Posts Tagged ‘chronic pain’

Perfect people don’t come to see me.

May 1, 2019

When it comes to the way patients flow,
You could call this gig a bit slow.
But the patients expressed
They’ve been pretty impressed
At the warmth that I can show.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. I have now returned to southern Alaska. Any identifiable patient information has been used with permission.

I currently deal with low patient flow on a daily basis. Yesterday I had, for the second time, 5 patients in one day; all the other days have gone more slowly. Yet with 5 patients, each scheduled for ½ hour appointments, I kept busy. My electronic inbox never gets to empty. I review lab work and incoming consultation results. In fact, my in box would keep me busy for about 2 hours a day whether or not I saw patients. Thus the electronic version of paperwork flows so fast that it has acquired a life of its own.
Still I have a good amount of time to spend with each patient. I impressed each one so far with my patience. I nod, I listen, I take notes. I get to ask the patient their agenda. The vast majority have been over the age of 70; the youngest so far this week was 48.
But I interrupted one patient. Within 2 minutes, I knew my trouble following his story came from his shifting focus. The numbers in his narrative didn’t add up. After a while I asked if he were having trouble focusing, which he was. Eventually, that one piece of information, more than any data from the telling, gave me the diagnosis.
One patient, who gave me permission to write this, has ankylosing spondylitis, a disease I myself have struggled with since 1967 (or maybe 1963). The best I could do during that visit came down to running a chronic pain support group with two people. We turned out to have a lot in common.
Addicts lie. This truth comes so consistently that, when I find a liar, I look for an addiction. However fun and charming the addict, their words cannot be trusted, especially when it comes to what drugs they use. I have not yet found a way to figure out when an addict stops lying.
But I listen to the addicts and alcoholics as patiently as I listen to the overeaters and the smokers. Perfect people do not come to see me. Everyone who brings illness through the front door comes with a back story of drama and irony, and I have the time here to dig for the patient’s agenda.
The patient’s agenda always wins. Asking what they want in 5 or 10 years uncovers that agenda better than anything else, but does not do so perfectly. Some people don’t know what they want. But asking what they want makes them think.


Coming back from New Year’s Day

January 16, 2016

When it comes to the question of pot

And all the supporters it’s got

It just doesn’t makes sense

Because now evidence

Shows that good for depression it’s not

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I’ve listened to Audio Digest Family practice for 37 years. In the beginning, my aging Karmann Ghia had no place for the tape cassettes. I wore out a tape machine about every 7 years.  Last century I upgraded my vehicles and started listening over the car stereo system.  Now that cars don’t have tape cassette decks, I get the programs on CD.

Yesterday we drove east through the flat Colorado wheat country after spending the holiday with family and friends, listening to an educational CD about medical marijuana on the car stereo.

The lecturer talked slowly, leading me to wonder about his firsthand experience with the drug.

Good evidence supports the use of medical marijuana for AIDS wasting syndrome (hardly ever seen anymore) and the nausea from cancer chemotherapy. After that the quality of research falls off with small studies and poor design.

I know a doc from Colorado who supports use of medical marijuana, and points out that the sativa variety has more THC, the stuff that gets people high, whereas indica plants have more cannabidiol. He asserts that the cannabidiol has the medicinal properties.

Even the pro-pot lecturer said that all the commercial products come from hybrids.

I put marijuana’s long tenure as an herbal remedy at the same level as Teddy Roosevelt’s touting the unique properties of champagne for dysentery and brandy for everything else. Alcohol turns out to be alcohol and while it may have a number of physiologic properties, it comes in last place as a pharmacologic agent because it doesn’t make anything better.

Marijuana does not relieve anxiety; quite the contrary, it brings paranoia. Nor does it relieve pain though it interferes with the ability to reason through questions about the 10-point pain scale.  It predictably drives down the level of testosterone for both genders which leads to terrible sexual dysfunction.  Eventually, it makes people depressed.  It might help some sleep, but they don’t rest.

