Undertreated for pain..... | Arthritis Information
Pain Management Failing as Fears of Prescription Drug Abuse Rise
ScienceDaily (Jan. 5, 2010) — Millions of Americans with significant or chronic pain associated with their medical problems are being under-treated as physicians increasingly fail to provide comprehensive pain treatment -- either due to inadequate training, personal biases or fear of prescription drug abuse.
A pharmaceutical expert in pain management in the College of Pharmacy at Oregon State University says the issue is reaching crisis proportions, and in two new professional publications argues that health consumers must be aware of the problem and in many cases become more informed, persistent advocates for the care they need and deserve.
"We have more sophisticated pain management techniques available now than ever before," said Kathryn Hahn, a pharmacist, affiliate faculty member at OSU and chair of the Oregon Pain Management Commission. "But many doctors are not fully informed about all the options available, and also often turn patients away because they're very concerned about the problems with prescription drug abuse.
"Because of this, many people suffer needlessly with pain that could be treated, and almost 80 percent of visits to community pharmacies involve pain issues," Hahn said. "We're in the middle of a storm here, and have to out some way to navigate through it."
http://www.sciencedaily.com/releases/2010/01/100104151929.htm Pain management can be a godsend when utilitzed as necessary.
I have an acquaintance who is rather hysterical when it comes to her medical problems [OA]: a paper cut means a trip to the ER. [Well, not quite, but you get the character profile.] At times she will grossly exaggerate her pain to the rheumatologist, who sees right through her. He offers her NSAIDS and typically she'll go home, try it, and if it doesn't work IMMEDIATELY or if she feels one tiny side effect, the drug is abandoned. Then she'll run to the pain managment doctor who should know by now that she's hysterical. Instead she'll complain nothing works and he brings out the big guns and she's overmedicated.
I realize that pain is relative to each person and that this case is an extreme, but I often question if all doctors really take the time to see through their patients and discern whether the pain med is really warranted. Or are they too fast to issue drugs? Or when's the last time and MD referred the patient to a psychologist?
I'm not saying this is true for all people, but I seriously wonder where the benefit is of giving someone a never ending supply of OxyContin and Ambien.
So that begs the question: are anesthesiologists too quick to step in and supply what the rheumatologist won't?
I only know a few people who go to pain management specialists and more often than not I'm mystified when I hear which drugs were prescribed.
whew I thought YOU were being under treated!!!
I take vicodin for my pain. It works. I have never felt over medicated. Takes the edge off the pain at best. Allows me to feel well enough to get dressed and live my day. I can not imagine not having adequate pain control. I feel bad for those that suffer with no help.Pain is so hard to read. Especially for the "invisible diseases".
I have been lucky in the fact that so many of my issues can be documented through tests. They are visible, so believed. Does that make sense? Plus, my blood pressure and pulse go haywire and I lose weight. I hate to read messages on this board where people are in pain and frustrated, yet the dr. can find anything for the cause. Autoimmune diseases are so tricky.
As you know, cause of my ranting posts recently, I have been having a super hard time lately. I love my pain management dr. He works with my RD and the jaw dr. to work out a good plan. But, while in the waiting room, I'll hear people who hate him. They don't get the meds the want/need, they have regular pill counts, urine tests...and so on. I can't help but look at these people and wonder if there really is something that needs to be medicated, or do they hate him cause he is on to them. It's never the cancer patient or amputee that is sitting there complaining, it is someone without an obvious problem. But, who knows what they are truly suffering from? I mentioned before about my "cast of thousand" drs wanting me to take time off. My pain dr. is the one who always seems to be elected to have this conversation with me. I asked him why do they keep pushing the issue and he laughed. He said go out to his waiting room and ask those who want disability to raise thier hands. He said 90% would most likely. He seriously considers 5%. But those that need it, really need it.
I would hate to have his job. Helping those that need it would be so fullfilling, but how do you sort out everybody? Very few people know that I go see a pain dr, it just doesn't sound right. I have seen security escort patients out cause he refuses to refill a prescription that shouldn't be gone, and I have heard people yell at the poor receptionist cause she won't make an appt for them that day. Ok..change my mind, I would hate to be the receptionsist...bless her heart, she gets it all.
So, if you are in pain, actively seek to get rid of it. But, it might be hard. I hate that it comes down to "proof", but what else really is there to do?
