Posted 9/4/2009 2:04 PM (GMT -6)
Thanks so much for posting this.
I still think that a well-trained PM is going to know enough to understand how to appropriately apply these standards. Personally, it always became quite clear who were the addicts when they would get kicked from the clinic I went to. The normal people would be concerned about their pain. If the PM offered them anything that would help the slightest bit with their pain -- prescription-strength advil, a script for massage, old-school a/d's (amitriptylene, nortriptylene, etc. -- forgive my spelling) -- they would jump at it. They weren't happy about it, but were glad to get even the slightest bit of relief. Plus, for withdrawals, they were generally pretty willing to take non-narcotic treatments like anti-nausea, clonidine, etc.
The middle group was people with addictive tendencies who worked very hard to manage their medications & to eliminate/reduce as much risk as possible by selecting tamper-proof patches, pain pumps, a person to administer daily meds, etc. They were closer to the addicts while on the meds (though were careful not to be breaking laws or violating ethics), but resembled non-addicts when they would be kicked from the clinic [which was rare].
On the other hand, the addicts just went completely off the deep end. They would scream that they were going to die if they didn't have a 3-month supply of narcs. They weren't willing to take any help at all if it wasn't a strong narcotic. "NOTHING" else ever worked even just the very slightest bit to help their pain. The difference wasn't that massage helped reduce their pain by 1 point whereas narcs helped reduce it by 4. For the addicts, the difference was nothing helped reduce their pain by even a single (or half) a point except narcotics which made them "pain free" most of the time. Since the goal of pain medicine is never, ever to make the patient pain free, that was a huge red flag for my PM. But he was really careful & considerate so he wasn't just jumping to conclusions. He always offered patients he kicked from the clinic withdrawal meds, but usually the addicts would just flat out refuse hoping to strong arm the doctor into giving them the narcs. It was just insane, really. Regardless of what they thought, they weren't hiding their problem from anyone. The whole waiting room could tell when someone had a serious addiction problem.
I know a lot of CPers get all worried that they will be labeled by their PM's as addicts. Though that label is used a LOT in hospitals, by PCP's, by family/strangers/co-workers, etc., there is a lot of new research & information out there at this point for PM docs. Licensing boards put a lot out there. Professional associations put a lot out there. There have been numerous articles in professional journals that go in to much more detail than the information Stella just posted. I really don't think that PM's have much of an excuse to not be able to tell the difference and from what I've seen and heard, it is not too common that PM's make the mistake of mislabeling people as addicts. Just another argument for trying as much as possible to find a specialist. Some PCP's are well-trained in pain medicine, but it seems much more common that PCP's haven't read up on how to properly dose CPer's, how to correctly identify addicts & other key topics required to properly treat/manage CP patients imho.
But I think patients need to take some responsibility too. When I used to teach elementary school, I used to tell my students that they not only had to actually listen when someone was giving a presentation or lecture, but that they also had to appear to be listening -- i.e., turn their face towards the speaker, face their body as much towards the speaker as possible, make eye contact from time to time if it is a small group, nod their heads when they understand & take notes if that is helpful & appropriate. I think a similar notion holds true for CPer's. We need to not only actually be not-addicted, but we also need to appear to not have the traits of addicts, as much as possible. That's where I think Stella's post can come in handy. Sharing medications (esp. controlled substances), stockpiling medications without our doctor's knowledge, going to multiple pharmacies without informing our doctors, getting prescriptions from other doctors without 1) telling the new doctor who we are seeing & what we are taking and 2) as soon as possible calling/emailing our PM to inform them of what new meds we were prescribed while their office was closed, refusing to try alternative treatments like massage, PT, behavioral changes, acupuncture and so on, deciding on our own to take meds more frequently prescribed without checking with our PM's FIRST to see if that's okay, taking meds for something other than the reason they were prescribed (like taking meds prescribed for back pain for a headache, or taking pain meds to help us relax), etc. can end up making us LOOK like addicts even though we're not.
Now, I am not suggesting hiding things from our PM. Anyone who knows me knows I am 1000% against that. All I'm saying is maybe (& I include myself in this) we need to dial it down a bit when we're with our PM's. They're not counselors. They don't need to hear about all our fears. They are our caregivers, though, and they do need to right away know if there need to be changes to our treatment. I think sometimes we get so anxious about out PM's mislabeling us "addicts" that we make med changes on our own. That ends up making people look way more like an addict than if they had just called their PM's office & explained that the pain was out of control.
But that said, you are right on, ChP, about concerns re: pain med access being something a number of patients think about. Anxiety/Depression many times do co-exist with chronic pain/chronic illnesses (I don't know the current numbers -- at one time I read it was 60% co-morbidity rate of CP & Depression). However, there are lots of wonderful treatments out there to manage the anxiety/depression. CPer's don't HAVE to suffer with anxiety/depression. They can get treated & substantially improve those symptoms. While adequately managing pain can have a positive effect on mental illness, likewise adequately managing mental illnesses can have a positive effect on pain. Treating the depressive disorder & the occasional very anxious thoughts/feelings, had definitely helped me both feel better & to get the pain a bit more under control.
By treating my depression & managing anxiety with things like visualization, forcing myself to think positive thoughts, etc., I worry less about having meds available & what would happen if I ran out (pain would get worse, lose job, lose home, be homeless -- arrrgghh!). Instead, I focus on the fact that with only a couple of exceptions, I've never run into any problems at all getting my prescribed medications on schedule. And even when I have had a couple glitches (DEA shut down a pharmacy I used & once my PM was out for 2 months & his back-up would only offer to prescribe me certain meds, all of which I was allergic to), I found a way through the problems. Yes, it was unpleasant for a couple weeks, but I didn't die & I didn't become homeless & I didn't even lose my job. I was in a lot of pain, but I took it as a time to try out alternate treatments. When I start to feel stressed, I try to focus on how well things eventually worked out those times. Like I said, it wasn't very pleasant so I don't mean to make running out of pain meds less than it is, but I try not to make it more than it is either. Not accusing you of doing that, just sharing my experience. Hopefully that will help others, but if not it is always a good reminder to me -- especially now that I have only a week's worth of meds left until I run out. :O My PM was not being honest with me about why he switched me to a new medication, so I lost my trust in him & need to find a new PM.
Anyways, I know this was a really long post, but I do want to encourage everyone to try to think about how Stella's post might be helpful to you. If we each are able to somehow change our actions/words just a little on even one of those items (if any apply), I think it would help. For me, I'm picking the one about talking about pain meds for much of the office visit. When all of us band together & commit to showing clearly that we really are above reproach, then all that's left is to get doctors better educated. One thing at a time, I guess. :)