Chronic Pain Patients
Chronic Pain is defined by D.C Turk, et al as "pain that extends beyond the expected period of healing". Prior arbitrary definitions of pain lasting 3 months or 6 or 12 months are probably not helpful from a practical standpoint and are too limiting. Whatever the definition, it is certainly a common source of prolonged suffering for millions of people, and is not new to this century.
The Pain of Andromache, 1783
Taking care of chronic pain patients is one of the greatest challenges for physicians and nurses within both the inpatient and outpatient setting.
There are multiple reasons for this...
• We often find ourselves at odds with patients. They frequently want more pain medication than we feel comfortable giving.
• Pain is very subjective. There are no truly objective measures of how severe someone’s pain is. The 1-10 scale that we often used is interpreted in different ways by our patients.
• Sometimes it is very difficult to tell the difference between the patients who really have severe pain, the ones who only think they have severe pain due to psychosomatic illness, and the ones who are drug-seeking addicts. Many times there are combinations of these factors all in the same patient.
• It’s medically risky business because many times if we give enough medication to truly control the pain, we may actually harm the patient by suppressing respirations or blood pressure and deaths have occurred as a result. There is sometimes a fine line between controlling the pain and harming the patient.
• There is also the risk that a depressed or otherwise mentally unstable patient will use the medication you have prescribed to commit suicide.
• It’s legally risky also because it may expose you to malpractice suits, not to mention withdrawal of your license to practice medicine if your prescribing of analgesics is deemed to be inappropriate by state or federal agencies.
• There is often considerable peer pressure by colleagues and associates not to ever prescribe narcotics for nonmalignant pain.
And yet, there are those patients who legitimately have severe chronic pain for which there are no treatments available other than narcotics. What should we do with these people? Should we ignore their suffering, their misery, and their inability to function and live out their lives in peace because of their pain?
Most of the so-called pain clinics unfortunately are not pain clinics at all – at least not for the chronic pain patients to which I’m referring in this article. Many pain clinics are really only for acute pain patients. They consist of either anesthesiologists or physical medicine specialists who treat patients with trigger point injections, epidural injections, nerve blocks or other non-medicinal modalities of pain control. Only a few of these clinics will go a step farther and actually care for the chronic pain patients who have failed all other treatments and the only thing left for them is medication. Most of these types of patients fall back to the primary care doctors who have varying degrees of discomfort caring for these folks.
I have no reservation about discharging a patient who is clearly a drug-seeking addict. However, I personally don’t think it’s right not to care for the patients that you really believe are suffering with chronic pain. If there truly is a pain clinic in your area that specializes in caring for patients like this, you may wish to send the person there for a consultation and continuing management of the chronic pain if at all possible. The primary care doctor can continue to manage all the other aspects of the patient’s care but all analgesics and sedatives should then be managed by the chronic pain clinic.
If you don’t have the luxury of having one of these clinics in your area then you will probably need to take care of the person yourself. You could discharge the person from the practice, but then where will the patient go? You could say, "Well, that’s not my problem", but maybe it is in a larger sense. You have to decide for yourself. Somebody has to take care of these people. If not you, then someone else. Perhaps you would be able to take care of them more safely than some other doctor who doesn’t know as much about the risks. After all, you are at least interested enough to be reading this article. Your partners may insist that you not take care of any of these patients because they will not feel comfortable seeing them when you're out of town. There are a lot of issues to consider.
If you do decide to continue to care for chronic pain patients, make sure you know the guidelines for care that have been written by pain management specialists. Get your pain patients to sign a contract on how their pain will be managed and ensure that they bring in a written report or log of the severity of their pain and how the medication has improved their functionality. Enlist family support whenever possible. Make sure they keep regular appointments so that you can examine them and look for any adverse effects of the medication. If your patient refuses to comply with your rules after you’ve explained the medical risks of strong analgesic therapy, then you may have good reason to discharge them for noncompliance.
This is a difficult issue for many caring physicians because of our desire to alleviate suffering on one hand versus risk of harm to the patient and indirectly to ourselves if something goes wrong. It is truly a challenge in many situations, but if you follow the proper guidelines, both your patient and you should remain safe. Many of these patients will be very grateful for your help after so many others have turned them away.
- American Academy of Pain Management
- American Pain Society
- American Academy of Pain Medicine
This page was last updated on October 9, 2010.
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