A REAL NEED FOR PAIN MANAGEMENT
Today we have an onslaught of negative reports on the use of medication to treat chronic pain. These specious attacks have affected every area of pain medicine in an extremely negative manner causing more and more pain for those who suffer, even those who don't require medication. Lost in all the condemnations, proclamations and recommendations about pain treatment is a most basic scientific fact about pain. Its first and foremost impact, other than agony, is its dramatic, aggressive assault on the cardiovascular system. Check with your neighborhood medical consultants: 5th grade students. The boy who encounters a splinter and the girl playing hopscotch who twists her ankle will both tell you their pain causes their heart to race. Better yet, go to your ultimate peer review consultant: your grandmother. She well remembers the stories and days when women commonly died due to the pain of childbirth when the heart stopped or a brain stroke occurred. Thank god we now have opioids, channel blockers, and muscle relaxants--if only those who regulate or pay for them will let physicians prescribe them!
Ignorance about the cardiovascular consequences of pain is profound even among some learned pain specialists. First, some basics. Acute and chronic pain, being the ultimate stress, causes a flood of adrenalin and related compounds to be released from the adrenal and pituitary glands. The most obvious, discernable, and easily measured consequences are an elevated pulse rate and blood pressure. Secondary physiologic consequences of excess adrenalin in the blood may include, in the short run, lipid abnormalities, cardiomyopathy, stroke, arteriosclerosis, and heart failure. Perform a little test to demonstrate the consequences. Check the pulse rate on the next patient you encounter who complains of constant, severe pain. Don't be surprised to find a resting pulse rate over 100 per minute. It's shocking. but many under-treated, intractable pain patients maintain pulse rates over 88 and sometimes over 120. This editorial was, in part, motivated by a "failed back surgery-autoimmune-tried everything-consulted everybody" patient now on two opioids who e-mailed me telling me her pain is poorly controlled and accompanied by a house-bound state and her at home pulse rates over 100. Naturally, pulse rates this high call for more aggressive pain control such as another epidural, dosage increase, or an ancillary pharmacologic agent. Bottom line is that effective pain treatment must strive to bring pulse rates and blood pressure into normal ranges.
Cardiovascular consequences, including heart stoppage, stroke, or heart failure are among the most common, if not the most commom, causes of death in chronic and intractable pain patients. Clearly pain will aggravate any pre-existing cardiac, lipid, or diabetic condition. One of the travesties of scientific ignorance is that a number of physicians have been erroneously accused of malpractice after one of their pain patients died. Too often coroners and other onlookers jump to the false conclusion that pain medication and an "over-prescribing" doctor cause the death when in actuality the patient died a cardiovascular death from under-controlled pain. Just as in childbirth, a sudden severe pain flare can cause excess adrenalin output, cardiovascular collapse, with sudden death. Another common cardiac manifestation is unrecognized congestive heart failure. It can cause sedation and sleepiness and can easily be confused with medication overdose. The treatment here is digitalis rather tha Naloxone.
Without question, detoxification and withdrawal of medications from a bonafide, intractable pain patient may come to rank as one of the great medical frauds of the 21st century. The notion that intractable pain patients are somehow better off with no medication and debilitated with pain is absurd and dangerous. Pain patients and families, in order for some outfit to make the big detox bucks, have actually been told that opioids and other pain medications are the cause of pain and that the patient will be "cured" by detoxification. Many intractable pain patients have died of cardiovascular collapse when their pain flared during too aggressive withdrawal from medication. Any ethical physician who attempts detoxification of a chronically medicated pain patient must monitor the pulse rate and blood pressure and be prepared to cease withdrawal and reinstate medication if the pulse rate or blood pressure rise.
Regular pulse and bood pressure monitoring should be routine practice in pain treatment, and patients and families should self-monitor at home in severe pain cases. This author recommends that pulse rates be kept below 88, and pain treatment should progessively and aggressively increase in intensity to bring the cardiovascular system into normal homeostasis with a pulse rate of 68-76. Without good cardiovascular control, the lifespan of an intractable pain patient will be cut short.
This author recommends that intractable pain patients and their families buy an inexpensive at-home pulse and blood pressure monitor and provide a monthly report onn the results. There simplky isn't a cheaper, better and obejective marker of uncontrolled pain than a pulse rate.
Forest A. Tennant, MD, DrPH.
Practical Pain Management Journal.