Yet I would agree that the FDA needs to take it off Schedule 1 so that we can start doing decent research on it.   The plant makes hundreds of compounds that can stimulate receptors throughout our bodies, and its potential remains basically untapped.

I ask everyone past the age of puberty about use of tobacco, alcohol, marijuana, and other drugs. While most people at my current assignment avoid excesses, those who don’t account for a disproportionate share of the ones who need medical help.  If someone uses marijuana, I ask how much, and whether they’re using legal stuff from across the border or the illegal weed purchased locally.  I hope that the Colorado product has fewer adulterants, but it remains largely unregulated.

Today I attended a patient with chronic pain (and a number of other problems); two weeks ago we decided gradually decreasing the morphine dose would be a good first step towards returning functionality. You could see the improvement from across the room, and we talked about the increasing exercise tolerance.  I let the patient decide on the pace of treatment, and two weeks from now we will look for more progress after another dosage reduction.

As always, I heavily recommended exercise.

Two cups of coffee after a bird strike.

September 2, 2015

A bird sure made our plane late

We missed by a hair at the gate

So a bit of caffeine

Kept my wit keen

With a steady patient flow rate.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

The smallest bird striking the largest commercial aircraft in the US in the 21st century demands an airframe inspection.  The regional jet coming into Sioux City ruined the day of a dove.  And so we sat in the departure lounge for a couple of hours till the inspection and the inevitable paperwork.

In medicine, the documentation takes as long as the visit, and I would imagine in aviation it takes longer.  I napped and I read.

Late to leave, late to arrive, we got to Gate H1 in Chicago O’Hare just after the flight closed.  The gate agent took care of the rebooking cheerfully and professionally.  He gave us meal vouchers and better seats.  We strolled the airport for a while, I got a torta and guacamole.  We settled down in the seats designed for discomfort.  I napped and I read some more.  We took off on time and got into Pittsburgh just past midnight.

I had slept much of the day at that point.  Connie, the GPS, took us on slow back roads that would enhance a leisurely Sunday afternoon, but doubled the drive time.  We wasted no time at check in but didn’t roll into bed till 2:00AM.

I had not one but two cups of coffee with breakfast.

It doesn’t sound like much but, outside of chocolate, my body doesn’t see much caffeine.  Thus a little goes a long ways.

I nearly fell asleep before the first patient arrived at 9:30.  After that a steady, reasonable pace kept me awake and engaged and despite my initial dread I found myself grinning in the afternoon.  The PA arrived at 2:00, and the reasonable pace continued.  We took care of 48 patients in the 12 hours.  I got to speak Spanish with 2 (though both spoke English well).

This late in the summer, poison ivy continues to bring misery to multiple patients per day.

Sometimes patients with chronic pain ask for opiates, drugs in the same class as morphine.  But as time has gone on we’ve found that while such medications can ease pain in the short-term, in the long run they fail to relieve pain and they ruin functionality.  Frequently the patient will say in one breath that they need more of a drug that doesn’t work.

I wrote a prescription for a 5 day supply of hydrocodone for a person with a broken bone.  I hadn’t needed my DEA number for more than six weeks.

I give a lot of warmth and understanding to the people who have chronic pain at the same time I explain why opiates are a bad idea.  I print off a copy of my post,  I get mixed reactions.  Those serious about pain management read it carefully, those serious about just getting the drugs pitch a fit and stomp out.  And I can’t predict who will do what before hand.

I left the clinic at 8:37, ready for bed.

If you use caffeine rarely, it will serve you as an ally.  If you use it habitually you will be its slave.

The scientific method applied to a long, failing med list

May 14, 2015

Pills and skills: you need a tool set to deal with chronic pain. (Caution: longer than average.)

December 9, 2012

This post is far from laconic

On a subject that’s close to demonic

I don’t think it’s wrong

To write twice as long

On pain, not acute, that is chronic.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

A lot of people deal with a lot of pain in this world.  I’m one of them.

