By R Carter
|The Old School of Thought|
I was a practicing Certified Registered Nurse Anesthetist (CRNA) from 1977 until 2002 before my career was ended by degenerative disc disease and a five level lumbar fusion. In that time I administered close to 25,000 anesthetics in my career.
I trained in a rural regional hospital out west, in Garden City Kansas, where the economy is based on farming and ranching. As such we saw a lot of injuries to extremities; hands, arms, feet and legs. Someone was always getting something crossed with some kind of machinery and getting injured. For that reason, about 40% of the anesthetics I gave were known as regional blocks. Local anesthesia used to make a specific body part numb, followed by IV conscious sedation or a general anesthetic when indicated. My instructors called these anesthetics the Cadillac of Anesthesia because patients did so well with them during and after surgery. Rarely did we have to use patient controlled IV infusion pumps post-op for pain management, we simply topped up a block and would do so for 1-3 days after surgery. Patients went home in shorter periods of time taking less pain medication, returned to work sooner and were happier. In a small community, some would drop by your house with a pie or cake, thanking you for doing it so painlessly, ah yes those were the days. When was the last time you wanted to give your medical provider a gift for a job well done?
When I got out of school I went to work in a large trauma center and at first I thought, this is the perfect place to continue what I was taught in school, but to my surprise, performing the Cadillac of Anesthesia was frowned upon and why? Because it took too much time, speed for the sake of volume and profit took precedence over all other concerns.
Consequently general anesthetics were the default, followed by patient controlled IV infusion pumps with opiates. This was between 1980 and 1985; looking back I can see how such attitudes contributed to the opiate crisis we have today. When I launched out on my own in 1986 I went back to doing blocks, providing patients with that Cadillac anesthetic and it showed in the number of high ratings the surgery department got for the services provided.
|The New School of Thought|
Anesthesia departments around the country are now doing research on these types of anesthetics but with a twist, relying more on non-narcotic analgesics in the post-op period, with a rescue opiate when needed, and the results are encouraging as reported by Dr. Michael Englesbe, a surgeon in Michigan and Co-Director of Michigan OPEN (Opioid Prescribing Engagement Network). To listen to him and his team, they are discovering something new, something old goats like me were taught decades ago.
These techniques work great for acute pain in opiate naive patients, but for chronic pain patients undergoing surgery, there are still difficult challenges which have not been overcome; and there is little or no research I know of looking at how to manage post-op pain in opiate tolerant patients who live with chronic pain.
|The Present State of Acute Pain Management in Chronic Pain Patients|
As I support and advocate for the chronic pain community I talk to hundreds of chronic pain patients (CPP) and this topic comes up often; as many of them have had multiple surgeries after being on opiates for years. With uniform consistency CPP will tell me that having surgery is a last resort, just short of dying and rightly so. For in this climate of opiate hysteria with fixed arbitrary limits, CPP are always undertreated for pain. In part this is due to providers being inexperienced with opiate tolerant patients, they have no frame of reference for it’s not taught in schools or residencies anymore.
I’ve been told the average medical student gets about two weeks of instruction in pain management while in school. They get no training for opiate tolerant patients, instead they are instructed to refer to a pain specialist. There are no tools for measuring the level of tolerance a CPP has, it’s literally a trial and error method requiring hands on experience, therefore students have no grasp for what constitutes adequate pain management in CPP.
This problem, the lack of research and education for treating acute pain in a CPP, is an area which has been continually brushed aside as healthcare professionals try to come up with new solutions for treating pain. As I look at NIH funding for medical research, on average less than $200 million is spent annually on chronic pain research out of a nearly $30 Billion dollar budget for research. Why is this?
