A Pain I Did Not Know

Bradley Flansbaum

Posted 1/22/12 on The Hospitalist Leader

It was apparent for many at the vanguard of hospital medicine 10-15 years ago, that certain provinces of practice—end of life and palliative care, nosocomial infections and prevention, delirium, bioethics, perioperative medicine—were understudied and overlooked.  Our niche and ascent on the wards were particularly rapid, in part due to the application of these domains to most hospitalized individuals.  They are essential components on our admission checklist.

Personally, I was interested in mastering these competencies as it placed me at a strategic advantage relative to my peers.  Even today, they are the cornerstones of my practice identity.  Moreover, I find them fascinating and they keep me engaged in hospital medicine.

Another forte on that list is pain management.  If we are similar (I hope), our focus on acute pain control is an outgrowth of the previous era’s neglect and need.  We still manage pain poorly, but through reading the literature and in conversations with colleagues, I am noticing a change, mostly positive.

Also like you, prescribing opiates is an almost daily occurrence.  No doubt secondary to experience, I also continually deliberate on analgesic aftercare.  Mainly, following a patients’ return home, who takes ownership of this need, and will appropriate prescriptions materialize.

When a patient transitions to the subacute or chronic space, how often do hospitalists write the cursory 20-pill script, blindly assuming the next two weeks’ worth, or 50-tablet refill, will miraculously materialize?  Does the primary care doc view this action the same way we perceive the absence of advanced directives on the inbound trip?  Maybe.  We see acute, they see chronic.  You know how that story ends.

Now look at the table below.  It needs no explanation:

The most prescribed medication in this country is a narcotic analgesic, and its dominance on the list is both robust and enduring.  Most of you know that the illicit use of drugs such as Vicodin are at epidemic proportions; its use, along with others such as Oxycontin, spread for reasons other than neglectful distribution by doctors.

More than likely, awareness of pain as an undertreated entity and efforts by regulatory bodies to encourage management propagated their use.  The mixed messages emanating from medical organizations (use them), and drug enforcement agencies (big brother is watching), has always cast a pall over best practice decisions.

To add to the confusion, and why I am writing this post, are two recently published commentaries in Archives of Internal Medicine on the treatment of chronic pain.  I follow the mainstream journals regularly, but the recommendations threw me for a loop.  Essentially, narcotics for chronic pain are ineffective, and we should avoid dispensing them.  An additional article in ProPublica reinforced the same.

From Archives:

We believe that the trend during the past decade to prescribe more opioids for more patients with chronic pain should be reversed. Health care professionals first should try to treat the underlying condition and to use effective nondrug treatments such as physical therapy, cognitive behavioral therapy, pain management techniques, and appropriate assistive devices. First-line drug therapy for chronic pain should include aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, and appropriate corticosteroid injections. Because 30% to 50% of patients with chronic pain also experience depression and anxiety, health care professionals should screen for these conditions. Treatment of these comorbidities, once they are identified, should be an important part of a patient’s treatment plan.

And from ProPublica:

Recent editorials in medical journals and scientific reviews cite little evidence of long-term benefit.

Most of the clinical trials for opioids to treat chronic pain “were small, lasted less than 16 weeks and excluded patients with a history of substance abuse, psychiatric illness and depression, who are at increased risk for opioid misuse and abuse,”

Given this shift, I denote the following:

1. Care transitions.  Trouble amplified x 2.
2. Analgesic responsibility. Unknown.
3. Angry patients (CBT, PT, biofeedback…and who is paying for this again?).
4. No narcotics.  NSAID’s out for most chronically ill folks and Tylenol not practical. ?
5. Angry primary care doctors.
6. No guidance from responsible authorities.
7. HCAHPS and pain management.  Myopia and “acute” only treatment.

This is only going to get more troublesome.  I am genuinely lost.