Editor’s Note: Recently Dr. Richard Radnovich wrote a piece suggesting to pain patients ways to improve their interactions with their doctors. It caused some lively response. One of our contributors, a pain patient, asked if he could write a counter-point, which we thought was a great idea.
Dr. Richard Radnovich D.O. is a pain warrior, a pain management hero. He’s one of the compassionate and ethical physicians who cares for his patients with pain. I imagine the good doctor has an understanding that chronic pain is in itself, a disease of the human nervous system, and I applaud his practice.
In a recent article here in the National Pain Report, Dr. Radnovich lists 10 things a patient should never say to his or her doctor about chronic pain. While some of Dr. Radnovich’s observations are valid, as a person who’s been treated for chronic pain since the mid-1980s, I have to disagree with a few of his points.
First, I must agree with the good doctor – most physicians would rather undergo root canal than treat a patient presenting with chronic pain. There are two reasons for this.
First, medical school training in pain in the US is conspicuous by its absence. Most veterinarians get better training in treating pain than medical doctors. Many medical doctors do not believe in chronic pain as a disease of the nervous system, but as a symptom that can be ignored. They don’t feel comfortable in treating pain. Secondly, there is a chilling effect on medical practitioners these days that inhibits their choice to use pain medication to treat pain - many believe they will put their hard-earned license in jeopardy for writing too many Rx for controlled substances. We ran an article a few months ago in NPR about a study examining doctor’s attitudes about treating pain. The study was performed by the notoriously anti-opioid organization PROP, and the conclusions were shocking. In some cases, over 50% of physicians felt ill-equipped in dealing with pain.
Considering we have 100-million people in pain in this country, and 3,500 pain specialists to treat them, primary care docs pick up the slack.
There was a documented 4-fold increase in opioid-related deaths during the period 1999-2008 according to the CDC. Although there is much controversy around these statistics, the message is clear – doctors are not properly treating people in pain with opioids. The CDC is now reporting that 1/3 of those deaths is related to the use of methadone, a highly effective pain medication with an extraordinarily long half-life. Untrained doctors, encouraged to use methadone as the ideal pain medication during those days, were unintentionally overdosing their patients with methadone because the medication builds up over the first week, slowly, to levels that can harm opioid naïve patients.
Well, today those mortality rates are down. The word is slowly getting out that programs like prescription monitoring systems, and better tamperproof extended relief pill formulations have cut that mortality rate by 25%.
Yet, there is still a pain crisis in America. Too many people are forced by their practitioners to live in pain. “Suck it up” one PCP told me. I won’t report my reply here.
Medical research has demonstrated the need to effectively treat chronic pain because when left untreated, chronic pain causes changes in the central nervous system through “neuroplasticity” that cause “short circuits” in the spinal cord causing pain signals to be sent to the brain without the presence of a pain stimulus. Modern techniques like fMRI demonstrate that untreated chronic pain cause changes in the brain stem and mid-brain, inhibiting ‘down-level’ processing of pain - one of the body’s natural defenses against pain. Other changes amplify pain causing hyperalgesia in people with chronic pain. We are still learning about the detriment of untreated chronic pain.
So, when a patient presents to a doctor with chronic pain symptoms, diagnosis and treatment is essential. However, we’re missing an entire group of patients when we follow the thought process of Dr. Radnovich.
I’ve been treated for chronic pain for over 30 years. I’ve undergone just about every treatment available to me appropriate with my medical condition. I know what works and what doesn’t. I know how well opioid analgesics help me, and I also understand what non-medical modes of treatment help reduce my daily pain. I undergo annual interventional pain treatments to reduce pain, and visit a pain clinic regularly to review medications, and seek new and better solutions.
Most who live with chronic pain understand that pain is never completely gone. For me, level 3-4 pain is tolerable most days. My opioid analgesia, at doses now considered high, but which are now less than half the dose they were 10 years ago, remove perhaps 20% of my pain. Interventional treatments, like medial-branch neurotomy reduce my pain by 50% when performed by a good technician. Walking helps, as does a variety of other activities that I’ve discovered over the years, some with the help of my pain psychologist. Then again, some days nothing helps but my medication. For a patient like me, nothing is more frustrating than seeing a new doctor and hearing - “let’s see about getting your opioid dose down to XX MMED (mg morphine equivalent per day), when at times, I need more medication, not less.
Let’s look at Dr. Radnovich’s ideas. His first two about complaints are true for some, but for others – they do hurt all over. This is a cardinal sign of fibromyalgia and I would suppose important information in making a diagnosis. His second point about “my pain level is 12” is something he needs to ignore. Most pain patients are undertreated and exhausted from living with chronic moderate pain daily. Here they are looking for help, and they want to communicate that their pain is serious. When a patient says “my pain level is 12” perhaps she’s actually saying “please help me doc. I can’t take it anymore.”
Ok, suggestion three is relevant. Let’s treat today. Yes, you may have fallen off the swings as a child. Is that relevant? A good doctor will take a thorough history and physical examination. Ideally, he’ll find the cause of pain if possible, and treat it. Here I have to agree.
Suggestion 4 is silly. My pain doctor asked me during my first visit – who’s your lawyer? Is this a work-comp case? When I replied I had no lawyer, he was surprised. Many people who present with acute pain have work related accidents.
Number 5 – don’t ask for a specific pain drug. Why not? I’ve been prescribed opioids for 25 years, daily. I know that OxyContin is “safe” doses does little for my pain, and doesn’t last the advertised 12 hours. A trained pharmacist is better at dealing with the answers why my metabolism of oxycodone is out of whack. However, I respond well to hydrocodone, methadone, and morphine. Shouldn’t the doctor know that? It’s in my chart. In my experience, a doctor hasn’t read my chart during a first visit. I feel it’s my responsibility to know my chart, so I carefully go through it. I rely on opioid analgesics regularly and I lost my shame of their use 20 years ago. Doc, I’m giving you important information.