You hit on the very thing that pisses me off about my illnesses. I suffer from migraines, fibro, and seroNEG RA. I can be, and sometimes am, in so much pain that I am vomiting.... but I've got no "proof". I am thankful when my joints swell because that is something I can show my doctor. I know how messed up that sounds, and of course I'd rather not have RA at all, but if Ive got to have pain..... I want to have some physical indicator.
My RD is great and has never once doubted my pain. But I am also VERY careful about being completely upfront with him, and any other doctor I see, about the amount of vicodin I take. I make sure to NEVER exceed the amount prescribed. I do whatever I can to avoid any appearance of drug seeking behavior. I do all this because I have chronic pain and no "proof". I HATE it!! I don't think there is anyway to give words to how much I hate it.
My father in law is a surgeon. Very old school. Still thinks fibro is a psychiatric condition. You have no idea how I wish I had some positive test to show him so that I could stop his exhausting cross examination of my medical care. And you know what? I never asked to have these issues!! I do not like my 'chronically ill girl' identity!! But if I have to have it, would a little proof be so much to ask for??!!!! Leila,
I'm not saying that ALL psychiatric conditions always go hand in hand with fibromyalgia, but the studies show there is a remarkable correlation between the two.
So if your father-in-law reads the journals, this could be the basis of his opinion.
In over 1 out of 3 cases the FM patient has MDD [Major Depressive Disorder]. Of course, one could argue which came first, chicken or the egg......psychiatric problem or fibromyalgia. And still in other cases people can not accept that they have a psychiatric condition and find it easier to complain of physical symptoms.
There also seems to be a preponderance for overdiagnosis of FM.
I think the key here is to keep an open mind because the jury's still out. My hunch is that in the not-too-distant future researchers will discover that varoius psychiatric disorders are warning signs of impending rheumatological disorders. I think this is one more example of how little we know about the human body and how it functions.
[QUOTE=leila]You hit on the very thing that pisses me off about my illnesses. I suffer from migraines, fibro, and seroNEG RA. I can be, and sometimes am, in so much pain that I am vomiting.... but I've got no "proof". I am thankful when my joints swell because that is something I can show my doctor. I know how messed up that sounds, and of course I'd rather not have RA at all, but if Ive got to have pain..... I want to have some physical indicator.
My RD is great and has never once doubted my pain. But I am also VERY careful about being completely upfront with him, and any other doctor I see, about the amount of vicodin I take. I make sure to NEVER exceed the amount prescribed. I do whatever I can to avoid any appearance of drug seeking behavior. I do all this because I have chronic pain and no "proof". I HATE it!! I don't think there is anyway to give words to how much I hate it.
My father in law is a surgeon. Very old school. Still thinks fibro is a psychiatric condition. You have no idea how I wish I had some positive test to show him so that I could stop his exhausting cross examination of my medical care. And you know what? I never asked to have these issues!! I do not like my 'chronically ill girl' identity!! But if I have to have it, would a little proof be so much to ask for??!!!! [/QUOTE/]
I too have an RD who actively treats chronic pain and I feel very lucky!
Neither my PCP or my RD have ever downplayed my pain or thought that I had any kind of "drug seeking behavior."
I did have a run in last year with my oral surgeon who thought it was odd that I was prescribed Vicodin. I asked him if he had bothered to read my chart, because if he had it would have been pretty obvious why I used Vicodin. He admitted he had only glanced at it and when he went back, he apologized after reading that I suffered from AVN....
Sam...
The first article you sighted was nearly 11 years old. (Psychosomatics Feb 1999)
The second article you sighted was undated, but the most recent sighted reference was May 2001. I'm sure you agree that much can be learned about a medical condition in 10 or 11 years.
The third article you sighted was written in 2002. It did not dispute the existence of fibromyalgia as a legitimate disease, but instead concluded that patients need a comprehensive workup for other rheumatological conditions before a diagnosis of FM is made.
No one argues that depression and anxiety are often comorbidities of chronic pain. This makes sense from a biochemical stand point. But, the idea that FM is a psychiatric condition is not only outdated and dismissive, it is now known to be patently false.
http://www.webmd.com/fibromyalgia/news/20081103/fibromyalgia-a-real-disease-study-shows Nov. 3, 2008 -- A new brain scan study concludes that fibromyalgia is related to abnormalities of blood flow in the brain. There seemed to be no relationship between these abnormalities and presence of depression or anxiety. "We found that these functional abnormalities were independent of anxiety and depression status," Guedj says in a news release.
