Welcome to the current newsletter issue of
Advances in Medicine (AIM)- Take AIM against pain.
Feel free to send me an e-mail with your own thoughts
and experiences. Email: timsams@mypainreliefdoc.com.
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FIRST, DO NO HARM
It is a little known fact of pain management that psychological
and behavioral factors are often the major determinant of the
benefit received from a medical treatment. Pain psychologists
screen patients for orthopedic and abdominal surgeries, spinal
cord stimulators and morphine pumps, even for opioids or epidural
injections. In effect, pain psychologists provide second opinions
for a variety of medical treatments. We are the last line of
defense against unnecessary and likely unhelpful medical
treatments. This requires that pain psychologists have an
intimate knowledge of the medical and psychological criteria of a
given treatment for a given diagnosis.
I interviewed a patient this year (Jackie) who I did not clear
psychologically for a spinal cord stimulator. Jackie's worst
pains were in her low back (muscle strain and spinal stenosis),
and both legs (diabetic neuropathy). She also had diffuse pain
almost everywhere from fibromyalgia. She was a candidate for
stimulator implantation for her leg and back pain. She was
desperate to have the stimulator placed to try to obtain some
pain relief, having fought for several years to get her insurance
company to authorize treatment.
Pain itself is an unpleasant physical and emotional experience
that has the four qualities of sensations, thoughts, feelings,
and behaviors. Any one of these qualities can make pain either
better or worse by opening or closing biochemical pain gates in
the body. Medical treatments will only help the sensation aspect
of pain. They cannot help the other three aspects of pain, which
we call "suffering," and which themselves can dramatically
increase pain.
A patient is not a good candidate for a medical treatment,
especially a highly invasive one, if: The expectations for
treatment benefit are unrealistic, It is unlikely that pain
relief will be achieved, It is unlikely that improved function
will be achieved.
Pain relief and improved function are less likely to be achieved
the more that the suffering aspect of pain is impacting on pain
severity and functional limitations.
There are numerous variables that suggest Jackie is not a good
candidate for additional stimulators. She has been
psychiatrically hospitalized on several occasions, even before
her pain, which reflects poor life coping. She has a history of
alcoholism and drug abuse reflecting the use of chemicals to
manage stress. She rated her pain as always a 9 of 10 severity,
suggesting that she is unaware of the inevitable variations in
pain, and will have difficulty assessing whether treatment causes
changes in pain. She is severely depressed and anxious while
feeling helpless, hopeless, and victimized. She refuses to take
anti-depressants because, as she says, "I'm allergic to all of
them," but, she is taking four anti-anxiety medications. She had
dropped out of several episodes of behavioral pain treatment,
saying, "A shrink can't decrease my pain."
She does not want to return to work, does not want the
responsibility of caring for her child as a single parent (which
she has turfed to her live-in parents), and does not want to
cultivate a romantic relationship. Thus, she is not motivated to
maximize her ability to function, just to hurt less, which she
hopes will allow her to function better.
Previous medical treatments including injections achieved
reported permanent pain decrease. However, she denied any
improved functioning following these treatments and still rates
her pain as 9/10 on average. She spends 23 of 24 hours lying down
while her parents care for her child. Thus, she is grossly de-
conditioned largely due to her depression, which is severely
exacerbating her pain due to muscle weakness. She acknowledges
having an extremely low pain tolerance and being bothered by any
amount of pain. She is taking massive doses of prescription
narcotics, though she denies pain relief from them.
The suffering (thoughts, feelings, behaviors) aspects of Jackie's
pain experience is profoundly, even catastrophically affecting
her pain sensation and function. Though she is likely to report
pain relief from the stimulator trial and eventual implant, she
will probably still rate her pain as 9/10. She will not
demonstrate improved pain with increased functioning. She is at
high risk for a complicated, painful post-implant recovery and to
complain of severe soreness at the site where the battery is
implanted. It is extremely unlikely that she will be more
functional. There is a good chance that she will actually be
worse off with the stimulator, and only a very small chance she
will be better off.
The first rule of medicine is to "do no harm." We owe it to
Jackie and all patients to refuse to provide treatments where the
likely risks outweigh the likely benefits. I am a firm believer
in letting people make decisions about their own bodies, but we
have a legal obligation and a moral obligation down through the
centuries to do no harm. The spinal cord stimulator is not a
springboard for recovery for this patient. She is not cleared at
this time.
The story does not end here. Jackie was highly motivated to have
less pain through the stimulator. We agreed that if she would
complete a course of behavioral treatment over a four-month
period and could demonstrate decreased pain and improved
physical, social, pleasurable, and productive activity, we would
reconsider implanting the spinal cord stimulator. She was
outraged. However, she has begun neuromuscular re-education,
autonomic quieting training, individual behavioral pain
management, pain class, and will be reading my pain manual/book.
She is responsible for achieving specific goals daily, weekly,
and monthly, including increasing activity and exercise.
She has begun taking an anti-depressant and is being weaned off
of some of her anti-anxiety medications. We are tapering her dose
of narcotics as well. I am meeting with her parents to decrease
the extent to which they are enabling her complete dependency on
them. She has put aside her anger toward me and actually seems
encouraged.
I think for the first time she realizes that medical treatments
are not a panacea. She will probably have a stimulator trial in a
few months and we will require a greater-than-normal amount of
pain relief and improved function to proceed with the permanent
implant. But, at that point, she may be able to use the
stimulator as a springboard for even greater improvements in
function. Her motivation to improve her function seems to be
increasing.
This was a very tough case. As always, your comments are welcome.
Good light,
Dr. Tim
My Pain Relief Doc
http://www.mypainreliefdoc.com
Copyright 2006. Dr. Tim Sams and My Pain Relief Doc.
All rights reserved. http://www.mypainreliefdoc.com
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