Greg Hood, MD, Internal Medicine, 11:12AM May 25, 2014
Medical knowledge advances. Unfortunately, the nature of advances in medicine is such that there are steps sideways and sometimes backwards before there is a step forward. Further complicating matters, established habits can die hard. For example, how do we now regard the over prescribing of antibiotics and yet how enduring are patient expectations and, particularly in some quarters, prescribing patterns?
Antibiotics can be useful in some cases of fever. However, there are many instances in which antibiotics are inappropriate and/or ineffective, such as fever related to viruses, fungi, drugs, and tumors, as examples. Unfortunately, there can be additional consequences to such antibiotic prescribing, including adverse drug reactions, antibiotic associated diarrhea, C. dificile colitis, and increased resistance to antibiotics on the part of bacteria, not to mention the effects on the prescriber of administrative scrutiny and feedback.
Similarly, narcotic pain medicine can be very helpful, when used for the appropriate type of pain. However, there have been a number of advances in our understanding of pain, types of pain, as well as options in medication over the years since the rates of prescribing began the well-publicized acceleration. Just as causes and types of fevers can be broken down into different classifications different types of pain can as well. Pain, for example, can be divided as nocioceptive and non-nocioceptive.
Non Nociceptive Pains, nerve-originated or nervous system generated, sympathetic (CPRS I & CPRS II) or otherwise, arise from within the peripheral and central nervous systems, with the pain perception being generated through nerve cell dysfunction. While opiates can have a generally limited effect, the example of Gabapentin (and other medications: TCAs, SNRIs, etc.) has revolutionized the management of many such cases since its introduction well over a decade ago. The improvements in targeting pain relief for neuropathic pain, and the ability to wean off narcotics seemed as miraculous to my patients at the time as the resolution of bacterial infections with antibiotic therapy must have seemed to patients at the inception of the antibiotic era.
Psychogenic pain remains as perhaps the greatest overall challenge in pain management in today's world. Psychogenic pain refers to physical pain that is either caused by, increased by or prolonged by mental, emotional or behavioural factors. Not typically indicative of its own mental disorder, psychogenic pain is most commonly affiliated with or induced by "the pain of life", i.e. social rejection, grieving, or other strong emotional experiences, such as a broken heart. Depression and similar diagnoses are presently much better understood to be the cause or a contributor to various patient pain presentations as well. Many cases of pain involve elements of pain which have little or no response to narcotic analgesia. In other cases narcotic related pain is only a subset of the pain presentation. Complicating this, some patients experience improvements in affective disorders in response to the action of narcotics on the opiate receptor pathways[citations below].
How will today's prescribers be judged regarding the application of narcotics to cases of pain in which sedentary lifestyle and movement / range of motion avoidance play key roles? Studies dating back many years have underscored the improved functional performance of active patients when compared to their peers regardless of severity of arthritis (mild/moderate/severe). Newer, though still limited, studies have shown improvements in mild to moderate low back pain with yoga instruction. Is the prescribing of a narcotic in such a case intellectually analogous to prescribing an antibiotic for manifestations of sinus allergies?
There are also regional variations in management styles. The problems with narcotic prescriptions, diversion, and illicit use are well known problems in Appalachia, as an example. A study, referenced below, also shows antibiotic prescribing has variation across regions of the country as well. These variations, both in antibiotic and analgesic prescribing, do not correlate with appropriately explainable variables. They underscore the importance of refining the narrative surrounding pain, and pain management.
(Blue map is Kg's of prescribed painkillers, purple map is overdose rates)
These conclusions have application in the fields of primary care and pain management, but also the public consciousness. As a society we must become more broadly educated and literate as to the elements and nature of pain, as well as what medications can, and cannot do. The ability of these medications is to reduce some types of pain, not to make each patient pain free and unencumbered, although that is often times the implicit expectation of the patient or the unintended impression left by the provider when the care plan is explained.
Genetic variations do not yet commonly factor into primary care pain management algorithms. There is an excellent, thorough review in the Medscape article cited below. The individualization of treatment protocols comprehensively based in the type of pain, the severity of pain, the psychological condition of the patient, pharmacogenics and pharmacogenetics and the genetic encoding/variations of the patient does not commonly exist within the bedside practice of medicine today. Thirty years from now how will our successors in the profession judge the "evaluation and management" of the various manifestations of human suffering that we currently still tend to lump together (or divide apart) simply under the title of "pain"?
Yuting Zhang, Ph.D., assistant professor, University of Pittsburgh; Len Horovitz, M.D., internist, Lenox Hill Hospital, New York City; Sept. 24, 2012, Archives of Internal Medicine, online
Bair, Matthew; Overcoming Fears, Frustrations, and Competing Demands: An Effective Integration of Pain Medicine and Primary Care to Treat Complex Pain Patients; Pain Medicine, Volume 8 " Number 7 " 2007