Title: When Bad Backs Happen to Good People
Author: Jordan S. Fersel, MD
In her passionate and compassionate article of 11/15/17, "The Death of Pain Management" ,Janice Reynolds, a retired pain management nurse, places her finger with precision on the pulse of what ails the field of pain management. It does not seem at this point that the opioid crisis is the direct resultof doctors over-prescribing narcotics, most doctors I know are afraid to prescribe pain killers for the fear of being sanctioned, fined, or having
their medical license revoked.
When a patient comes to a doctor, it is common that acute pain is the primary complaint. We are used to trying to identify and treat the cause of pain, which in many cases is an indicator of something more serious, but not always. There is a triage system in each physician's mind as to the seriousness of the message of pain. While sometimes we may over-react, but in my mind, the best physicians ask themselves, "what is the worst thing
that this pain can indicate" and act accordingly. We all know the old adage, prepare for the worst, but hope for the best, and with regard to acute pain that is a 'best practice' in medicine.
But what about the patient that has sustained a work or motor vehicle related injury, has arthritis or any autoimmune disease or chronic infection who complains of long-standing pain that does not go away and that has not responded to conventional medical treatments and interventions?
I can tell you that traditionally, it has been difficult to find a physician willing to treat these chronic pain patients. The reason for this is that these patients do not fit into traditional Western medical models of cause and effect, stimulus and response. There may still be pain despite reducing a fracture, and there might still be severe
back pain following an injury with normal MRI results. And there may even be patients will horrible looking spines on MRI who complain of no pain. And patients have the right to complain when there is severe pain. And physicians or government officials or politicians, or DEA agents are not able to feel this type of pain unless they are unfortunate enough to become chronic pain sufferers themselves. And there is no reliable way for the physician to differentiate between those who have real chronic pain and those who fake it in order to gain access to narcotics, except possibly by examining their behavior.
So let's say the doctor refuses to believe that the patient has chronic pain. Two options exist for the patient. Find another physician, perhaps more sympathetic than the first.
But the new doctor may not really understand what is causing the pain either, it's just that he believes the patient when he says it hurts and it doesn't go away. And if you can't find a doctor to prescribe you pain medicine, you may come to believe that it is all in your head, or more likely, attempt to purchase painkillers on the street, because they are out there...
What happens to chronic pain patients that self-medicate? Well, they may just feel better, but more likely they will use too much of the narcotics, and this will result in all types of complications from constipation to physical and psychological dependence, to respiratory depression and death. This group is taking dangerous medications with no medical oversight. And that group of self-medicators is growing larger by the day because physicians are simply not willing to lose their hard earned licenses to help a chronic pain patient in need of relief. At least not when there is a tsunami of law enforcement, government officials and even other doctors waiting outside the office door so that they can free society of the 'offensive' pain medication prescriber. And more and more patients then seek relief on the streets, where dangerous and potent impurities such as Fentanyl may be mixed in to the narcotics causing overdose and death.
The reason this article by Janice Reynolds is so powerful is because she recognizes that the challenge here is not only the over-prescribing of opioids. No, patients overdosing is the result of the real crisis not it's cause. If you don't define a problem properly, you will never solve it. What is the real problem we should seek to resolve? What is the war that needs to be waged if the War on Drugs is not the right war? Simply put, what we have all been missing, but what Janice Reynolds understands, is that it is the War on Chronic Pain that needs to be waged. And how is this war to be waged?
- Better understandings of the mechanisms of chronic pain. What are the patterns and concepts that will support the often contradictory facts that the physician is confronted with? Can we develop simple models of why chronic pain is occurring based on our knowledge of physiology, anatomy, radiology and pharmacology and in the future, molecular medicine? Can clinical research deliver the answers or will basic research or some combination of the two? How can we deal with placebo effects and lack of randomization in our search for answers? Will we ever be able to objectively measure pain as 'outsiders' relative to the pain sufferer? How much of suffering from pain is related to the psychological state, and what is the relationship between the two?
- Once we have some answers, (and they can even come by trial and error or observation and become 'best practices') some understanding of mechanisms that fit with our understanding of neuroscience and medicine, we can try evidence-based therapies. It is clear that narcotics produce some effect in terms of pain processing in the brain, because otherwise they would not be in such great demand by pain sufferers. Can marijuana produce similar benefits without the side effects? The jury is still out on that one, but I suspect the benefits will be limited. Can we find other treatments that will effectively treat chronic pain by decreasing inflammation in the body and enhancing the body's ability to heal itself. I think the field of Regenerative Medicine may hold some crucial answers.
- Once we have some useful solutions that provide real relief, then education becomes the key. Every physician needs to have a working knowledge of how chronic pain works. Who will teach this to medical students and doctors and how much time will be spent on becoming proficient in the understanding of chronic pain?
- There will always be an element of society that is attracted to the psychological effects of medications that alter the central nervous system. These individuals are not the same as chronic pain patients! Hopefully, with better measurements and models of chronic pain these two groups will become differentiated. Right now they both seek the same medications, but for different reasons, and that is fuel that is powering the opioid crisis. It is not only the province of law enforcement or government to distinguish between the two, but hopefully for all our benefits, law enforcement will work together with physicians to identify the individuals that help fuel this crisis.
In my book, When Bad Backs Happen to Good People, I have started to open the discussion of some of the mechanisms of chronic pain so that we will begin to find useful solutions in the near future.
J. Fersel, M.D.
Jordan Fersel, MD, is a board-certified, pain-management fellowship-trained physician who earned a BA in biology from Queens College and an MD degree from Mount Sinai School of Medicine. He has been director of Pain Management Services at Trinitas Medical Center Oncology Unit for several years. Dr. Fersel and his wife, Esty, divide their time between Philadelphia and West Orange, New Jersey.