Treatment

Most Americans are aware of the scams some people use who claim to be in pain, but who are not truly suffering.   (See Pain Behaviors).  There has been widespread coverage of persons who make claims of injury and appear for doctor appointments or other evaluations using neck brace, cane, walker, or wheelchair, only to be later observed reaching overhead to shelves, hoisting heavy boxes, or even video-taped jogging when they claimed to not be able to walk.  Unfortunately, insurance carriers, worker's compensation, the Social Security Administration, and doctors have been lied to deliberately by many patients.  

As well, physicians carry a special and difficult burden of making sure they are not prescribing controlled substances inappropriately.  "The Controlled Substances Act (CSA) of 1972, which supersedes and replaces the Harrison Act and all intervening federal drug legislation, makes it a federal offence to prescribe controlled substances to a drug addict for the purposes of treating or maintaining their addiction, except where the physician holds a separate DEA license to provide methadone maintenance." (Quoted from the following website article which discusses pain treatment: http://www.doctordeluca.com/Library/UWOD/UWOD5-DenominatorAbuse.htm).¹   There is also fear among physicians of the DEA, even though medical schools have no curriculum that teaches "fear of DEA" and that many physicians have misconceptions about what triggers a DEA investigation.²

Having been duped before, with the burden of potential loss of professional license and fines/imprisonment, and believing the myth that all persons on pain meds will become "addicted," most doctors have been wary to prescribe ANY pain medications and especially narcotics.   Many doctors fear the repercussions of giving prescriptions so much that they refuse to prescribe anything, for anyone, including those patients who are terminally ill.  In the 1980s when many patients were sent home to die, Home Care Nurses had to plead and argue with, and advocate to doctors on behalf of cancer patients whose pain was left untreated completely.  Some of these doctors refused because of their belief that the person would become addicted!  It took a lot of persuasion to convince those physicians that, while addiction is not an issue with someone who is truly in pain, what difference is "addiction" when a person is just a few months, weeks, or days away from dying!  During the early days "Dying with dignity"  became the hospice and nurses' cry for adequate pain relief for terminally ill patients.  Unfortunately, the similar cry of "LIVING WITH DIGNITY" for patients with benign chronic pain has been largely ignored.

LIVING WITH DIGNITY

The American Pain Society (APS) encourages health professionals to regard pain as the fifth vital sign, along with pulse, blood pressure, temperature and respiration.3 (see http://www.acofp.org/member_publications/0503_3.html  "Practical Pain Management: Millions of patients suffering from the under treatment of chronic pain look to their family physicians for relief."  Arthur G. Lipman, PharmD, FASHP).  Lipman goes on to say: "Common reasons for the under treatment of pain include underreporting and concealment by patients; healthcare professional under prescription of analgesics and nonpharmacological pain relieving measures; nurse under administration of analgesics4 and pharmacist hesitancy to dispense and counsel patients about analgesics. Underlying all these may be inadequate assessment of the patient’s pain compounded by lack of knowledge or information about available treatments."

"According to the American Pain Society, pain is one of the most common reasons that people visit a physician.  While headache and back pain top the list of complaints from CNMP, others include arthritis, endometriosis, temporo-mandibular joint disorder, vulvar pain, trigeminal neuralgia, shingles, and fibromyalgia.7 Yet, according to one survey, three out of four pain sufferers do not receive adequate pain treatment.8"

It is estimated that there are 20 to 50 million Americans living in daily chronic pain (Dr. Eric M. Chelven³ states 30-50 million, while Dr. Hochman believes the number is closer to 20 to 30 million.⁴ See end of this page for more information.)   Because of the liability fears addressed in the above paragraph, it is estimated that only 3,000 to 5,000 physicians in America practice "chronic opioid therapy" (see Chevlen; see Hochman - as quoted in another article).  Based on these numbers, there are not enough physicians willing to treat patients in severe pain with the narcotics which may be necessary to improve quality of health and quality of life.  

Of the 20 to 50 million people in pain, few are actually treated  for their pain, many are treated with drugs more appropriate to other conditions than what the individual has, and most persons who do receive narcotic prescriptions are under-treated with doses that do not adequately control pain.  Most patients reporting pain are inappropriately treated for "depression" or "anxiety".  While both of these conditions may be present with pain, there is no exact correlation the two.  For some persons, depression and anxiety were present before they experienced chronic pain, but for many other people, depression and anxiety came only after suffering ongoing pain.  It is therefore an inappropriate assumption that depression or anxiety is "the cause of" chronic pain.  But, it is true that many may suffer depression and anxiety from living with untreated or under-treated pain.  Some doctors seem to think that only the depression and anxiety need treated, but this still leaves patients to suffer in pain.