Acute pain, short term in duration and a useful signal to avoid destructive situations, distinguishes itself from chronic not only in terms of duration but in neurophysiology.

My back started to hurt at age 13; my pediatrician initially attributed the problem to growing pains.  Worsening symptoms brought me to the orthopedist at age 17; he proposed surgery and I declined.  By the time I came up for my draft physical during the height of the Viet Nam war, I had a solid 7 year history of back problems well documented.  But the x-ray of my low back gets more credit for keeping me out of a stupid war and saving my life than the pain.

Normal people have five vertebrae between the last rib and the top of the pelvis.  I have four; what should be the bottommost one, the fifth, is fixed to the pelvis on one side but not the other, giving me a mechanically unsound low back. 

So I survived when 50,000 of my generation did not, and my back hasn’t stop hurting.

By the time I hit age 30 I had seen seven different doctors; in their aggregate they convinced me that the pain was in my head.  In so doing, they taught me the most important part of learning to live with the pain.  In a shared triumph of therapeutic decision making, they hadn’t started me on narcotics.

In fact I owe my life to a disease called ankylosing spondylitis, which hits the spine in much the same way that its cousin, rheumatoid arthritis, hits the joints of the arms, hands, legs, and feet.

In the intervening years I had a disc go bad.  One of my low back vertebrae has slid forward on the one below up (spondylosis and spondylolisthesis), and I have developed a worrisome curvature (scoliosis) in the same region.  All in all, I have five bad diagnoses between my ribs and my pelvis.  I’ve only met three people who have worse backs than mine.

When I finally got the right diagnosis of my main back problem, I got a prescription for indomethacin, a very powerful anti-inflammatory drug.  I took it for a decade and I paid for pain relief with loss of kidney function.

I have learned a great deal about chronic pain management on a personal basis.  As with most other problems in medicine, successful management includes both pharmacologic and non-pharmacologic approaches (pills and skills).

We currently measure pain on a ten-point scale; zero being no pain at all and 10 being the worst pain of a person’s life.  When thinking about my pain, I think about the hours after abdominal surgery when I refused narcotic pain relief; it hurt about as bad as when my disc broke open and pushed against the nerve that goes to my shin muscles. 

Life, just the ordinary course of living, includes pain, on the ten-point scale, up to level 4.  At level 6, I start to withdraw socially, and at level 8 I cannot acquire new information or learn. 

As the years went by, I put together a skill set, much like a set of tools, to deal with the pain.  None of the tools would take away all the pain, but each could take away at least a half point.  I recommend my chronic pain patients put together their own tool kit to learn to live with pain.

Indomethacin helped me by at least 3 points; its close relative, naproxen (the active ingredient in Alleve) helped by 2 points but also hurt my kidneys, and now I’m permanently off the entire class of drugs.

Acetaminophen (Tylenol) takes two points off my pain and deserves a Personal Favorite Drug designation.

A 6 level of pain turns into a 4 with a good night’s sleep and into an 8 after a night with poor sleep, and everyone knows it; much of the time and energy I put into pain management goes into sleep management. 

Skelaxin, a muscle relaxant, takes two points off pain caused by spasm.

Enbrel, a drug that costs $1500 a month, takes 4 or 5 points off my pain because it quells the root cause of my ankylosing spondylitis pain, inflammation.

Acupuncture can take two points off.

Massage or a long hot shower is each good for a point.

I can lose between a half point and a point of my pain by socializing, just getting out and talking with other people.

A good, long aerobic work-out can drop a point or two.

A person becomes completely insensitive to pain during orgasm; and relatively insensitive to pain during foreplay and afterglow; how much the activity reduces pain and how long the reduction lasts varies from person to person. 

Good footwear, including shoes, orthotics, and socks, can take off a half point each if I have been ignoring their importance.

Capsaicin cream helps me more in the winter months than in the summer months.  The active ingredient in jalapenos interferes with the dorsal root ganglion’s ability to transmit the signals of chronic pain.  I have no problem slathering it on whenever I need it.  However, most people need to start with a small area, the size of a quarter or half-dollar, apply it three times a day, and not enlarge the area for three days.  And everyone needs to wash their hands with soap and water twice after applying it.

