The following concerns Jane Brody’s recent article in the NYT. It illuminates why the under treatment of chronic pain persists, and why it is not yet recognized for the public health disaster that it is. However, a response follows that puts Bakhit back in his cage.

(Bakhit is medical director at the Pain Management Center of Roanoke.)

The pains of pain relief Opioids can't be routine

Cyrus E. Bakhit

Sunday, March 20, 2005 - I read with interest the two-part personal health article written by Jane Brody ("Brand new knees come with a hefty dose of pain," Feb. 15, and "Doctors have much to learn about controlling pain," Feb. 22 Extra sections). In this diatribe, she relates her experience of bilateral knee replacement surgery. She laments about a variety of things from post-operative swelling of her legs to unreasonable medical charges.

I would like to limit my response only to her complaint of post-operative pain care. Brody should realize that she was given an average amount of pain medication, which is sufficient for the vast majority of patients who undergo the same type of surgical procedure. In fact, some patients require less medication than she received. I do agree, however, that in the face of escalating pain, and without any other obvious explanation as to the cause of this escalation, her doctors should have consulted a pain management specialist.

There are certain conditions, which could potentially follow the type of surgery she had, that would require special attention and treatment rendered usually in the setting of a pain management clinic. Conditions including entrapment neuritis and complex regional pain syndrome, which commonly follow trauma and/or surgical procedures, need to be attended to in a timely and aggressive fashion before they progress to a chronic stage and cause severe disability.

I was alarmed about her implication that the use of high-dose potent narcotic-type medications, or so-called opioids, should be considered at an early stage of a pain condition. She mentions that she "learned about a high functioning man ... who takes 500 milligrams daily" of OxyContin. I think that Brody, just like many others, owes her ignorance to the so-called experts who would have us believe that taking a truckload of powerful opioids such as OxyContin would have no adverse sequelae and should be routine.

Having practiced interventional pain management for more than 10 years and having been in the company of true experts, I can assure Brody that there is nothing routine about prescribing or taking opioid medications, especially at high dosage. To be honest, in more than 10 years of practice and having treated thousands of patients, I have rarely seen "a high functioning" patient who was managed on high-dose opioid medications. What I have noticed is patients who are physically wasted, emotionally drained and still complain of pain despite being on enough pain medications to put a half of a city block to sleep.

The truth is that a well-trained and experienced pain-management specialist would treat chronic pain conditions with a variety of modalities, including use of opioids at a reasonable level, synergistic medications such as anti-convulsants and anti-depressants, minimally invasive interventional treatments such as nerve blocks or more advanced techniques, exercise programs or physical therapy and, in some cases, use of psychotherapy and cognitive behavior therapy. Treatment has to be tailored for each individual patient and each individual condition. In some cases, the use of high-dose opioids may be appropriate, but it needs to be kept as the last resort option.

Brody may have a point about "doctors have much to learn about controlling pain." However, no sincere discussion can be carried out about this issue without examining other important controversies surrounding the subject. Ignoring these other complicating factors would be akin to ignoring an 800-pound gorilla. So I would like to remind Brody about some of these other issues. How about the issue of abuse and diversion? The abuse and trafficking of diverted prescription drugs profoundly affects all of us around the nation, but particularly in rural and semi-rural areas such as ours. Surveys indicate that the rate of abuse of pharmaceutical drugs has become double that of illicit drugs. A recent study done in a private pain clinic in a community similar to ours in a neighboring state revealed that the incidence of abuse in a certain subpopulation can be as high as 40 percent.

If Brody thinks this is an isolated study peculiar only to that community, let me assure her that it is not. A variety of factors are involved, including strong economic incentive to divert these medications. Some of these "seekers" are extremely motivated and sophisticated, they know what to say and how to act in order to gain the confidence and compassion of even an experienced physician. This makes it extremely difficult for physicians, since they are trained to be healers, not policemen.

Do you see the gorilla? How about fear of prosecution? For every prosecution that is mentioned in the media, there are literally hundreds of other cases surrounding physicians who are being investigated, charged and in some cases convicted. In the majority of these cases, the charges are dropped, as they are found to be baseless. However, even the process of investigation by itself can be enough to destroy a physician and his practice forever.

One of the most disturbing examples is that of a Utah physician taking care of his geriatric patients and who happened to prescribe a moderate amount of opioids to a few of his terminally ill patients for comfort measures. He was prosecuted and convicted of manslaughter. After he spent six months behind bars, a second trial exonerated him and all charges were dismissed. Nevertheless, the doctor found himself in financial ruin and he has yet to regain his medical license.

Do you see the gorilla? The problem is nowhere near as simplistic as mere lack of education on the part of physicians. The real tragedy is that patients with legitimate problems who are in need of adequate pain management end up suffering needlessly. This is a shared struggle and involves doctors, patients, law enforcement and the public in general. As such, it will take a societal approach to resolve.

I have a piece of advice for Brody. If she is going to go around the room handing out blame and pointing fingers at doctors for lack of education, how about at least acknowledging the presence of the 800-pound gorilla in the middle of the room?

Cyrus E. Bakhit
[email protected]

(Please feel free to contact the author with your thoughts)

Under treated pain and 800 lb. gorilla

Dr. Bakhit:

This "gorilla" you are referring to: Apparently there are two of them, the threat of addiction and the threat of groundless prosecution. The first has no more to do with opioid pain management than the man on the moon, and I will not waste time trying to review the tons of literature that show that. The second, groundless prosecution, is very real, and the reason that nobody has shot it is that the people in a position to do so, namely you and your many colleagues, are afraid to do it.

As the DEA and countless ambitious prosecutors continue their merry way, prosecuting the most vulnerable physicians, i.e. the ones willing to use opioids seriously, such as Dr. Knox, you and most of your "pain management" colleagues are content to sit back, tell your pain patients they ought not to hurt that much, and endorse fat paychecks for any non-opioid management, regardless of effectiveness.

So you have advice for Brody, namely not to go around blaming without acknowledging the gorilla. Well, here is some advice for you: Acknowledge that the gorilla prowls because the people who ought to fight it, such as yourself, are sitting on your hands, getting fat on all sorts of "alternative therapy" that doesn't work, while letting people like Knox and Hurwitz go down the tube.

I submit that the reason that you in your ten years practice have rarely seen a "high-functioning" patient on high-dose opioids is because they never had a chance to function -- you never gave them any. I do not believe you have treated thousands of patients on adequate doses of opioids. I do not believe that thousands of patients have responded to your "variety of modalities", your cognitive therapy, blocks, physical therapy, synergistic medications and psychotherapy. I believe instead that they were given no choice, and either got well by themselves or drifted away from your clinic. I do not believe you can produce one patient that was "physically wasted or emotionally drained" due to his opioids. But I'm sure you've had many who were physically wasted and emotionally drained by their continuing pain you didn't really treat. In my forty years of family practice and pain treatment, I have seen hundreds, if not thousands, of refuges from pain management clinics; I am still trying to recall one who felt they were treated adequately or humanely, or who thought their experts really believed in them.

And if you never saw a high-functioning patient on doses of 500mg of Oxycontin, why don't you talk to my ambulance driver who has taken 600mg of morphine a day for ten years without an accident and with a perfect driving and attendance record. He'd love to have a conversation with you, and in fact would like to add a little non-verbal communication.

Ms. Brody's consultants and mentors, such as Dr. Jennifer Schnieder, are not "so-called" experts, YOU ARE!

Joseph H Talley
[email protected]

(Dr. Talley welcomes your comments also.)

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