Managing Chronic Pain Patients
Chronic pain management requires careful patient screening and assessment, individualized treatment plans and regular patient monitoring. Consider these two scenarios:
Andy Romano, age 39, had been a patient of Janice Franks, ND, for more than 10 years. After he suffered a crushing right shoulder injury in a car accident, Andy was being treated for chronic pain and had undergone several surgeries, but he never regained normal use of his right arm.
When he first saw Dr. Franks, Andy reported daily intense and unrelenting pain, and the pain had increased to the point where he needed progressively stronger opiates for relief. More than once, Andy’s wife had expressed concerns about her husband’s long-term use of narcotics and the potential for addiction, but Dr. Franks tried to reassure her that other patients were on much higher levels of pain medications.
Troubled by the prescription and its adverse effects, Andy’s wife took her husband to a physiatrist for a second opinion. The physician at this pain clinic administered two corticosteroid injections to Andy’s glenohumeral joint, and the relief was rapid and pronounced. About this time, Andy was pulled over by the police for weaving in and out of traffic. After an evaluation by a specialized officer who arrived on the scene, Andy was charged with driving under the influence of drugs. As part of a deal with the district attorney, Andy was admitted to a drug rehabilitation facility to wean him off the opiates.
After a long rehab, which included the use of acupuncture for pain relief and to improve his range of motion, Andy was able to get by with only the occasional use of ibuprofen. Andy and his family filed suit against Dr. Franks, alleging inappropriate prescription of narcotics that resulted in drug dependence and physical disability, and ultimately led to a DUI charge and its major detrimental effects.
Shelly Rogers was 29 years old and had recently moved from another state when she presented to Thomas Riley, ND, who practiced in partnership with another naturopathic doctor.
Shelly’s chief complaint was migraine headaches, which she had since she was a teenager. She said she had a copy of her medical records from her past physician’s office and would drop them off in the next couple of days.
After his initial assessment, Dr. Riley suggested that she try a feverfew herbal extract and magnesium. Shelly stated that she had a severe ragweed allergy and experienced a “total allergy explosion” from trying feverfew in the past. Additionally, she was taking magnesium already.
Dr. Riley then suggested that she try a triptan, which he found to be a very effective pain reliever for some of his other migraine patients. Shelly said her former doctor had specifically advised her not to take triptans because of a strong family history of stroke—a recognized contraindication for the use of triptans. She said she had been using Lortab 10, as previously prescribed with good success and no ill effects.
She had an empty pill bottle for Lortab 10, and Dr. Riley gave her a new prescription for a 30-day supply of Lortab 10. When she was seen one month later, she reported good relief of her pain and requested a prescription refill.
Several months later, the receptionist at the ND practice alerted Dr. Riley that Shelly had been calling in for refills of her medications—often one or two days after seeing Dr. Riley—to report she had lost the original prescription and needed another. Dr. Riley’s partner had taken care of one of these requests while Dr. Riley was on vacation and noticed the pattern.
Upon investigation, Dr. Riley confirmed that Shelly had actually filled all the supposedly “lost” prescriptions in addition to their replacements at several local pharmacies. She always called the office on Dr. Riley’s day off. In addition, Shelly had not provided her medical records as she had promised.
Because the practice was transitioning to an EHR system, this ruse went unnoticed for some time. However, the next time Shelly called in for a Lortab 10 refill, she was told to make an appointment to see Dr. Riley to get the new prescription. She said she would call back to schedule, but she never did.
Change in Pain Management is Needed
These two case scenarios involve different aspects of chronic pain management and different medical-legal issues associated with the prescription of pain-relief medications. Much of the difficulty with pain management came to light in the 2011 Institute of Medicine’s report entitled Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research.
- 100 million Americans are affected by chronic pain, making it a significant public health issue.
- Chronic pain costs the U.S. more than $560 billion annually in medical treatment and lost productivity.
- Much of the chronic pain experienced by Americans isn’t treated correctly or effectively.
