to protect us from injury by letting us know about it quickly. From there, we add layers to the experience. Initially these may be helpful, teaching us to avoid the source of pain, but sometimes they are not. But, sometimes, people develop behaviors to manipulate others to assist them. Sometimes these behaviors even make people feel miserable from pain behavior long after the nociceptive impulse is gone.
Patients with pain behaviors out of proportion to pain and those with addictions make surgeons leery about prescribing narcotics for pain. The legal system reinforces those fears. But, more recently, there are also laws requiring the treatment of pain. And, we must remember, as physicians, one of our tasks is the alleviation of pain.
So, how does this balance work in real life. I would say that most of the time it works pretty well. Most surgeons, and other physicians, become pretty skilled at guessing the amount of pain medication a patient need. Guidelines are available based on patient size, and physicians use their experience to adjust these at times, based on knowledge about the patient.
But, what about when we are wrong? Overdosage can be disastrous, but fortunately, is most often treatable when recognized in time. They can become addicted or sell the unneeded drugs. There can significant penalties for physicians who do, including loss of license or prescribing privileges or worse.
Underprescribing can leave the patient in pain, and sometimes teach a patient to hoard narcotics or seek out other sources. It can also lead to longer hospitalization with its inherent risks and more outpatient visits. And, more states are enacting legislation requiring physicians to provide adequate treatment of pain.
Fortunately, I have never experienced an overdosage as a patient. But, I have experienced undertreatment of pain twice. The first was many years ago, before I was in medicine, when I thought I was tough and declined a narcotic prescription for a fracture. I had never used prescription pain medication before, despite some other injuries. A couple days later, I returned, thinking I would be prescribed the meds I had declined earlier. My chart was not immediately available. I was accused of drug seeking and not given a prescription. I weathered that injury with over the counter medications. And, like many patients, I decided that it was a mistake to decline a prescription, and would accept them, even if I didn't think I needed it. After all, I could decide if I needed to fill it.
The second was more recently. I had an epidural placed that seemed to have no effect, except to cause an allergic reaction to the tape used. In recovery, I told the recovery room nurse that I was in pain, and rated it more than my previous 10/10. Her response was to tell me that since I had an epidural in place, I should have no pain. And when I asked her to get the doctor and suggested that I needed medication, and even suggested a few that I have prescribed in similar situations, she disdainfully suggested to the the doctor that, "she even knows the names of several narcotics." The resident then informed her that I was an attending surgeon at a neighboring hospital. The poor nurse, who hadn't noticed that in her review of my chart, turned bright red. Since the pain was inadequately treated, I was afraid to move. Fortunately, I did not develop a pneumonia or venous thrombosis as a result, but many patients do when they aren't mobilized in a timely fashion.
I recount these two episodes simply to suggest that patients may ask for pain medication for legitimate reasons. I certainly understand the reluctance to overprescribe. But, there are also problems with underprescribing. We must observe our patients carefully so that we can appropriately adjust dosages. It is a delicate balance.

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