PainCare, hardly about pills…

Pills w many bottlesPain management is in many ways the oldest specialty of medicine with evidence of pain control through use of naturally occurring substances many thousands of years ago.  Serious pain usually accompanies (and sometimes continues after) healing of wounds and tissue injury including contusions, sprains, strains, bone fractures, lacerations, nerve compression, and the like.  In other ways pain management is one of the very newest of medical specialties, carving an important niche with advanced “modern” tools to combat pain.  The specialty has met with remarkable success in acute pain – to such an extent that there is virtually no reason why anyone with acute pain and access to a pain manager cannot expect good to excellent symptom control.  This expectation was even codified by the U.S. Congress in the form of a somewhat unfortunate patient “bill of rights.”

But for CHRONIC pain…ahhh if it were only that simple.  Attempts to use the same approaches as with acute pain conditions have often failed, and failed miserably in the long course. A prime example is the use of NSAIDs and opioids, two fantastically reliable drug classes for acute conditions, and in the early stages of more chronic conditions, but commence to spiral downward in efficacy as time drags on.  NSAID intolerance in the form of gastrointestinal bleeding and perforated ulcers and even coronary emboli (Celocoxib), severely limits usefulness when applied for more than a few months.  And once the need for opioid use has begun, NSAIDs fade into the background, and are usually and purposefully discontinued.

Opioids, the epitomy of a ‘double edged sword,’ are often prescribed for years for chronic pain patients with rather sparse evidentiary support for long term daily use from the medical literature.  Tolerance is the inevitable concomitant, and serves to erode the pain relieving qualities of the very drug that worked so well initially.  Dependence, meaning the development of withdrawal symptoms upon discontinuation, is also an expected concomitant even with very mild/low doses (but persistently consumed) opioids.  Withdrawal is perceived by the patient as evidence of the usefulness of the opioid, when in fact this withdrawal pain is only partly the patients underlying pain, but largely a “pain inflation” induced by the lack of the drug that suppresses the pain.

It is easy to understand how spiraling doses of opioids for chronic pain develop, and yet also to understand the false sense of analgesia opioids provide in the chronic setting.  This mechanism is hardly different from the use of beta blockers, diuretics, ACE inhibitors and other drugs for hypertension chrono/inotropic cardiac control.  When the patient suddenly discontinues such medication, hypertension can quickly become malignant to the extent of precipitation of a life threatening event such as a stroke or myocardial infarction.  This example serves to highlight one of the only positive features of opioid withdrawal….it is generally quite safe…supremely uncomfortable, but safe.

At Paincare, 70% of referrals are currently consuming daily opioids, the great majority on highly potent agonist opioids such as oxycodone, morphine and fentanyl.  Such patients are referred because the “easy” treatment of the pain (opioids) has worn out its welcome.  The primary care practitioner is no longer comfortable with the increasingly higher doses needed to defeat tolerance, and prescribing for ‘early outs’ (i.e. overuse).  The patient then becomes our problem.

The very laborious solution to this quagmire, is to first gain the trust of the patient by continuing the regimen, then to [only] suggest a gradual wean from the opioid, then finally institute said wean.  For a patient who firmly believes the opioid is “the only thing that works,” weaning is extremely difficult to institute and maintain and will often take months to years.  This patient resistance can only be broken down through herculean efforts at education, counseling, and reassurance by the pain practitioner.  At PainCare it is found that at some point, a transition to buprenorphine is a most viable and valuable step.  Buprenorphine is a very weak opioid, but an avid binder to opioid receptors.  Due to the strong binding, the receptor remains occupied, thus alleviating the anxiety and physical (but largely emotional) stress of eliminating the beloved full agonist opioid (oxy, morphine, fentanyl) the patient has depended on for years.  Patients who successfully make this conversion routinely feel alert, engaged with life, and are now responsive to physical rehabilitation and conditioning, occasional steroid injections, medication previously eschewed such as gabapentin, tramadol, tapentadol, and anticonvulsants.  Again, the primary hurdle is establishing the degree of trust necessary to lead the patient toward this goal.

None of the above should imply that all patients will comply.  There will always be those who take a drug for unintended purposes (e.g., sedation for a sense of well being over analgesia).  If these patients have verifiable pathology that can generate the pain that is described, they can be extra difficult to identify and transition to more appropriate drugs to treat the underlying problem.  Also, the above should not imply that some chronic pain patients are simply addicts.  Many practitioners make the mistake of identifying all dependent opioid treated patients as addicts.  While all addicts are dependent (have withdrawal upon cessation of their drug), not all opioid dependent patients are addicts.  Most studies suggest that the small minority of patients with verifiable severe pain generators are addicted.  That minority grows when patients with less severe pain generators are considered.  It is therefore important that general practitioners of medicine not start full agonist opioids on patients with only modest evidence of pain generating pathology.

In conclusion, it is optimal for general practitioners of medicine to refer pain patients within a few weeks of continuous opioid use and allow the experienced pain practitioner to decide whether the patient requires subspecialist attention (ortho, neuro, etc.) or simple diagnostic injection with more specific definition of the pain generator, targeted physical rehabilitation with or without benefit of even temporary pain relieving blocks, viscosupplements for arthritic joints, radiofrequency lesioning of sensory nerves to pain generators, botulinum toxin for tight trigger points, spinal cord or peripheral nerve stimulation, etc. (i.e. the more advanced techniques).

About Dr. Michael J. O'Connell, New Hampshire
Dr. Michael J. O'Connell of Barrington, New Hampshire, has forged a distinguished career spanning over three decades, as entrepreneur, physician, businessman, philanthropist and healthcare consultant. As former owner, administrator and CEO of a 225+ employee multi-specialty medical practice, Dr. O'Connell has dedicated his entire professional life to helping patients with family medicine and especially those experiencing chronic pain and all aspects of addiction. Since selling his family of healthcare businesses, he has never once contemplated retirement despite his rich and fulfilling journey, but instead has turned his focus to consulting in an industry starved for courage and creativity. Having weathered many political, technological and legal challenges, there is hardly a storm he has not confronted, a tempest he has not quelled, an urgent need he has not met. While the talking heads and self-proclaimed experts in the field have assumed the conventions and standards of the times, Dr. O'Connell does not believe in merely reflecting the herd mentality, but rather in leading the charge. Eschewing political correctness, Dr. O'Connell says and does what needs saying and doing, and not what the mindless masses expect. In addition to the continual education afforded by his variegated life experiences, Dr O'Connell earned his BS in Biochemistry at the University of NH in 1975, his Medical Degree from Dartmouth College in 1981, interned at Walter Reed Medical Center in 1982, Residency/Fellowship at UCSF in1986, and finished his Masters in Healthcare Administration at UNH in 1995. Dr. O’Connell enjoys many outdoor activities, including rock climbing, snowboarding, hiking, and golf. Through the decades Dr. O'Connell has supported many non-profit charities to include the St. Charles Home in Rochester NH, the Tri City VNA and Hospice, Hyder House, and Cocheco Valley Humane Society. To the latter organization alone Dr. O'Connell has donated over $180,000 and pledged another $250,000 in the “Bring-Us-Home” campaign for a new building. His “Matching Donations Christmas drive” has generated over $175,000 in charitable giving from the community. In addition Dr. O'Connell has participated in many dozens of other volunteer and donation efforts locally as well as in Africa and the Dominican Republic. For a listing of how I gave back to the community during my career and continue to do see: https://michaeloconnellmdnh.wordpress.com/

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