When I was first diagnosed, I did a google search entitled "Is Fibromyalgia a Real Disease?" Try it. I could not find a recent article that disputed its existence as a legitimate physiological condition.
http://www.fmnetnews.com/basics-news-archives-respond.php The New York Times ran an article (Jan 14th 2008) questioning the existence of FM. Here are rebuttals from multiple Rheumatologists and professors of medicine.
So yes, if you are reading decade old medical journals and forming your opinions based on such... then you are likely to believe that FM is a psychiatric condition. However, if you read old enough journals, you are likely to think that migraines, PMS, IBS, seizures, and Torsion Distrophy.. (to name a few).. are also "all in your head".
Lets not make life harder for each other than it has to be...ok? Yeah... My links aren't working... figures! The first article I sighted is short so I thought I'd just include it here, for your reading pleasure..
Fibromyalgia a ‘Real Disease,’ Study Shows
Researchers Say People With Fibromyalgia Have Abnormalities of Blood Flow in the Brain
By Caroline Wilbert
WebMD Health News Reviewed by Louise Chang, MD
Nov. 3, 2008 -- A new brain scan study concludes that fibromyalgia is related to abnormalities of blood flow in the brain.
"Fibromyalgia may be related to a global dysfunction of cerebral pain-processing," study author Eric Guedj, MD, of Centre Hospitalo-Universitaire de la Timone, in Marseille, France, says in a news release. "This study demonstrates that these patients exhibit modifications of brain perfusion not found in healthy subjects and reinforces the idea that fibromyalgia is a 'real disease/disorder.'"
Fibromyalgia is a chronic disorder characterized by widespread muscle pain and fatigue. It affects 2%-4% of people, mostly women. It has been called the "invisible syndrome" because it can't be diagnosed based on a lab test or X-ray.
For this study, researchers took brain scans on 20 women with fibromyalgia and 10 women without the condition. Participants also answered questions to assess measures of pain, disability, anxiety, and depression.
The brain imaging technique, called single photon emission computed tomography (SPECT), is able to detect functional abnormalities in the brain.
Past imaging studies of patients with fibromyalgia had shown abnormalities in cerebral blood flow, also called brain perfusion. In some areas of the brain, blood flow was below normal, and in some areas, it was above normal. In this study, by using whole-brain scans on the participants, researchers were able to analyze how perfusion in each area of the brain related to measures of pain, disability, anxiety, and depression.
Researchers confirmed that patients with fibromyalgia exhibited brain perfusion abnormalities in comparison to the healthy participants. These abnormalities corresponded with the severity of the disease. An increase in blood flow was found in areas of the brain involved in sensing pain and a decrease was found within an area thought to be involved in emotional responses to pain.
There seemed to be no relationship between these abnormalities and presence of depression or anxiety. "We found that these functional abnormalities were independent of anxiety and depression status," Guedj says in a news release.
also....
However, in 1987, the American Medical Association (AMA) acknowledged fibromyalgia as a true illness and a potential cause of disability. Many well-respected organizations, such as the AMA, the National Institutes of Health (NIH), and the World Health Organization (WHO), have accepted fibromyalgia as a legitimate clinical entity.1 Fibromyalgia is now recognized as one of many central pain-related syndromes that are common in the general population. Research advances have lead to the conclusion that disturbances within the central nervous system (CNS) known as central sensitization represent the most likely source.2 Here is the link...
http://emedicine.medscape.com/article/312778-overview No guarantees of it working tho..
and... Fibromyalgia was once often dismissed by physicians and the public as a psychological disorder or "waste basket" diagnosis because of an absence of objective findings on physical examination and usual laboratory and imaging evaluations. Many physicians still do not accept fibromyalgia as a discrete illness. However, recent basic and clinical investigation has rapidly clarified the neurophysiologic bases for fibromyalgia and has led to its new classification as a central sensitivity syndrome (CSS).1 Indeed, fibromyalgia can now be considered a neurosensory disorder characterized, in part, by abnormalities in CNS pain processing.2 Increased understanding of the biological bases underlying fibromyalgia is rapidly leading to a new era of specific pharmacologic therapy for the condition.
Written by this guy...
eMedicine Specialties > Rheumatology > Soft Tissue and Regional Rheumatic Disease
Fibromyalgia
Author: John Buckner Winfield, MD, Herman and Louise Smith Distinguished Professor of Medicine in Arthritis Emeritus, Department of Medicine, Senior Member, Neurosensory Disorders Center, University of North Carolina at Chapel Hill; Consulting Rheumatologist, Appalachian Regional Rheumatology
Contributor Information and Disclosures
Updated: Jul 14, 2009 Here's the link (cross your fingers)
http://emedicine.medscape.com/article/329838-overview
Hey Leila, defensive much?