Yet the NIH is easily pouring close to $1 Billion a year into research for alternatives, non-opiate pain relief and or addiction concerns. They will spend more than $5 Billion on cancer, $1.2 Billion on Heart Disease and $1 Billion on diabetes yet the cost in dollars for chronic pain out strips all of these combined.
|Americans not Angry Enough Yet|
As such the CPP community is both outraged and resentful over it, but they seem to be the only ones and of course, no one is listening to them. CPP see it when going to an ER following an injury or due to a chronic medical problem, they’re almost always accused of being drug seekers and are turned away with no medical treatment at all, or medical treatment minus any pain management. The stigma of taking opiates for chronic pain has the medical profession treating CPP almost as if they were lepers, fearful that any pain medication is going to send the individual into some kind of out of control drug seeking benign. That’s the stigma.
|From the Perspective of an Anesthesia Provider|
Coming from a healthcare background I had trouble wrapping my head around such stories until it happened to me. In January 2019 I fell, breaking my left humerus in two places, at the elbow and the shoulder, the elbow required surgery.
I had to wait two days before I could have surgery and through the entire time I was offered nothing more than what I had been taking for chronic pain. Speaking from experience as a pain specialist and a patient, I can tell you this is the same as being an opiate naive patient and being offered aspirin or Tylenol for two broken bones. When my pain level would reach an 8 or 9, the only thing I could be thankful for was not being at home where I kept a loaded gun next to my bed.
What I was allowed take in the way of pain medication was a token jester at best, allowing healthcare providers to document that the patient was medicated, but then not enough to raise any concerns for the opiate police, who are out there monitoring such efforts.
And that’s what this is all about, fear of repercussions for treating pain adequately. Opiate hysteria is throwing people under a bus with token jesters to give the appearance of doing something when in fact; nothing of significance is being done.
|The Cost of Pain in Numbers|
The CDC estimates each year 214,000 people die from injuries, 1 person every 3 minutes. But these deaths are just the tip of the iceberg. Each year, millions of people are injured and survive. They are faced with life-long mental, physical, and financial problems.
- 2.8 million people were hospitalized due to injuries in 2015
- 27.6 million people were treated in an emergency department for injuries in 2015
Of the 27.6 million injuries about 8% of them occur in CPP, that’s 2.2 million people each year or 4 people every minute. These estimates are based on 2016 CDC estimates of the number of CPP per US population. They are individuals who are already taking some type of pain medication and have a tolerance to opiates.
I can say with confidence that for opiate tolerant patients, those who require opiates daily, on average they require anywhere from 2x to 4x as much medication for pain relief as an opiate naïve patient. They can tolerate these amounts without risk for OD because of that tolerance. But CPP don’t get this for two reasons:
- First, it requires time and effort to titrate (find the right amount) of such doses.
- Second, opiate hysteria prevents healthcare providers from considering anything except a token effort; even for opiate naive patients.
So, taking the CDC at face value about being faced with life-long mental, physical, and financial problems due to injuries, isn’t under treating pain for weeks on end, essentially contributing to their injuries?
That’s the pill our government wants America to swallow, just so they can try to stop those who abuse and overdose on opiates. With CPP committing suicide for lack of pain management, many are beginning to ask if it’s worth it. I can’t help but think that if I were an attorney, I would be seeing gold in them-thar-hills. But as yet, I don’t see attorney’s chasing this ambulance and it leaves me scratching my head for why.
|A New Hope as Medical Experts Wake Up|
In May 2019 the Pain Management Best Practices Inter-Agency Task Force Report was released, you can read excerpts from those finding in this link. In a nutshell what they say is that for the most part, medical researchers backed by government funding through NIH, have been chasing only part of the problem by attacking pain management with prescription opiates. This includes the 2016 CDC Guidelines for Chronic Pain Management. They call for increased NIH funding for chronic pain management research, a multimodal approach to pain management and additional funding to providers for doing this in-depth work when managing pain.
|The Cadillac is back|
The report also talks about acute pain management for opiate naïve patients and CPP. It advocates for the use of regional blocks in combination with general anesthetic techniques to reduce the need for opiates during and after surgery.
As you can well imagine, I was quite pleased to see this, having come from an old school where this was taught. Looking back I can see that after forty years of profit before patient care, it took an opiate crisis to bring some common sense back to the practice of pain management for both for opiate naive patients and CPP.
Even though some are couching it in the context of something newly discovered, us old goats know it just ain’t so, leaving me just one thought. When are these youngsters going to start listening to their elders?