New Treatments for Cancer Pain. Part 4.
We notice that the elderly that don’t complain as much. They don’t appear to be as frustrated, they don’t appear to be as anxious, don’t appear to be as angry. They have different expectations. Most of the elderly patients we are dealing with now survived World War II, many of them have vivid memories – at least from their parents – of the depression. They think you are supposed to be in pain. That’s just the way life is, so they are not really frustrated by this. They don’t understand that we have the capability to relieve all that. And very often they are afraid. They are afraid of tests, they are afraid of the meaning of the pain. They think you are doing everything you can and they desperately want you to like them. Patients desperately want to be liked by their physician. So they are not going to do anything that makes you think that they think you are not really good. Unfortunately this is true. Sometimes they think that they will be punished for reporting the pain and that happens to a distressing frequency in some extended care facilities.
How many of you recall seeing, about two years ago, a report on 60 Minutes and they ran it twice, about a physician in Maryland who lost his license for prescribing Dilaudid for chronic non-malignant pain patients? Anybody remember seeing that? Right after that aired – and it was a wonderful story – they actually had interviews with two of his patients who had chronic non-malignant pain and one of them, between the time the segment was taped and the time it was aired, killed himself because this physician lost his DEA license. He could no longer prescribe opiates and these patients couldn’t find anybody else who would give them opiates for the chronic non-malignant pain, and one of them committed suicide. It was a very sympathetic portrayal.
If you have a physical exam in your chart, if you have a history that documents why you are doing what you are doing, you have progress notes that measure outcomes and measure pain – simply, how is the pain? “It’s a seven. It’s a five.” And measuring activity levels. “Have you increased your activity level any? Have you done anything else?” All that and an accurate record of the prescriptions you have written, makes you fireproof because you are practicing medicine.
Now, you also tell them, “I’m not going to permit any illegal activity in regard to drugs and in order to do that I’m going to occasionally do urine drug screens.” They agree that you have their permission in regards to medication use and the law to report any illegal acts to the police. So when you get one of these patients in who’s been using a lot of Vicodin and their urine drug screen says there’s nothing in there, you must notify the police that you have a probable seller. Because that’s what you have. Now you have to insist that no other physician writes for controlled substances without your permission and knowledge. That all of their medications get filled by one pharmacy. You don’t care who, but you’ve got to know who. And the pharmacist is going to get a copy of the pain management plan. And trust me, they will let you know if someone calls in on a Saturday night with a refill, or a Thursday afternoon, and they will let you know if there are deviations from that plan.
The concept of co-analgesia is one that we often forget. Tylenol is a pretty mild analgesic. Codeine is even milder. Codeine is less analgesia than Tylenol. But when we combine the two of them together we get a pretty good analgesic. Think how much better it is to add Motrin to morphine. When I get consulted by physicians or others for pain management questions, with severe pain, the thing I do most often is not increase the opiate dose – because the kind of people who are calling me up have heard me talk and are using plenty of opiates generally – what I usually do is add a co-analgesic and maybe change the intervals slightly. Co-analgesics. Now it doesn’t make any difference which NSAID you use. There is tremendous inter-patient variability and we have no idea which one is going to work. So what I suggest you do – I mean, we have to do sequential trials to figure it out, but where do you start? Well, where you start is ask the patient if they have ever had any NSAID’s that worked well for them as analgesics. If you get a positive response, use it. If you don’t, use the one that you are most comfortable with because you know it. If that doesn’t work, use your second choice. You ought to have three. If that doesn’t work, try your third choice. There is no structure activity relationship in the NSAID’s. They are just tremendous inter-patient variability. And intra-patient variability.