There is also a belief in psychiatry that some patients who develop pain or pain syndromes are actually expressing psycho-somatic pain, or that others are experiencing "body memories" from previous abuse (childhood abuse up to domestic abuse in adulthood).   While it is true there can be very real "pain" felt as a type of "body memories" which can surface years after abuse, it is inappropriate to therefore conclude that "all chronic pain" results from unresolved emotional issues stemming from childhood abuses.  As one who has experienced both physical chronic pain, and body memory pain, I can attest that the two are very different.   Body memories are typically short-lived, arising before abuse memories come up and during the discussion of those memories.  The quality of the pain is different, although this is difficult to describe (as is physical pain of other conditions is also hard to describe).   Body memory pain is often vague (headache, stomach ache, profound tiredness, as a few examples), and is often reported in conjunction with feelings described as "yuckky" (or other similar words.  Body memory pain typically lessens as one proceeds with talking about specific memories and body memory pain resolves as healing occurs of one's emotions and integration of the memories continues.  Chronic physical pain will not change that dramatically nor resolve through talk-therapy or changing how one views their past.  It is as much a disservice to have doctors believe that reports of benign pain indicate an unresolved trauma as it would be to have a doctor say that the severe pain of appendicitis or a kidney stone is caused from psychological wounds.  The difference in the latter two conditions is that physical exam, blood work and other tests quickly reveal the source of the pain, while chronic pain often cannot be seen on any objective test (X-Ray, MRI, CAT-Scan) -- But this does not mean chronic pain is not real or that it does not have a physical cause! (For a discussion of the lack of validity of "body memories" in the broadest sense as some say, see Body Memories: And Other Pseudo-Scientific Notions of "Survivor Psychology" by Susan E. Smith, published in the Institute for Psychological Therapies' web site.   It is a very interesting article with many valid points!  Physicians might find the article helpful.   I personally do not believe body memories includes all the body sensations some claim, or that every sensation is a memory.)

The belief that all chronic pain is not real and is due to psychological causes is a very real bias encountered by many patients, leaving them to cope with very real pain, untreated.  A pastoral counselor knew a woman who was a schizophrenic. This over-weight, middle-aged woman was at times delusional and had hallucinations. Her words often made no sense in the current conversation.  There were times though that she was in touch with reality and everyday events. After about a year, the pastoral counselor says the woman started telling her doctor about "rocks in her stomach" and "they're eating me."   The doctors thought these statements were simply part of her hallucinations, even when she was not actively hallucinating and was reporting she had pain in her "belly."  This went on for months.  The doctors just kept increasing her anti-psychotic meds.  Within a year, she died.  Her belly actually had been the cause of pain;  on autopsy, they found a 40 pound cancerous tumor that her weight and fat, round belly had concealed.  The cancer had spread to her bones, possibly fitting with her comments of  "someone is chewing on my bones."   Her reports of pain were not just "all in her head."  Had even one of her numerous Medical Residents ordered an X-Ray, MRI or CAT-Scan they would have found the reality of her pain.  I can only imagine the amount of  suffering that woman went through!  [Note: It is important to note that some persons with cancer never report pain.  But this person was stating she had pain, but because of her known psychiatric history she was ignored.  Every report of pain needs to be believed and investigated.  Even when a patient has a known psychiatric disorder, every report of pain still needs investigated.]

THE MYTHS OF SOMATIZATION

I learned early that most medical physicians are not very trustworthy to know a patient's psychiatric or abuse history or new psychiatric diagnoses,. because doctors are not always adequately informed.  Often doctors hold as much or more biases than society towards the mentally ill.  Certainly doctors seem to latch-onto any hint of even a normal psycho-social problem as though a person needs counseling!  I have always wondered if a physician-as-patient is made to feel like they are "psychiatric" or need professional help if they are overly tired from heavy work-load, cannot get aroused after a long day at work, have marital problems, or have bratty kids who don't always obey?  I doubt that doctors even acknowledge that they, too, have these very real problems to any personal physician -- because for them it is just "normal problems" while for regular patients, it is a sign of "dysfunction" and a need for "professional treatment"!   In their clinical practices, once a psychological problem is revealed and confirmed by the patient or other professional - - from situational depression, to chronic depression; from anxiety to panic attacks; or different conditions arising from childhood abuses -- doctors will then repeatedly judge all future physical complaints as psychological.   (And the judgments continue long after a person has successfully dealt with issues in therapy: there will always be the stigma attached and the suspicion that the person is psychologically "unbalanced.")

Indeed, an article on "The Somatizing Patient" (Servan-Schreiber, etal.)⁵ that was published February 15th, 2000 in American Family Physician, a professional medical journal, states the belief that 80% of female patients complaining of pain are actually suffering from somatoform disorder or somatization.   Additionally, the authors state that of the 80% of female patients, the majority have had a childhood abuse history.  This belief certainly puts the female patient in the insurmountable position of having to prove that her complaints of medical problems or pain is real.  The patient simply will never be believed by doctors who subscribe to such a belief!  The simple fact is that women have become more vocal about abuse histories and that more females than males experience childhood sexual abuse.  Since Freud, there has been a bias that women are "hysterical" and Freud even discounted reports of incest as mere fantasy.  Unfortunately, today's doctors seem to have read more Freud, rather than discarding these myths to gain a clearer understanding of childhood sexual abuses and its long-term issues.