Leila wrote:
"Sam... The first article you sighted was nearly 11 years old. (Psychosomatics Feb 1999). The second article you sighted was undated, but the most recent sighted reference was May 2001. I'm sure you agree that much can be learned about a medical condition in 10 or 11 years. The third article you sighted was written in 2002. It did not dispute the existence of fibromyalgia as a legitimate disease, but instead concluded that patients need a comprehensive workup for other rheumatological conditions before a diagnosis of FM is made."
Leila,
You missed the point. Your father-in-law may have been impressed by those earlier articles, which may have shaped his negative opinion of more recent articles.
In fact, here's an article below, written in 2006 that fairly well supports earlier studies. "CONCLUSIONS: There is substantial lifetime psychiatric comorbidity in individuals with fibromyalgia. These results have important clinical and theoretical implications, including the possibility that fibromyalgia might share underlying pathophysiologic links with some psychiatric disorders."
Psychiatry gets a bad rap all the time. Three's a stigma where there shouldn't be. People need to remember that a good number of psychiatric disorders are the result of neurochemistry gone awry. If brain chemistry goes haywire, it can affect numerous physical functions......including arthritis.
Here's another article that attests to comorbid disorders.
Don't discount old studies because oftentimes the subject is so well researched that there's no need to replicate studies in more recent years.
Sam12342010-01-09 14:36:15Sam, if I did not understand the intent of your post..I apologize. I was not discounting old studies, just pointing out that newer studies are sometimes more accurate. Especially in the case of FM, which has not been particularly well researched until more recently. My brother in law is bipolar, so we are all very well versed in what can happen when neurochemistry goes awry.
It is also fairly well known that ANY chronic pain condition carries a substantial lifetime risk of psychiatric comorbidity Beginning with the influential article of Romano and Turner (38), the association between chronic pain and depression has generated more research and theoretical interest than any other area of the chronic pain/psychopathology literature. Much of this interest can be attributed to the frequency with which chronic pain patients suffer from depression (39). A number of the studies (19, 24) reviewed above identified extremely high rates of MDD in chronic pain patients, with current and lifetime rates of this disorder of about 45% and 65%, respectively, in the CLBP population and both current and lifetime rates of about 80% in the chronic upper extremity pain population. However, most studies report prevalences in the moderately high range. For example, Banks and Kerns (37) reviewed 14 studies that used DSM criteria for diagnosing depression in chronic pain patients and found that 9 of these studies reported current prevalence of MDD to be between 30% and 54%. In contrast, recent estimates of current and lifetime major depression for the entire US population are 5% and 17%, respectively (40). ...from this article....Chronic Pain and Psychopathology: Research Findings and Theoretical Considerations
Jeffrey Dersh, PhD, Peter B. Polatin, MD and Robert J. Gatchel, PhD http://www.psychosomaticmedicine.org/cgi/content/full/64/5/773
But that doesn't mean that chronic pain is a psychiatric disorder...
unless I am not understanding your definition of a psychiatric disorder.
Also, from this article From Medscape Rheumatology > Expert Interview
Diagnosing and Treating Fibromyalgia in a Patient With Rheumatoid Arthritis. An Expert Interview With Daniel J. Clauw, MD Medscape:
There is some evidence that fibromyalgia is comorbid with depression and is therefore a clinical symptom of depression.
Dr. Clauw: The simple answer to that is "no," because, even in a tertiary care setting where people with fibromyalgia do have a high rate of comorbid depression, depression is seen in about 50% of individuals. This means that 50% of people with fibromyalgia do not have depression. In a primary care setting, only 20% or 25% of people with fibromyalgia will have comorbid depression.
So at one level, labeling fibromyalgia as a subcategory of depression would be the same as labeling diabetes as a subcategory of depression because 25% of people with diabetes are depressed. Most chronic medical illnesses will lead to a higher rate of depression than in the general population. In terms of psychological impact, fibromyalgia is really not different from chronic low back pain or a variety of other chronic pain states. A significant percentage of people with any kind of chronic pain or illness will be depressed, and that does not mean that the depression and the chronic illness are the same disease.
