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Thread: Pain lumped inappropriately

  1. #1

    Pain lumped inappropriately

    Responding to what were supposed to be authoritative findings on chronic pain management guidelines by 12 experts, Dr Chou, head of the American Pain Society and an expert on opiates criticized the notion that "chronic pain" had diagnostic specificity or value or could in fact be lumped and considered as ONE entity. He noted that particularly in the published reports on ablative therapy that trying to treat all causes of chronic pain as one thing was insupportable. He noted that pain is NOT one thing and chronic pain, as a term, has no value in designing and evaluating appropriate therapy. Every time someone tries to standardize guidelines, they come up against the fact that we cannot use words like "disease" to structure treatment. We have to know WHAT disease we are talking about.

    I find it practically unforgiveable at this late date that we still see articles about treating nerve injury pain which do not distinguish the pains. Those with post SCI pain nearly always have ordinary pain and frequently neuropathic pain. If someone takes opiates and the ordinary pains are benefitted, we are inviting error to assume their neuropathic pain necessarily was benefitted. Why not include a table, which indicates degree of relief for ordinary pain, dysesthetic burning, lancinating pain, muscle pain, pins and needles, etc matched against the various therapies. This would be so much better than some article on ablation claiming 60% of those with PAIN were better. What does better mean. Do all the pains improve in synchronous fashion. It makes no sense, and it makes me distrust the investigator that he does not appear to realize these pains differ. Dr. Ron Tasker long ago showed that ordinary noxious pain is different from nerve injury pain. That was about fifty years ago. How long does it take to update the thinking on this topic?

    I was very pleased to read Dr. Chou's remarks. Since most panels are interested in standardization, nearly all studies seem to have gained a consensus, whether or not they actually are regarded by regulatory agencies, who often find legal issues to override medical ones.

    Recently, the governor of one state signed into law NINE new laws designed to prevent deaths from prescription drugs. I worried the result might just be to convince more doctors it wasn't worth prescribing pain meds since who could figure out NINE laws anyway. Do you really think your doctor is happy to give you pain meds when revocation of his license is playing in the back of his mind. The appalling stories we read here about expensive denials of pain meds in the ER may have nothing to do with medicine and everything to do with fear.

    This sounds cynical, but one would like to see data on whether suicides actually decline, or whether alternative methods increase. This is not to not greatly lament the accidental deaths from prescription drugs, but there is always a spillover into the lack of availability of pain drugs for those who actually need them. Unfortunately, we cannot avoid the balancing of these interests. Alcohol is usually a contributor to accidental overdose but we are not banning that.

    It is a debate which will never end, until someone like Hargreaves figures out a better nonaddictive pain medicine. This is unlikely to happen soon since funding for basic pain research is so pathetically unforgiveably cheapskate and borderline nonexistent from the govt. A fortune is spent regulating what we have, when we really ought to just find something that works and is non addictive, since more is spent on pain than ANY OTHER MEDICAL PROBLEM. This would also cut back on the demand for opiates from places like Afghanistan.

    We are bailing out Greece with 150 billion. How about one measly billion to the basic scientists at NIH to study basic pain research. We spend 80 billion in the war on drugs, not including Defense spending, so better to eliminate the need for opiates than to impoverish ourselves regulating it.

    There are a lot of hospitals. EVERY dose of opiate that is given must be logged in an official log by a REGISTERED NURSE. Often, when an opiate is given, ONE designated RN must use her key to unlock the opiate cabinet and SUPERVISE the whole business. Just the cost of this one little aspect of record keeping is mind boggling. If opiates are "radioactive and dangerous" why not spend a dime inventing something better? So far as I know there is only ONE hospital who has a full time nurse whose job is to check in on patients to make sure their pain is being adequately treated (the University of Washington).

    Chou's comments are spoken like someone who knows what he is talking about. A review of his comments can be found at Medscape. You have to register.
    Last edited by dejerine; 05-02-2010 at 07:43 PM.

  2. #2
    As usual, spot on dejerine!

  3. #3
    Amen, Dej, and go Dr. Chou.

    The idea of asking what kind of pain is helped when meds are administered is so common sense that I'm not surprised at all the medical profession doesn't use it.

    This reminded me of my first visit to the Johns Hopkins Pain Clinic. The intake forms there include the crude drawing of the front and back of the body, with the instructions to mark off where you have pain. There's no request at all to tell them what kind of pain it is that affects each area -- as long as they know where you hurt, they're happy.

    Well, I wasn't happy with that -- especially when I discovered that they lumped spasticity in under the heading of pain -- so I spent a long time shading the different areas of the body with patterns and creating a key that indicated what kind of pain each pattern represented (e.g. dots=spasticity, right-facing hash marks=lancinating pain, left-facing hash marks=nociceptive pain). The doctors referred to that chart exactly ... zero times.

    How is it they can ever expect to treat something they can't define and won't take the time to understand?

    Now, how do we get dej hooked up with Dr. Chou? If we could put the two of them in charge, we might start to get something useful to help us coe.
    It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience.

    ~Julius Caesar

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