The authors, three physicians at University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania state that

"The primary care physician's emotional response to a patient can serve as an early cue to pursue a somatization diagnosis. A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person, or a sense of being overwhelmed by a patient who has had numerous evaluations by other physicians, may be a signal to the clinician to consider somatization in the differential diagnosis early in the patient's evaluation."  In effect, the article says that if a person complains of multiple problems, and the doctor begins to feel frustrated, irritated or angry, then the doctor should suspect somatization disorder!

The problem with such a belief is five-fold:

1. Today's world of medical practice emphasizes short appointments that address one or two complaints, so that the doctor can seek reimbursement through insurance.  Insurance, especially Medicare and Medicaid, pay little regardless of the amount of time spent with the patient or the number of their complaints.  The doctor is paid the same fee structure, regardless of whether they see a patient for 40 minutes or 2 hours (I believe the longest appointments are billed under "expanded" or such wording.  And the reimbursement does not increase based on additional medical problems.  Physician documentation ("charting") is also geared to addressing 1 problem per visit.  

2. Insurance companies or lack of insurance restrict what tests a doctor can order.  Insurance does not want to pay to do the work-ups required to make a good diagnosis, and hospitals do not want to absorb the costs of full diagnostics for those with no insurance or who are under-insured.

3. Patients who live on limited incomes, in poor housing, with inadequate funds or food stamps for a good diet, who cannot afford vitamins, have more financial and life stress, and who are often female (single-parent to elderly - widowed, divorced or never married - and who have no other family support to act as a financial safety net for times of trouble), often DO have more medical problems than younger, middle-class patients who have good housing, more money, access to a good diet and vitamin supplements, and have a spouse and other family supports who can act as a safety net financially (but the safety net is rarely needed).   The fact that the poor patients have more real medical problems is not a difficult concept to grasp in a true holistic approach to medical care.  But, it is often nurses or social workers who can see the larger picture, more than physicians who have never experienced this kind of ongoing poverty and who are not very good at seeing through holistic eyes.  Women are also more open about medical problems, whereas many men shun even going to the doctor for any reason.

4. When real complaints of patients are diagnosed as somatoform disorder or somatization disorder (more severe than somatoform disorder), the real medical problems remain unaddressed, untreated, and are then compounded by legitimate emotions of frustration, anger, and anxiety, in addition to feelings of powerlessness and humiliation over not being believed.  The real medical problems are left to continue, and in many cases, to become chronic or just get worse.  (One woman had recurrent sinus infections which did not respond well to antibiotic treatment of the normal 7 day prescription.  Repeated X-Rays only showed minimal changes or no infection, so her complaints were minimized.  Only when surgery was done was it confirmed that the woman had a fungus in her sinuses that had started eating into the bones.  Treatment was then tailored to the fungus, and she has had few sinus infections since getting appropriate treatment.

5. Minimization by doctors of real physical problems can often lead to a downward spiral where a condition can become chronic, or that can led to death from medical neglect or from suicide when patients become overwhelmingly discouraged from being chronically ill or in constant, unrelenting pain.  But, rarely are autopsies done on these patients who were identified as somatizing, and no study has been conducted to collect records of these patients to study the rate and causes of death, so there is no way to know the truth.

MULTIPLE MEDICAL COMPLAINTS VIEWED AS SOMATIZING

In the article on somatization (at http://www.aafp.org/afp/20000215/1073.html), a table is given which I have copied here.  The authors state as a preface:

"Table 1 lists many of the symptoms and syndromes affecting patients with somatoform disorders. Most of these symptoms also occur in patients with organic pathology. As isolated symptoms, they would require a full medical work-up. However, somatizing patients have too many symptoms, in too many organ systems, that last too long. The intensity of the symptoms often strikes the physician as being out of proportion to the healthy appearance of the patient. The syndromes listed in Table 1 may be legitimate in many patients but are typically impossible to verify in somatizing patients."

TABLE 1 Symptoms and Syndromes Commonly Reported by Patients with Somatization Gastrointestinal symptoms Vomiting Abdominal pain Nausea Bloating and excessive gas Diarrhea Food intolerances Pain symptoms Diffuse pain (i.e., "I hurt all over.") Pain in extremities Back pain Joint pain Pain during urination Headaches Cardiopulmonary symptoms Shortness of breath at rest Palpitations Chest pain Dizziness Pseudoneurologic symptoms Amnesia Difficulty swallowing Loss of voice Deafness Double or blurred vision Blindness Fainting Difficulty walking Seizures (pseudoseizures) Muscle weakness Difficulty urinating Reproductive organ symptoms Burning sensations in sexual organs Dyspareunia Painful menstruation Irregular menstrual cycles Excessive menstrual bleeding Vomiting throughout pregnancy Syndromes Vague "food allergies" Atypical chest pain Temporomandibular joint syndrome "Hypoglycemia" Chronic fatigue syndrome Fibromyalgia Vague "vitamin deficiency" Premenstrual syndrome Multiple chemical sensitivity Information from Blackwell B, De Morgan NP. The primary care of patients who have bodily concerns. Arch Fam Med 1996;5:457-63.

