TIPS & TOPICS
from David Mee-Lee, M.D.
Volume 8, No. 10
February 2011

In this issue

SAVVY – Nonpharmacological approaches to chronic pain

SKILLS – Evaluating and engaging pain clients

SOUL –Choosing Forgiveness

Until Next Time

Welcome to the February edition of TIPS and TOPICS (TNT).

SAVVY

Understanding and managing pain has been a clinical challenge for years.  But in the press, it seems to be a hot topic this month.  Articles about pain and pain pills appeared this month in the American Society of Addiction Medicine (ASAM) News (Vol.26, No. 1; 2011); on the front page of USA Today newspaper for February 24, 2011; and in the Special Double Health Issue of TIME magazine, March 1, 2011 edition.

On the same day as the USA Today article, the Associated Press reported, “South Florida is the national epicenter for illegal dispensing of prescription drugs such as the highly addictive painkiller oxycodone. State officials said recently that 85 percent of all oxycodone pills sold in the US come from Florida and that the nation’s top 50 medical prescribers of such drugs are located in the state.” The Drug Enforcement Agency (DEA) has been shutting down these “pill mills”. Authorities caught one Florida man who earned an estimated $150,000 a day from the 7 (now-shuttered) pain centers he owned.

Here are just a few other facts about pain medication and prescription addiction:

Americans consume more than 70 percent of the world’s legal medicinal supply of opiates, according to Congressional Record and international treaty data.
Prescription drug overdoses nationwide have doubled in the past 5 years, according to the latest reports from emergency room doctors who participate in the government’s Drug Awareness Warning Network.

http://www.chron.com/disp/story.mpl/metropolitan/7416082.html?%20Medicine%2529

About 7 million people age 12 or older regularly abuse prescription drugs, making such drugs the third-most-abused substance after alcohol and marijuana  (National Survey on Drug Use and Health, 2010.)

Prescription drug abuse is the fastest-growing drug problem in the United States. Because prescription drugs are legal, they are easily accessible, often from a home medicine cabinet. Further, some individuals who misuse prescription drugs, particularly teens, believe these substances are safer than illicit drugs because they are prescribed by a healthcare professional and sold behind the counter.

TIP 1

Try Nonpharmacological Options for Treating Chronic Pain.

Medications are effective, but only one part of a comprehensive pain management approach. Patients are often focused on medication, especially if they have a tendency towards addiction and/or already have a co-occurring opiate dependence disorder.  Clinically, I would often refer clients to hot packs and cold packs, progressive relaxation and cognitive behavioral therapy.  But Passik’s paper outlines a much wider variety of nonpharmacological approaches which complement medication (Passik, SD, 2009):

Ia. Physical – Self-administered therapies
·   Bandage wraps
·   Corsets
·   Counterirritant creams
·   Exercise
·   Heat or cold application
·   Limitation of activities
·   Postural changes

Ib. Physical – Physical medicine
·   Deconditioning
·   Hydrotherapy
·   Massage therapy
·   Mechanical devices e.g., splints
·   Physical and occupational therapy
·   Range-of-motion programs

II. Psychological
·   Attention control exercises
·   Biofeedback
·   Cognitive-behavioral therapy
·   Desensitization
·   Distraction
·   Goal-setting and pacing strategies
·   Guided imagery
·   Hypnosis
·   Patient education
·   Psychotherapy for comorbid conditions e.g., depression, anxiety
·   Relaxation training

III. Interventional
·   Bracing
·   Injection and radiation therapy
·   Nerve blocks
·   Neuro-destructive surgical techniques
·   Transcutaneous electrical nerve stimulation
·   Vertebroplasty

I’m no expert in pain management, but there are lots of informative resources in the references below.

References:

Listing of non-pharmacologic options for treating chronic pain from Table 1 in Passik, Steven D (2009): “Issues in Long-term Opioid Therapy: Unmet Needs, Risks, and Solutions”. Mayo Clin Proc. July 2009;84(7):593-601. www.mayoclinproceedings.com.

National Pharmaceutical Council I: Joint Commision on Accreditation on Healthcare Organizations. Scribd Eb site:
Pain: current understanding of assessment, management, and treatments. 2001.
http://www.scribd.com/doc/7563477/Pain-Current-Understanding-of-Assessment-Management-and-Treatments-An-Overview-of-Two-Monographs.  Accessed February 26, 2011.

SKILLS

Increasingly clinicians are confronted with something like the following scenario:

Clinician: “How can I help you?”

Client: “I need Oxycontin (oxycodone, opiate analgesic)”

Clinician: “Well we don’t just hand out pills.  So do you have a pain problem?” (If you run a “pill mill”, you would say: “Come on in – cash only.”)

Client: “Yes, but Oxycontin is the only thing that works and that’s all I want.”

Clinician: “We can help you with your pain problem and medication is a part of that plan, but only one piece of a comprehensive pain management plan. Would you be willing to try non-medication methods as well?”