Several governmental and professional organizations have sought to improve the management of pain and to reduce the diversion, misuse and abuse of prescription painkillers, especially opiates. Opiates can be effective for managing chronic, non-terminal or nonmalignant pain when prescribed appropriately, but they have a high risk of serious adverse effects and their street use is disturbingly high.
What Can We Learn?
Treating patient pain—chronic or acute—is never easy. Pain is an inherently vague, subjective and multifaceted concept that is individualized by each patient. NDs must recognize that one patient’s “2” may be another patient’s “7.”
The management of severe chronic pain has become even more difficult due to the sheer number of people affected by pain and our society’s increasing abuse and illegal diversion of these drugs. In light of these factors, it is important to pay particular attention to:
Take a thorough patient history with heightened awareness of:
- Sleep apnea
- Past history or a family history of alcohol or street-drug abuse, tobacco use, preexisting cardiac or respiratory disease
- Age greater than 61 years
- Medication history (for drug-drug interactions or previous adverse reactions to or intolerance of analgesic or sedating medications)
- History of depression, anxiety or other mental illness
The presence of any of the above in a patient’s history may contraindicate the use of a specific medication or increase the likelihood of an adverse event and subsequent patient harm. Taking the time to identify at-risk patients can help maximize the patient analgesic benefit and decrease the risk of drug diversion. Also, using a pain treatment agreement with the patient can further prevent diversion and provide an early alert when situations occur.
Patients with condition such as Complex Regional Pain Syndrome (CRPS, formerly knowns as reflex sympathetic dystrophy) react poorly and sometimes adversely to commonly beneficial treatments. For example, the slight needle prick of acupuncture can set off a chain reaction of pain.
These patients are at the top of the McGill pain scale. They may benefit from novel approaches, such as Ketamine infusion, and they need very individualized naturopathic care. Their ability to tolerate and cease benefiting from enormous doses of Demerol, propofol or fentanyl should not be underestimated.
These should be individualized to each patient’s specific circumstances, pain needs, past history and goals. Is the patient hoping to reduce his pain from a “7” to a “2”? To be able to return to work pain-free? To treat pain without opioids or without any medications? Knowing what each patient wants and expects should be the foundation of each patient’s pain management plan.
Patients will be more likely to comply if they are involved in the development of a pain management strategy. In addition, it will be easier to measure treatment outcome/success against defined goals. Avoid open-ended treatment plans involving these drugs.
Aim for the lowest dose that provides effective pain relief for each patient, but recognize that it may take time to find the perfect dose. Monitor at more frequent intervals for early recognition of potential problems—patient sensitivities or side effects are more likely early on in a drug regimen—and reassess after adjusting a medication or dose.
Forty-nine states have prescription drug monitoring programs (PDMP). Check your state-specific PDMP at each visit and include the report in the patient’s records.
Office protocols for follow-up contacts and appointments with chronic pain patients can help detect signs of drug misuse or indicate or predict addiction. These behaviors include:
- Requesting increased dosage or additional medication
- Noncompliance with other pain-relief therapies
- Requesting a specific analgesic
- Behavioral changes that adversely affect work or daily living
- Repeated “lost” prescriptions
- Use of multiple providers, healthcare facilities and/or pharmacies to obtain medications
Good patient understanding of treatment, including the rationale behind that treatment and its potential risks and consequences, is particularly important to successful pain management. Written take-home patient education materials, in addition to the ND’s verbal explanations, increase the likelihood of therapeutic success.
In the event of litigation, your use of established guidelines will be extremely useful in your defense.
Know when to obtain a consultation or when to refer a patient to a pain management expert.
Risk Management Is Important
It is important part of an ND’s risk management to understand the unintended consequence of the misuse and abuse of prescription painkillers. For more risk management tips, please read our blogs on several important topics.
ND Insights is published for NCMIC policyholders. Articles may not be reprinted, in part or in whole, without the prior, express consent of NCMIC. Information provided in ND Insights is offered solely for general information and educational purposes. Names and events are created for illustrative purposes only. It is not offered as, nor does it constitute, legal advice or opinion. You should not act or rely upon this information without seeking the advice of an attorney.