The article continues with: 

"There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea.^9,11-14 In one large family practice sample,¹⁵ multiple somatic complaints provided the best indicator of depression.

Second, patients with somatization disorder commonly have coexisting depression (up to 60 percent), anxiety disorders such as panic or obsessive-compulsive disorder (up to 50 percent), personality disorders (up to 60 percent)^9,16 or a substance abuse disorder.¹⁷ In fact, the risk for a psychiatric disorder in a primary care patient increases linearly with the number of physical complaints.⁹

Finally, several studies have suggested an association between somatization and a history of sexual or physical abuse in a significant proportion of patients.^{17-21" (See original article for footnotes.)}

The problem with the chart, and the belief that patients who have more than one physical complaint must be somatizing, is that it is very common for patients to have more than one real physical ailment, and each ailment can have many symptoms (see my comment # 2, above).  The chart reflects the bias many doctors have in treating patients with complex medical problems.  And, often, the first symptoms of a medical problem may be vague and overlap with other possible medical diagnoses.   Therefore, a "simple" medical problem in the beginning, left untreated, can continue until the problem is so severe that it almost literally jumps up and smacks the doctor in the face; and then, the doctor is called to action - often too late!.

Medicine is an art practiced within scientific guidelines, but it is still overwhelmingly an art.  It takes a discerning doctor who is willing to practice the "art" instead of being ruled by the often imprecise science --- but too often doctors get stuck mentally in believing that the science (i.e. test outcomes) are always reliable and always show the truth of the presence or lack of a medical problem.  The so-called "normal limits" of blood tests are not always the individual's "normal," as attested to by thousands upon thousands of individual cases.  

What is "Within Normal Limits" for One, is NOT "Normal" for Another

Patients can teach doctors a lot about how illness and disease may be the same "diagnosis" but how much a single diagnosis can be present differently in individual patients.   But, doctors are not teachable - especially being taught by a patient!  Cases where doctors have made mistakes are not used as examples to illustrate the fact that medicine is still mostly an art.   Fears of malpractice claims leave physicians forever stuck in believing their skills are purely a science, and increasingly, patients are left to suffer when the "science" of medicine has not advanced enough to reveal the reality that no doctor can see inside a patient's body, and chemical analysis through blood tests and X-Ray, Imaging, or other scientific testing are only indicators of which way to look for a disease.  

New research is constantly being conducted to improve the ability to diagnose what cannot be readily seen.  "Scoping" procedures and the newest full body scans and the cameras that can be swallowed to give a picture of the internal body are perhaps the closest medicine has come to really seeing inside a body, but even these will never be precise in diagnosing all conditions.  Scopes, scans and cameras cannot SEE the chemical exchanges between cells, or determine why a slight shift from normal in blood tests can cause one person severe symptoms while another patient never notices the shift.  Or, why one person's shift in blood work is seen by the presence of significant tissue damage, while another person has little to no tissue damage (a perfect example is diabetes).  This is true in almost all diseases, where "within normal limits" can actually be different patient-to-patient.  Here are some examples to consider:

One patient faints when their blood sugar falls below 50 (normal 70-120), while another person develops only a slight headache and tiredness but continues to work the rest of the day.    Another person has blurred vision when their blood sugar is below 80 (which is supposedly WNL - within normal limits).

One person may have normal blood work for suspected thyroid disorder.  But, the patient had depression, violent rage, heart palpitations, feeling of cold, but never lost any weight.   So she was dismissed for almost 5 years as being "hysterical", suffering anxiety and depression, until they did a thyroid scan with radio-isotopes (which is not usually done without the bloodwork to back it up).  This patient was diagnosed with Graves Disease, where the thyroid is over-active.  The disease causes devastating personality and behavioral problems.

In other situations where blood work cannot confirm nor rule out a diagnosis, many patients are left thinking they are crazy, or are talked to like they are inferior human beings with psychological problems rather than a medical problem:

A young man came to the emergency room with burning in his eyes.  He was quite dirty, in greasy and ripped clothing, with a thin work-shirt covering a stained T-shirt.  The doctor dismissed him as a drug addict, who had "looked at the sun too long while being high."  An observant nurse asked about the man's activities that day.   He had been had working on his car all day he said (explaining his dirty, greasy clothes, face, hands and rest of his body).  While he greased wheels, changed the oil, drained the radiator in his mother's garage, other friends were using welding torch or repair metal parts of a motorcycle they were restoring.  The patient had not worn a protective welding hood on because he didn't think he needed it; he wasn't the one doing the welding.  But he had suffered "welder's flash" which causes severe burning in the eyes, caused from not wearing protective eye-gear when around someone else who is welding.   The man was treated with an eye ointment specific to the cause and within two days, his eyes were fine.  But, had the nurse not questioned him, the man would have been turned away as a mentally disturbed drug user. 