Client: “Just give me the Oxycontin!” (Pitch and tone of voice rising)

TIP 1

Engage chronic pain clients by focusing on the pain, not the pill.

This tip may be more easily said then done.  It is not unusual for a physician who finally becomes fed up with the patient who is overusing medication, “losing” prescriptions all the time, doctor shopping, emergency-room hopping, to just cut the patient off from pain medication.  Also when a clinician first meets and assesses a client  more interested in pain medication than pain management, it’s easy to simply refuse admission and treatment.


Yet after just one assessment interaction, it is not easy to decipher the possibilities:

· Is this a person desperate and hopeless about their chronic pain? Do the demands for medication just look like pure drug- seeking? Is this really more of a cry for help, not blatant addiction?
· Has this client been treated by a physician who is only focused on medication?  Is the physician unfamiliar with, or disinclined to use, non-medication methods of pain management?
· Perhaps the client has indeed tried a wide variety of nonpharmacological options, but just hasn’t found the most effective mix of options?  Is this the case?
· Perhaps it is appropriate right now to focus on the actual medication itself. Is it the right medication and/or the right dose?  Do prescription adjustments need to be made?
· Have stressful psychosocial problems intruded on this client’s life recently? Have these stressors interfered with the client’s pain tolerance?
· Are we faced with a client who may have some chronic pain issues, but is now overcome with opiate dependence which is now controlling their life and demands for medication?


So let’s replay and modify the Clinician-Client interaction to assess and engage the client:

Clinician: “How can I help you?”

Client: “I need Oxycontin.”

Clinician: “Well we don’t just hand out pills.  So do you have a pain problem?”

Client: “Yes, but Oxycontin is the only thing that works and that’s all I want.”

Clinician: “I can see that you are desperate for Oxycontin and we may very well be able to give you that.  But we have to assess if that is the only and best plan for your pain. Would you be willing to take a fresh look at what might be the most effective and efficient comprehensive plan to help your pain?”

Client: “Well, yes, but I want Oxycontin because medication is the only thing that works for my pain.”

Clinician: “Are you saying you are fully pain-free and functional just by taking the medication?”

Client: “Well I didn’t say that I was pain-free and functioning totally well, but I want the medication.”

Clinician: “Yes, I can see that you are desperate for Oxycontin and as I said, that may very well be an important part of the pain management plan. But medication has its own risks of causing an addiction illness, which can increase even more pain and distress in your life on top of the chronic pain problem.  So we have to assess if medication is the only and best plan for you. We have to make sure you haven’t developed complications with an addiction illness. Would you be willing to take a fresh look at what might be the most effective and efficient comprehensive plan to help your pain?”

Client: “Well, yes, I have to get some relief from this pain, it’s killing me.”

This last Clinician-Client interaction reaches the goal of this tip: shining the light on the pain, not the pill.

· The focus is now on the pain and what will be effective.  This is where all those nonpharmacological options can be explored.

· If the client is unwilling to try non-medication approaches, that certainly points towards an addiction illness in your assessment.
· Concurrent pain treatment and addiction treatment may now be necessary.

SOUL

For all of us fortunate to live in democratic countries we take for granted the right to protest and disagree with the government.  It is historic to witness the unleashing of anger, pain and cries for empowerment and freedom unfolding in Tunisia, Egypt, Libya and other Middle Eastern countries.  It is easy to cheer for the underdog and the suppressed, and urge on their fight for freedom of speech and participatory rule.

But what of all the hate and bloodshed?  How did Ghandi and King and Mandela protest peacefully and tolerate years of personal disempowerment and pain?  I haven’t studied their lives enough to be the one to answer those questions. However, I did hear recently a pastor and teacher explain his definition and understanding of forgiveness.

He said: “Forgiveness is choosing to lay aside your right for revenge.”

That struck me as true and profound. From how he talked, he had clearly studied and pondered forgiveness for many years. Me? Not so much.  I wondered if what he said was original and with the instant help of Google, I plugged in his phase.  As you can guess, is there anything new under the sun?!

This idea of forgiveness -having to do with a difficult choice and commitment to overcome your desire for revenge- has been written and spoken about a lot.
Just one link I found helpful was this one:
http://www.emotionalcompetency.com/forgiveness.htm
I’ve never met Leland R. Beaumont, the creator and webmaster of this emotional competency website.  But his Forgiveness- Choosing to Overcome Your Desire for Revenge summarizes many concepts worth pondering.

So who hasn’t been the victim of some injustice?

Maybe nothing near what the current protesters in the Middle East have endured. The path to forever live with fear, rage, hurt, anxiety and revenge leads away from peace, serenity, joy, vitality and freedom.

It is a spiritual practice to choose forgiveness – to choose to lay aside your right for revenge.

Until Next Time

Thanks for reading. Join us again in late March.

David