Why do so many doctors see this behavior as drug seeking instead of what I like to call “treatment seeking?” The patient knows his or her own pain better than any doctor, until that doctor learns enough about the patient to form an opinion. I’m trying to help that doctor get the data he/she needs to understand my case.
Item 6 deserves a similar answer. My chart shows that I don’t abuse drugs. Have you read my chart, doc? Too many doctors believe the propaganda that people abuse opioids. The statistics are all over the map on this, as so much of this so-called research is biased. Opioiphobia is rampant in our medical community, and entire organizations are dedicated to eliminating the use of opioids in non-terminal chronic pain. They would like to turn back the clock to the 1960s, when most American’s “sucked it up.” I’d love to hear them tell that to their grandmother.
Number 7 says don’t tell your doctor that you’ve tried everything. I ask Dr. Radnovich — how much time do you spend with a new patient? Is time adequate to acquire an accurate medical history? Why shouldn’t I help you and save you some time?
I have a health summary that I have prepared for new doctor interviews. It runs to three pages and I don’t expect a doctor to read it from front to back, but I use it to point out important events, diagnoses, treatments, and related medical conditions so that a new doctor has a very good idea of where I sit clinically. This allows that doctor to start thinking about how to treatment, instead of wasting time with other concerns.
Number 8 – Don’t insist on specific tests. Personally, I have a degenerative spine disease that includes a moderate-severe spinal stenosis. I haven’t had an MRI since 2012. Isn’t that information relevant to my case, and my pain level? Why wouldn’t I say to a new doc – I haven’t had an MRI since 2012. Don’t you think it wise that we order one?
Numbers 9 and 10 I’m going to ignore. Gluten allergies may or may not be relevant. The same can be said for Dr. Phil. A good doctor will do the work to find out.
Dr. Radnovich, please consider the fact that some pain patients who present in your office may know a hell of a lot about medicine, their condition, treatment options, their response to those treatments, and new research related to their condition that you haven’t had time to read.
Some patients, especially we old timers, understand that our pain doctor is partners in helping one manage their pain. Gone are the days when an antediluvian physician sends down the Do and Tax on stone tablets like some kind of modern day Moses. There’s a lot of information out here for people to absorb, and I’m not talking about Oprah. There’s real medical data available online, we have access to medical books, blogs like PracticalPainManagement.com, organizations like the US Pain Foundation that encourages patient self-knowledge, and many other sources to familiarize ourselves with our disease state. People today are better educated and most of us who have lived with intractable pain for many years have thought the problems through in multiple dimensions. Some of us have pain psychologists that have helped us in our “journey.”
You docs may have the clinical experience - no argument there - but we’re the experts on our pain until you decide to gain that expertise. It’s a long process that requires trust and mutual respect.
Here’s my largest complaint with your piece. The doctor-patient relationship relies on truth flowing in both directions, and you seem to have ignored that most important piece of the picture.
When I interview a new doctor, I seek primarily a man or woman, who listens, thinks, is open to new ideas, knows truth from BS, and has the flexibility to work with me as a partner in my own healthcare. I realize that this relationship requires a huge responsibility on my part, which I fully accept. You see, in the many years I’ve been visiting doctors for help with my pain, I’ve discovered that the more knowledgeable gets the best pain care, and for my own ability to function and enjoy a certain quality of life, I do my homework. I expect my medical partner, that is, my pain doctor, to have done his, and to accept me based on how I present myself in his consulting room. I may be moaning in pain, requesting a 50% increase in medication one month. My doctor will not dismiss my needs out of hand, but will find out why and act, using his clinical judgement, appropriately.
Dr. Radnovich, there are millions of people like me out there looking to improve their lives by reducing their daily pain. We are highly opioid tolerant and require higher doses of medication than your state board may “recommend” in their guidelines. This absurdity is like telling a diabetic that he can only have so much insulin, or a hypertensive that he’s got to cut down on his clonidine.
We’re each individuals, and we’ve presented in your office looking for help. If you can’t give it, tell us. But please don’t try to push us into a mold for all pain patients. It can’t work that way.
If a doctor feels uncomfortable prescribing controlled substance to a pain patient, then she can use the tools at hand. Prescription Monitoring Systems, medical records, telephone conferences with past providers, the myriad surveys for detecting abuse potential, use of tamper-proof opioid formulations, two-week prescriptions, and even the more controversial techniques like UDT, pill counts, and controlled substance agreements. Of course, there are organizations like the American Pain Society and the American Academy of Pain Management that can help a conscientious practitioner to stay up to date on pain practice and improve her skills in differentially diagnosing addiction from pseudo-addiction.
Finally, Dr. Radnovich, this piece is not meant to be a slap in the face, doctor. You are a hero. You are treating the pain and suffering of your patients. In my book, you have reached the pinnacle of your calling and are on an important spiritual journey. I respect that journey and I respect you as a man and as a professional.
But please remember that chronic painers come in all sizes, shapes, styles, and colors. Fitting square pain patients into round treatment holes serves neither your patient nor your practice, (nor the profession of pain management.)
Thank you for considering my ideas in relation to your own, and please keep following your star.
Kurt W.G. Matthies is a writer and former engineer who has lived with the pain of severe chronic spine disease for over 30 years. He comments on chronic pain issues for National Pain Report. You can follow Kurt @kwgmatthies on Twitter.