Many are increasingly reporting side effects of medications, but are disbelieved.  Or, other people are on combinations of medicines, each with their own side effects.  Often the side effects collide with each other, forming a disturbing mix - some which can be disastrous.  

One elderly woman reacted badly after being given a new blood pressure medicine, which didn't mix well with her 14 other medicines.  

About 7 years ago, Ultram was introduced as a non-narcotic analgesic with no addictive properties.  But, many patients reported that they felt they NEEDED to take another pill, even when they did not WANT to take another dose.  Within the past year, it was determined that Ultram was indeed a highly addictive medication.

Prosac and other SSRI anti-depressants were thought to be wonder drugs for depression, until it was found that patients were more likely to become extremely suicidal or violent.  Teenagers have the risk of becoming violent towards themselves or others.

Some Cox-II inhibitors, another class of drugs thought to be safe and effective, were pulled from the market after patients who were taking these meds died.

The list goes on.  But the majority of patients reporting unexpected side effects, or physical complaints that do not fit a particular "clinical picture," are routinely ignored and disbelieved.  Worse, these patients are often belittled, humiliated, and rejected by medical persons.  Persons suffering chronic benign pain often experience this lack of medical treatment, along with heavy judgments about their psychological state, without much medical investigation by any physician.

Hope for Relief & Gratitude!

When a patient finally does think they have found a doctor who will help them with their pain, they face another potential bias of doctors.  Yes, even gratitude is suspect!  Expressions of gratitude by a patient for having finally found a doctor who believes them, along with any description of the patient's perceived or real lack of treatment by another doctor, is viewed by doctors as being manipulative behavior on the part of the patient!   This is especially true of pain patients, who are always being judged on every behavior, action, and conversation - down to the exact single words a patient uses!  Again, this scrutiny by physicians is because most doctors believe that pain complaints are often due to something other-than real pain, and because doctors believe every pain patient may well be a "drug seeker" or "drug addict" who is trying to manipulate the doctor in order to get narcotics or other drugs.  

In fact, expressions of gratitude and descriptions of past bad treatment by other physicians, is often simply just that -- the patient's deep relief at having found someone who finally believes the very real pain the person has and the patient's hope that finally, finally that a cause will be found by an investigative physician who is as determined as the patient to know why they have such pain, so that the appropriate treatment will begin.  Even if the diagnosis is made of a real problem, but one that is untreatable, patients will still be relieved.  But, doctors are trained to be skeptics, and are uncomfortable hearing the complaints about their peers (and secretly fear the same criticisms will be made of them too!).  And so they see a patient's relief and return of hopefulness as pure manipulation!   What a disservice this is -- to any patient!    

In a different context, however, doctors react less-forcefully to the same expressions of gratitude and hopefulness when the patient is one who they misdiagnosed previously, and later the very  real condition of the patient is found.   Take a patient who initially complains of nausea and belly pain.  X-ray and blood work is negative, and the abdomen is not tender.  The conclusion: nothing is wrong and the patient is sent off with generic advice about dietary changes. The doctor has been "dismissive" to the patient -- maybe the pain is really financial or marital problems, or emotional issues surfacing because the patient served in Vietnam 20 years ago?   Months later, with the patient more debilitated from nausea and weeks of vomiting, another doctor knows something is wrong and more blood work is done (all normal), and sophisticated tests like M.R.I. are run, which show "a shadow."  More tests are ordered but the shadow cannot be visualized well.  The M.R.I. is compared to the old X-Ray -- which turns out to show the same shadow, but that was overlooked by the radiologist months ago.  Then, the shadow was small, but now the shadow covers half the M.R.I. film.  But still, no doctor knows what the shadow is exactly.  So the new doctor on the case schedules an "exploratory" surgery.  Lo and behold, the person has a web-like cyst which has attached "webs" out and around the liver, pancreas, and half of his small intestine.  Surgeons remove all of this benign (non-cancer) cyst, but have to remove all of his pancreas, part of the liver and part of the intestines.  Recovery is long after this marathon surgery, with a stapled incision running from the nipple line to pelvis.  The patient is very grateful to the new-doctor-on his case for finally finding the problem, and the patient is quite vocal about the shoddy care the other physician gave him.  And well the patient should be angry!

