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May 22, 2016
This Week's Topic: "The Futile Quest for Pain Relief"
Question: "You seem to imply, with regards to chronic pain, that people should simply "deal with it.” That strikes me as harsh."
Dr. Adams replies: You are correct on both accounts. I do believe that a major task in front of those with chronic pain is the reality that they may forever be in pain, and that they have the responsibility to deal with that harsh reality. With current FDA warnings about serotonin syndrome, adrenal insufficiency, and possible decrease in sex hormone levels, patients may soon face greater hurdles in obtaining opioids. Patients consistently tell me that they loathe their increasingly ineffective pain medications, but dread losing access and fear the withdrawal process.
They approach each procedure as though this time the pain will be reduced or eliminated. They then become sullen, angry, more frightened, and more depressed since "nothing is really helping me except these drugs which have so many side effects." (A patient treating at a major medical school’s pain center mentioned a corollary issue. This patient lives a considerable distance from the pain program, but when he attempted to fill his prescriptions in his rural area, pharmacists (untruthfully) told him that they did not carry, have access to, or dispense his particular drugs. This happened at a second pharmacy the same day. The second pharmacy recommended that he try the first pharmacy.
When the pharmacist called them in the presence of the patient, they stated, "of course we do.” When he returned to the first pharmacy, they denied that they had received such a call.) When a patient has a permanent sensory loss (hearing or vision), they soon begin the process of accepting/adapting...coping. One could reasonably argue that these patients are not in physical agony while pain is an all-encompassing aversive experience. Nonetheless, the patient has an obligation to build and maintain a life despite the pain (as occurs with traumatic amputation), and physicians have a duty to assist in this process.
The greatest concern has always been that the patients can be led to believe that "just one more" procedure will be the magic bullet, and their life will return to a normal existence. In the private population, I see many more patients referred to me because they and their physicians accept that pain will be chronic. In the area of workers' compensation, I do not see patients referred for the purpose of accepting their pain.
Treatment of injured workers tends to be procedure-dominated: treat until all options are exhausted and then release MMI. When this occurs, patients are frightened, angered, confused, and feel betrayed and helpless to cope with their ensuing lives.