Fish oil capsules, from 2 to 6 grams a day, can reduce inflammatory pain by up to a point (I get about half a point) if used conscientiously for six weeks, but fish oil that sat too long on the shelf (more than six months) can make things worse.

Transcutaneous electrical nerve stimulator (TENS) units bring me about a point of pain relief, but only during certain parts of the flare cycle; they are much more effective for the pain that follows shingles.

I haven’t mentioned the anti-depressants like Cymbalta, trazodone, or nortryptylline.  Good agents all, a doctor in a call rotation can’t take them regularly because of sleepiness.

Study after study has shown oral narcotics capable of reducing chronic pain by 2.7 points, placebo by 2.1 points, and lowly Tylenol by 2.4.

A rheumatologic Skype call

November 4, 2010

Don’t go off on the wrong tack

Perhaps I have a knack

     It might sound inane

     But I’m dealing with pain

That comes from a very bad back.

Last night I did a long medical Skype call to another state more because of my personal experience with rheumatologic problems than my education as a physician.

Diagnosed with growing pains in the back at age twelve, things escalated when I was seventeen.  Over fourteen years seven doctors said the problem had no physical basis; I believed them.  After I started med school, I couldn’t make sense, either, of pain sometimes right, sometimes left and sometimes sharp and sometimes dull. 

In the process, I learned to live with it.

Things worsened in the aftermath of a marathon I ran in residency.  Morning stiffness lasted into the afternoon; breathing hurt.  My colleague, friend and mentor diagnosed ankylosing spondylitis, a problem like rheumatoid arthritis but affecting the spine rather than the extremities.

The previous doctors who missed the diagnosis had done me a great service; the limited treatment options at the time carried such toxicities that the manufacturers have since withdrawn them from the market.   By learning to live with the pain, I learned what my patients go through.  By 1990, I had acquired several tools, each of which would bring down the pain by a half or whole point.

By now I have tried most of the non-steroidal anti-inflammatory drugs (cousins of ibuprofen and Alleve) on the market.  Indomethacin worked well till my stomach rebelled; naproxen did OK but Vioxx did wonders. They damaged my kidneys.  A short course of prednisone worked too well; it put me into a near-manic state. 

On December 2, 2000 I had my first dose of Enbrel and thirty-three years of pain fell away abruptly.  All my fibromyalgia points melted as my body temp went from 94.8 to 98.4.  It took me six months but I learned to live without the pain.  The VA pays for this fabulously expensive drug.

I now live with the residual back pain from heavy wear of sixty years and a bad disc.  If I have to stop my injections the problem returns and I rely on the skills I’ve developed.

During the phone call last night, I detailed some of my techniques, to be used until a rheumatologist could start definitive treatment for a young patient:

Sleep management:  I write a lot about sleep in this blog because good health demands good sleep.  In rheumatoid arthritis, quality of sleep the night before predicts pain the next day better than pain the day before predicts sleep the next night.

Acetaminophen:  Lowly Tylenol relieves pain a point or two with the best safety record.

Massage:  Imagine the difficulty of running a placebo controlled trial with massage; everyone knows a massage feels good.

Heat:  Especially in rheumatic diseases, heat helps.  Moist heat beats dry heat.  Put a massage together with heat and you get a whirlpool.

Acupuncture:  This modality did the best of anything short of Enbrel; it brought my body temp up to 97.2.

Capsaicin cream:  Available over the counter, the active ingredient found in jalapenos interferes with the ability to transmit chronic pain. 

Socializing and other distractions:  When I wanted to get into bed and hurt, I really needed to be out and around people.

Fish oil capsules:  Must be taken six continuous weeks before they become effective.

Exercise:  Swimming helped a lot.

When I finished the conversation, I knew I carried credibility because I spoke from personal experience.