Now without a pancreas, this former run-of-the-mill diabetic has to have an insulin pump surgically inserted to control his blood sugars.  He recovers fairly well from that, but spikes repeated fevers.  After 7 weeks in the ICU, he has gotten one of the most common infections patients in hospitals can get: Staph.  Staph is a nasty organism and hard to get rid of, especially when one is already severely ill.  The IV antibiotics finally work, but now the man's veins are "bad" from repeated blood work and repeated IV site changes; his wife said his body was "one big bruise."  After 8 weeks of almost constant bed rest he is able to be moved to a chair, but now his heart rate drops to 30 every time -- a very serious problem!  Within days, the EKG monitoring his heart is so bad that nurses are in the ICU room 24 hours a day, with a "crash cart" just outside the door.  And one day, the expected unexpectedly happens - his heart stops.  They "bring him back" 3 times that morning.  He's fitted with a device to increase his heart rate, surgically implanted into his heart.  Fevers return; he sleeps most of the time.  Three very long months pass, fighting one problem after another.  After several weeks of difficult physical therapy, he is released to go home, still with an IV and home care nurses.  The family rejoices with the upcoming Christmas holidays and the man seems to be improving each day.  He's taken several walks on his farm to visit his beloved animals - life is returning to normal !   On January 2nd, he ate his breakfast with the foods on his special diet, prepared by his attentive wife.  He pushes back from the table, stands up and says he doesn't feel very well -- and collapses!  His wife, a nurse, knows he has stopped breathing.  While her son calls 911, she begins CPR on her own husband, and continues for 20 minutes until the ambulance arrives to their rural farm.  He has had a massive heart attack and major stroke!  Back in the ICU, unable to move his entire right side, he is in battle with his body, with his diabetes that is difficult to control without his pancreas, with fluctuating heart rate, and now a stroke caused by an embolism (blood clot that went to his brain).  

This once-hearty farmer of 200 pounds now weighs 88 pounds, a visual shell of his former self.  A man whose complaint was belly pain that was disbelieved and not diagnosed immediately, has gone to the brink of death at least 6 times (major times) and hovers constantly in illness now.  If this story seems unbelievable, I know it is true.  He is my friend who lives in a small town, whose doctors practice at a major Veterans Hospital.  His story is a perfect example of why doctors should never ignore pain complaints.  And, it illustrates a different reaction to a patient who is thanking the current doctor for better care, while at the same time voicing extensive criticisms of past doctors.

The impact of these common practices on Treatment of Pain

In Part 2 of the article on "The Somatizing Patient" (Servan-Schreiber, etal.), the authors go on to say:

"Patients often seem reassured when a specific name is given to the condition, such as "fibromyalgia," "chronic fatigue syndrome" or "irritable bowel syndrome." Such labels help them identify with the traditional disease model of their symptoms and reassures them that the physician is not thinking that it is "all in their head." To the extent that labels facilitate the physician-patient relationship and help focus the patient's efforts toward functioning better, there is no harm in using them. In one study, 90 percent of patients with chronic fatigue reported that receiving the diagnosis was the most important factor in their treatment course.4 Even when patients do not meet the diagnostic criteria that have been proposed for these different conditions, the labels can sometimes be used nonspecifically. For example, a patient can be told "you have a variant of fibromyalgia" if the main complaints are related to pain and"

Indeed, patients are increasingly told they have one of these three syndromes, even when the physical complaints do not conform to the diagnostic criteria for any of the three.  Some professional literature has described fibromyalgia as the "garbage diagnosis" given to patients whose doctors simply don't believe the patient's complaints.  Patients often report that doctors attempt to force the patient to adapt their physical complaints to the diagnosis; Even when patients state emphatically that they do not have certain symptoms, the doctor insists that the patient does have "some" amount of those symptoms!  One doctor insisted a patient had recurring bouts of alternating diarrhea and constipation, to fit the diagnosis of irritable bowel syndrome - when the patient had neither, and only reported nausea.  Later, X-Rays with barium showed a small duodenal ulcer and with appropriate treatment, the ulcer healed and the nausea went away.   A patient labeled with fibromyalgia finally had spinal X-Rays which showed a disk problem severe enough to require surgery.    

Far too many complaints of fatigue have legitimate causes (including the busy schedules and over-extending of time that many Americans of the "Baby Boomer" and "Sandwich Generation" face, with taking care of children and elderly parents at the same time.)

The fact that it is most often women who receive one of these three labels, along with the belief of physicians that the majority of women have underlying psychological issues, makes it blatantly clear that women's complaints of REAL PHYSICAL PAIN are simply dismissed.   My sister, an uncontrolled diabetic on several doses of insulin every day, reported chest pain for a year.  She was flat out called crazy, and instead of appropriate cardiac testing, three psychologists visited her in her hospital room and she was discharged the next day with advice to "take a vacation" (this advice, to a poor person living on disability income).   The chest pain continued. In a diabetic, the nerve endings become damaged; hence, any report of chest pain is a red-flag for cardiac problems.  She was known to already have heart problems, but the cardiac specialist told her it was "nothing" when her EKG was apparently normal.  He was condescending, rude, and humiliating when he sent her on her way, "Don't come back unless you have a REAL problem."  Within three weeks, my sister dropped dead of a massive heart attack.  

Far more appropriate for a patient complaining of pain is to rule out any major condition, FIRST.  If initial testing is unremarkable, a doctor should remain open to the possibility that the condition is simply not showing YET on standard testing (and that numbers assigned as "normal limits" on blood tests may not be "normal" for this patient).   Several MRIs, repeated at intervals, may be needed before the problem is severe enough to show on that test.  

