Houston, We Have A Pain Problem.

rosalindrobertson:

Many severe chronic pain patients have been reading the NYT feature on the “opioid-free ER” and rolling their eyes. 

And I have to admit, I am one of them. 

I’m curious when the revered NYT lost its objective eye and ditched researching medical stories, so I’ll supply some critique. 

The story is here.  

 Since Jan. 4, St. Joseph’s Regional Medical Center’s emergency department, one of the country’s busiest, has been using opioids only as a last resort. For patients with common types of acute pain — migraines, kidney stones,sciatica, fractures — doctors first try alternative regimens that include nonnarcotic infusions and injections, ultrasound guided nerve blocks, laughing gas, even “energy healing” and a wandering harpist.

First, opioids are not the first line of treatment for most acute or chronic pain situations. There is NO GUIDELINE that has EVER suggested this. 

Usually it’s an anti inflammatory… except, as many patients cannot tolerate opioids, many cannot tolerate anti inflammatories – patients with fragile stomachs and colons, patients with internal bleeding, patients with cardiac. Remember Vioxx? How everyone freaked out because it was causing heart attacks? How it was awesome (I loved it)  but got pulled off the market because it was unsafe and possibly killing people? 

Laughing gas is a social hazard. Please, come through my ‘hood and see all the dead whipped cream cannisters in the alleys after a party weekend. Yep, that’s laughing gas, it’s a propellant. It’s addictive and dangerous. Ohhhhh, but not an opioid, so we’ll step past the job of the reporter to point THAT out… 

Now, to the “energy healer”. Sorry if this is Your Thing but there is no clinical indication this does anything for people with established conditions, and I have yet to find a severe pain patient who finds this at all useful. In fact, many pain patients have spent thousands of their own dollars trying to pursue this treatment to find it has no clinical benefit whatsoever. The purveyors of snake oil in this field far outstrip pragmatic and proven therapies. 

I guess the NYT does not have google scholar. SHOW ME THE LITERATURE REVIEW. 

Wandering harpist, though, that blew my mind. When I’m curled up into a ball at a 9/10 and in the ER, sensory overload is a problem. Smells, light… and sound is the worst. I can feel every sound screaming in my nerves. So, to say it politely, the harp needs to go. 

And, again, no clinical data. They’ve been trying to get some for years, but this is a “theory”, just like the one that black bile caused cancer. I’m reading The Emperor of All Maladies right now (highly recommended) – and what it points out again and again is the almost religious fervour of doctors on a popular “theory” that everyone buys into that is wholly misguided and causes undue suffering to the patient. 

And this idea that it’s about my mindset needs to end. My pain is about a decade old, but my depression has been around three times longer. The cause of my pain is “abnormal” small nerve fibers and a nasty genetic condition. It is severe, it is ugly. Opioids are not great for it, but NSAIDS, which as mentioned are amazing, will certainly kill me. My digestive tract is in bad shape because of my disease – I’m only allowed NSAIDs every 30 days. 

I’ve got an excellent care structure – and that is what we need to provide. When I have to use opioids, I’m closely monitored and I stay within limits – and I go back to my doctors if they’re not working, not take more. This is key. 

Are opioids mis-prescribed? Absolutely –and constantly. Some twerp with a medical degree gave my friend oxy for gout. (Fun fact, opioids do nothing for gout, it’s a uric acid issue.) Another twerp insisted all my father could have for his knee replacement was oxycontin, ignoring that it made him vomit and he couldn’t stand. (It’s a family thing and a common reaction to oxy and percocet, I can’t touch the stuff either without becoming violently ill.)

The guy with the back pain in the article? No mention of the clinical treatment of low back pain, or why he wasn’t managed that way, which includes neural stimulation, massage, and heavy duty physiotherapy. Just drug him and strand him. 

Migraines? Opioids will make a true migraine worse – ask me how I know this -and the clinical emergency treatment is an IV (for dehydration) with an anti inflammatory (toradol) and anti nauseant (metaclop). Works like a damn. This has been the guideline in my local ER for at least 15 years, if not longer. 

But nitrous oxide is addictive and dangerous, and they’re touting pedaeatric applications in this like it’s no big thing. It is a very, very big thing. You think your teenager won’t figure out how to get that floaty feeling again? It’s called “huffing”. 

Speaking of big things, the article mentions ketamine and then throws it away. Ketamine is a veterinary anaesthetic used as a “rave drug” (Vitamin K), considered a narcotic, and has been widely abused since the 1990′s. It is addictive, and its administration requires medical supervision. Not exactly a “take home” if your pain is continuing. Dry needling can be very effective, as can nerve blocks, but they last a day, maybe two… and they’re expensive and time consuming for the patient. 

And what for the people who are resistant to lidocane? 

Each pain problem needs to be treated with multiple interventions. I spend a third of my day trying to deal with my pain through compressing, taping, physio, and yes, sometimes opioids. 

Opioids are not and should not be the first line treatment for most things. That’s something this hospital has done correctly.  But the NYT, without any skepticism or research, has not only treated following clinical guidelines as some Brave New Thing when it should be standard. Further the article gives credence to not only unproven interventions (harps and hand-waving), but interventions that can also cause a lifetime of addiction. 

Opioids still have clinical value, but they have never been the clinically recommended first line treatment for most pain, unless the patient has a serious and traumatic injury. 

And I’m sorry but if there is a chunk of bone hanging out of me, you’d better get the opioids out, and fast.