In mentioning my father in law's feeling that FM was a psychiatric disorder, I was not attempting to dismiss a possible "underlying pathophysiologic link" or chemical similarity to any other illness. But his "pull yourself up by your boot straps" attitude to the mere mention of FM. No amount of pulling on any footwear will eliminate chronic pain. If it did, I'd be pain free. What I was expressing was frustration with my current lot in life. You and I can disagree on FM until the cows come home... it won't change a thing. The irony is that I would have completely agreed with you 8 months ago. But as Waddie says "walk a mile".
leila2010-01-09 16:25:56While I don't have fibromyalgia, I find these articles very informative....
And, in my opinion, the vast majority of people dealing with chronic pain are not "drug abusers" and want nothing more than to be able to function.
With the injuries I have, I don't ever expect to be pain free...but I need to be able to live as normal a life as possible. The pain meds I take help me accomplish that goal. I'm blessed to have a medical team that understands that and is proactive concerning chronic pain. Apparently I'm not alone:
A national panel of pain management experts representing the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) has published the first comprehensive, evidence-based clinical practice guideline to assist clinicians in prescribing potent opioid pain medications for patients with chronic non-cancer pain.
The long-awaited guideline appears in the current issue of The Journal of Pain.
To create this guideline, researchers in the Oregon Evidence-based Practice Center (EPC) at Oregon Health & Science University collaborated with the APS and AAPM for two years, reviewing more than 8,000 published abstracts and nonpublished studies to assess clinical evidence on which the new recommendations are based.
"This guideline was a true multidisciplinary effort that sought to address in a balanced manner the many challenging issues that clinicians face with regard to when and how to prescribe opioids for chronic noncancer pain," said Roger Chou, M.D., principal investigator; director of the American Pain Society Clinical Practice Guidelines Program; scientific director of the Oregon Evidence-Based Practice Center at OHSU; and associate professor of medical informatics and clinical epidemiology, and medicine (general internal medicine and geriatrics) in the OHSU School of Medicine.
"A key part of this process was performing a comprehensive literature review to inform the recommendations — though an important take-home message is that even though the recommendations represent the best judgment of the panel based on the currently available literature, there is still a lot of research that needs to be done."
The expert panel concluded that opioid pain medications are safe and effective for carefully selected, well-monitored patients with chronic non-cancer pain.
Leila wrote: "
But his "pull yourself up by your boot straps" attitude to the mere mention of FM. No amount of pulling on any footwear will eliminate chronic pain. If it did, I'd be pain free. What I was expressing was frustration with my current lot in life. You and I can disagree on FM until the cows come home... it won't change a thing. The irony is that I would have completely agreed with you 8 months ago."
Leila, I fully agree that the "bootstrap" method is ineffective - has been proven time and time again that pain relief from the get-go makes for a much better outcome. [I was just trying to suggest where your father-in-law was getting his information.]
I don't understand how you can think I'm disagreeing with you. All I'm saying is that there IS a proven correlation between abnormal neurochemistry and FM. It doesn't show up in all cases, but it exists in numbers not to be sneezed at. That doesn't mean FM is psychosomatic; rather it means that there is some underlying component that is yet to be understood. If doctors construe the research to mean that people with FMS are "nutty" then they're not comprehending the study outcomes and frankly I'd get a new doctor.
this is an excellent thread... albeit without the post preceding mine I believe that most of the people whose posts I read regularly on this board desperately need sufficient pain relief. They are NEVER going to get addicted because it takes a certain mental state to become addicted to drugs. If you have that state, you're going to get hooked on whatever you can find. Someone with a physical problem alone isn't. I bet most of you are like me, taking the minimum of narcotics necessary to make my life livable and so I can sleep at night. I just recently, very reluctantly, started taking HALF the dosage of tramadol I'm allowed, and until things get worse that's where I'll stay. I agree that it must be terribly difficult for docs to tell who is in real pain and who likes the buzz. I can't imagine how they know. In addition, some people feel pain more than others, so you've gotta figure that out too. It's a shame when someone like Roccyd has to lose weight and have her system go wacky in reaction to her agony to "prove" her pain levels. Tough world we live in!Leila, I am in the same diagnoses boat with you. I have yet to achieve pain relief through RA meds. I am set to start Remicade this Friday and My RA doctor believes I should see pain management to get OFF vicodin. I don't know how she could mention that when she knows and see through finger swelling that I am in pain. She told me that vicodin is not a help in treatment for Fibro. Well then what is??I take Lyrica and it does help some, I found that out after being off of it for a week. I also stayed in bed that week. I don't think we as sufferers are asking too much from our doctors. We just ant some kind of relief and be able to lead a normal or semi normal life!
Copyright ArthritisInsight.com