The problem remains though of how to treat the millions of Americans  who report severe chronic and daily pain. Certainly not all these millions of people are psychologically impaired or are somatizing! (Sarcasm intended!)  It is preposterous to think that ALL these untreated or under-treated patients ALL fit the current beliefs held by physicians!

Need for re-education of Physicians

Hopefully the 3,000 to 5,000 doctors now specializing in pain management with opioid treatment will be able to educate their peers soon!  Unbelievably, students in medical school have only about 5 to 10 hours of instruction on pain, pain control and concurrent issues.  And much of that instruction centers on drug-seeking behavior, addiction, and Federal substance abuse laws, thus perpetuating the same myths among new doctors. 

Dr. Eric Chevlen, who is a teacher and frequent lecturer, focuses on several points in his lectures to other physicians.  Some important things to consider in administering opioids include (example of a CME  lecture, scheduled for Spring 2006):

Determining those chronic pain patients most likely to benefit from opioid therapy, based upon the potential risks and benefits

Initiating a trial of opioid therapy and assessing ongoing risks and benefits in the treatment of the chronic pain patient

Optimizing the analgesic potential of opioid therapy through titration, rotation, conversion, and adjunctive therapy in the management of chronic pain

Applying the basic documentation and medico-legal requirements necessary to support appropriate opioid prescribing 

Right now, society's views match the beliefs held by physicians: that people on narcotics are drug-seeking drug-addicts.  As more physicians become comfortable with managing pain as part of their everyday "Family Practice" office, hopefully they will be able to educate society and legislators about the stigmas and myths surrounding treating chronic pain with appropriate narcotics.   The federal government needs to acknowledge that the "War on Drugs" does not mean that people in pain should simply be left to suffer.  The Federal Government and each State needs to enact a "Pain Law" that outlines the human right to receive treatment of complaints of pain.  (The 106th Congress failed to pass H.R. 2260[106]: "Pain Relief Promotion Act of 2000." )⁶

America prides itself on organizations like the SPCA and county governments pay to employ someone in the capacity of Humane Officer who looks after the welfare of cats, dogs, other domestic animals and wildlife.  There are laws to prevent animal abuse and suffering.  And, when an animal IS seen to be suffering, appropriate pain medication is given BEFORE the animal is examined.  In worst cases, society condones and accepts humane euthanasia when there is no other treatment available.  While our society does not condone suicide or assisted suicide, certainly society as a whole can have the same compassion towards people in pain as what we do for animals in pain.  Far too often, patients complain: "They wouldn't let a dog suffer in pain the way I am suffering!"

NOTE: Some States have enacted "Pain Laws".  The General Assembly of the State of Ohio, enacted by the 122nd General Assembly, created an Act "Substitute House Bill Number 187" of the Ohio Revised Code Effective October 14, 1997, "To enact sections 4731.052 and 4731.283 of the Revised Code regarding the authority of physicians to prescribe,  dispense, and administer dangerous drugs for management of intractable pain."  This law was proposed by an Ohio Representative who watched his mother die of cancer, in unnecessary, needless and horrific pain.



Note 2: Patients' pain is often disbelieved by nurses too.   

"Culture not only affects patients’ expressions of pain, but influences the way nurses respond to and manage that pain. In fact, the values of nurses as a professional group may come into play. For instance, nurses value self-control and the ability to work well in stressful situations. They often expect patients to fall in line with similar ways of dealing with pain; that is, to be uncomplaining, calm, and objective.²

On the whole, nurses tend to under evaluate patients’ pain, attributing pain behavior to mental or psychological distress, rather than actual physical pain.^{7" (footnotes are from the original article)  -} As quoted from:  http://www2.nurseweek.com/ce/self-study_modules/course.html?ID=304&PageNum=2&Begin=6112

Bibliography:

1. David E. Weissman, MD, (Professor of Medicine - Hematology/Oncology - Medical College of Wisconsin), "Pain Management and the Bogeyman" published in "Reflections," a collection of essays by the health professionals of the Medical College of Wisconsin. Article Created: 2001-11-29  URL: http://healthlink.mcw.edu/article/1007067408.html

The Controlled Substances Act (CSA) of 1972, which supersedes and replaces the Harrison Act and all intervening federal drug legislation, makes it a federal offence to prescribe controlled substances to a drug addict for the purposes of treating or maintaining their addiction, except where the physician holds a separate DEA license to provide methadone maintenance. -- from http://www.doctordeluca.com/Library/UWOD/UWOD5-DenominatorAbuse.htm 

2  Alexander DeLuca, M.D.  "Understanding Drug War Statistics, Part 5: Denominator Abuse and the Chilling Effect; The misleading use of an incorrectly computed rate statistic"  June 17, 2004. "Addiction, Pain, & Public Health" website.   Posted 2004-06-17;  Revised 2004-08-19;  Modified: 2005-12-18.  This document is an edited excerpt of "Analysis of 'The Myth of the Chilling Effect.' http://www.doctordeluca.com/Library/UWOD/UWOD5-DenominatorAbuse.htm

