Treating the New Chronic Pain Patient
November 30, 2017
by Amy Givler, MD
I had a tooth pulled last month. I wasn’t expecting much post-op pain because the tooth already had a root canal, years earlier. Yet with my mouth clamped on a large cotton wad after the procedure, I heard my oral surgeon say to his assistant, “Print out a script for Norco 7.5’s – 30 of them.”
“No script needed, I don’t need opioids,” I said. Or at least I tried to say. What I actually said was, “O eyah eh-eh, Eh oh ee oy-oy.”
He turned to me. “What?”
Eventually I communicated my wishes, though he tried to talk me into taking the script. But I knew acetaminophen and naproxen would do just fine. I appreciate his concern that my acute pain would be adequately treated, but 30 pills seemed like overkill.
The Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Painrecommends healthcare professionals limit prescriptions for acute pain to three days in most cases. More than seven days are rarely needed.
One study linked opioid use after short stay surgery (such as laparoscopic cholecystectomy, varicose vein stripping and my tooth removal) with increased risk for long-term use. Opioid-naïve patients given an opioid script within seven days after surgery were 44 percent more likely to be opioid users one year later, compared to patients not given such a prescription.
Around my hospital, I’m known as “The Wall” when it comes to opioid prescribing. I simply don’t believe they benefit the vast majority of patients who receive them, especially for chronic pain. I don’t want to contribute to the problem of abuse or misuse, certainly, but there’s a deeper reason. I’m convinced they actually lower the pain threshold—so people who take opioids are feeling more pain overall (except for the few hours right after a dose) than they would be feeling if they weren’t on them.
Having this “wall-ish” reputation means I get assigned, in my outpatient clinic, disproportionally more new patients who are already taking opioids for chronic pain. In a broad, general fashion, I’m glad about this. I have a variety of strategies to help people manage chronic pain without opioids. But in a narrow, specific fashion, I find treating such patients exhausting. It is very hard to say “no” to a new patient who has been on opioids and now wants me to be the source of their supply.
So over the years I have developed a few strategies that help me approach a new patient with a pain complaint who is on daily opioids.
First, I mentally prepare myself. I make sure to review the patient’s chart before entering the room so I know what was said in triage and what their current medications are. I mentally review what I will ask: “What is your pain like? How did it start? How long have you been on opioids?” Of course, I will ask many other questions, but I determine ahead of time that I will listen carefully to the answers. I want to know this patient’s particular story. This is a precious human being, made in God’s image. I want my patients to feel “heard” and know I care about them as unique individuals.
Second, I emphasize, re-emphasize and then emphasize again my focus on treating their pain, even though I will be weaning them from opioids. I believe patients when they say they have pain. Pain is painful. It interferes with human thriving. I want to help relieve that pain—I just don’t think opioids are the way to do it. When they’ve been on opioids for a long time, I will taper them very slowly, sometimes over nine months. Of course, I am always on the lookout for treatable causes for the pain. But that is a subject for another time.
The goal is not zero pain, though that would be nice, but rather manageable pain. I stress function. I want people to live full lives. One problem with opioids is that they tend to cause inertia. People taking opioids don’t want to move. But exercise itself is a great way to lessen chronic pain. I also ask about sleep, because poor sleep and chronic pain go hand-in-hand. A low dose of a tricyclic antidepressant is often helpful to bring about good quality sleep. Other non-opioid medications include acetaminophen, NSAIDs and anticonvulsants, such as gabapentin or pregabalin. Over time, I often use combinations of medications such as these.
On a first visit, I won’t mention the words “depression” or “anxiety,” unless the patient speaks them first. But I may think those words. Depression and anxiety increase the experience of pain. Is the chronic pain causing the depression, or is the depression making the pain worse? I don’t know. But, early on, it doesn’t really matter, as I am just going to treat the depression. Also, many antidepressants have been shown to lessen pain, even if the patient is not depressed. But if I prescribe one, I make sure patients understand my reasoning. I don’t hide the fact that I’m prescribing an antidepressant. Counseling is often helpful, but it is usually the second or third visit before I refer, when the doctor-patient relationship is more firmly established.
Finally, I articulate hope. A life with manageable pain is almost always achievable. If today’s plan isn’t helpful, there are many more plans to try. I want to work with patients in treating their pain. Still, my best efforts to establish a “teamwork” mentality don’t always protect me from patients’ anger. After a 30-minute visit, one patient I thought was understanding—and agreeing with—the plan, shouted, “You’re not treating my pain!” And he stormed out of the room. And yelled his displeasure to the entire waiting room. And complained to the administration of the hospital.
Pity, because I think I could have helped him.
All this takes time. And emotional energy. Often, follow-up visits are also draining, so I try not to fill a clinic day with patients with chronic pain. If I’m worn out and have no more compassion to give, I won’t make good decisions. The temptation to write the prescription—“just this once”—may overwhelm me. My short-term problem would be solved, but the patient’s long-term problem would be worsened. As Sir William Osler said, “The physician needs a clear head and a kind heart.” For patients with chronic pain, both of these qualities are essential.