June 17, 2004. Posted 2004-06-17; Revised 2004-08-19; Modified: 2005-12-18. 
This document is an edited excerpt of "Analysis of 'The Myth of the Chilling Effect.'

also read:  http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.48606

  3.  Dr. Eric M. Chevlen received his M.D. from Ohio State University in 1974.  His internship was at Case Western Reserve University Affiliated Hospitals, and his residency was at Mt. Sinai Hospital in Cleveland. Dr. Chevlen served his oncology fellowship at the National Cancer Institute 1976-1978, and his Hematology Fellowship at the University of California at San Francisco, Cancer Research Institute. He is one of the few physicians in America to be certified by five specialty boards: the American Board of Internal Medicine, the American Board of Medical Oncology, the American Board of Hematology, the American Board of Pain Medicine, and the American Board of Hospice and Palliative Medicine. He has been a diplomate of the American Board of Pain Medicine.  Dr. Chevlen specializes in the treatment of cancer and pain and palliative care.. He also serves as the Director of Palliative Care at St. Elizabeth Health Center, and is a hospice medical director in Youngstown, Ohio.   Dr. Chevlen was one of a select group of medical specialists who testified before the Senate Judiciary Committee on April 25, 2000 concerning The Pain Relief Promotion Act of 1999 --- see the following website for the text of his testimony and remarks: http://commdocs.house.gov/committees/judiciary/hju62489.000/hju62489_0.htm     
The Bill, H.R. 2260[106]: Pain Relief Promotion Act of 2000 was considered by the 106th Congress, and endorsed by Medical professionals and the American Nurses Association,  but the bill never became law.

Dr. Chevlen is also an educator and researcher.  An assistant professor of internal medicine at Northeastern Ohio Universities College of Medicine, he lectures widely on pain and palliative care.  Dr Chevlen has indicated that he is a research consultant for Endo Pharmaceuticals, and has served as a member of the speakers bureau for Cephalon Inc., Janssen Pharmaceutica, Ligand Pharmaceuticals, Organon, and Purdue Pharma.  He has conducted research in the area of opioid analgesia.  With Wesley J. Smith (an attorney), Dr. Chevlen is co-author of the book Power over Pain.  He currently practices medicine in Youngstown, Ohio, where he lives with his wife, Laurel, and their two sets of twins.  [Parts taken from the website www.pain.com]

If interested, you may read an interview with Dr. Chevlen conducted by ww.pain.com  on the subject of cancer pain.

See also "Chevlen, Eric M., M.D. A Bad Prescription from DEA; The drug agency's misguided campaign against a painkiller,"  The Weekly Standard,  June 4, 2001.  Full article online at http://www.cpmission.com/main/misguided.html    Originally posted to doctordeluca.com 12/18/2003.  See also Terence Gorski's analysis which draws heavily on Chevlen's article: "OxyContin - Why DEA Enforcement Is Misguided"  - As quoted by Alexander DeLuca, M.D. on the "Addiction, Pain, & Public Health" website  This was originally posted to www.doctordeluca.com on 12/18/2003.  

4. Dr. Hochman is a pain specialist and the Executive Director of the National Foundation of the Treatment of Pain.  He estimates that the number of physicians practicing "chronic opioid therapy" was 5000 in 2002. This estimate is somewhat close to the "3000 pain specialists" estimated by Eric Chevlen. [Chevlen, 2001] 

5. Servan-Schreiber, David, M.D., Ph.D., N. Randall Kolb, M.D., and Gary Tabas, M.D.  "Somatizing Patients: Part I. Practical Diagnosis,"  University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.  AAFP Home Page > News & Publications > Journals > American Family Physician® > Vol. 61/No. 4 (February 15, 2000): http://www.aafp.org/afp/20000215/1073.html 

Ibid., "Somatizing Patients: Part II. Practical Management."  AAFP Home Page > News & Publications > Journals > American Family Physician® > Vol. 61/No. 5 (March 1, 2000): http://www.aafp.org/afp/20000301/1423.html   This 2-part article ".. is based in part on a paper written by the first author and previously published as Servan-Schreiber D. Coping effectively with patients who somatize. Women's Health in Primary Care 1998;1: 435-47."  (University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania A patient information handout on somatic illness, written by the authors of this article, is provided on page 1431.)

6. 106th Congress - H.R. 2260[106]: Pain Relief Promotion Act of 2000
Status: Passed House (91% of Republicans supporting, 69% of Democrats opposing.)
This bill was proposed in a previous session of Congress. Sessions of Congress last two years, and at the end of each session all proposed bills and resolutions that haven't passed are cleared from the books. This bill never became law.   Introduced: Jun 17, 1999   Last Action: May 23, 2000: Placed on Senate Legislative Calendar under General Orders. Calendar No. 566.  Sponsor: Rep. Henry Hyde [?-IL] -- http://www.govtrack.us/congress/bill.xpd?bill=h106-2260