The Narcotic Prescription Epidemic–Part II

2) the other major development in medicine was the correct general realization that we were truly not treating pain sufficiently in certain groups of patients. I can remember that prejudice toward chronic pain patients especially the back pain patients whom everyone but dreaded treating, as they very often bore out the vein that led to addiction as sure as shootin’ as we would say in the Southwest. A back injury, or back then a whiplash neck injury occurred that often unfortunately was minor. In a sizeable number of patients it was major, required surgery and was demonstrably real. But the majority of back injuries did not respond consistently or very successfully to surgical interventions. Subsequently the overwhelming majority of long term review studies retroactively done at many reputable neurosurgical and orthopedic meccas have shown again and again that back surgery often does little or nothing to ameliorate or relieve chronic back pain. In fact the more conservative measures, though not curative by any measure, even, “shudder,” chiropracty had more salutary effects in “managing” reasonably this chronic condition. Acupuncture, heat treatments, TENS unit local stimulation, nerve blocks and intra-dura or nerve root exit injections of depot local anesthetics and anti-inflammatories did more. The term “failed back syndrome’ came into vogue and helped to group together and target this suffering group of patients.

Other social trends started to appear in the 1980’s economically. The insurers and think tanks studied these patient groups intensively for years taking the newly discovered methods of outcome studies, pooled ‘big data,’ and applying them first to conditions such as heart failure. With regard to a more easily defined medical conditions such as “CHF,” in comparison to the more subjective psychiatric conditions, it became quite possible to put into place practice protocols and practices that autiting and “quality care organizations,” could demonstrate improvement in the care of patients with the ‘easy conditions’ such as community acquired pneumonia and CHF. These steps also began to decrease the rates of “rapid readmissions” of such patients, more efficiently managing them effectively at home and keeping them out of the more expensive hospital health care settings which cost ALL of use indirectly in our health insurance rates.

Not so with chronic back patients. Almost nothing worked and certainly not something as definitive and concrete as surgery whose results results were so astoundingly bad that the term “failed back [surgery] syndrome was stimulated into being. The surgeons of the Western medical world were professionally responsible (and I mean this sincerely) and responded by opening their tried and true approaches to impartial review to decide the issue of effectiveness. To their credit they did not close ranks and refuse review which seems to have become the more recent norm in preventing “transparency.” And the incidence of back surgeries somewhat indiscriminately for pain dropped like Grandma’s iron skillet. But to place this technique in context, it was one of the few tools we had and physical therapy was in its scientific infancy and had not had the years of studies to demonstrate its true effectiveness.

Pain is a subjective phenomenon. It is almost impossible to to measure if at all by objective means and data. The fundamental flaws was its quantification was dependent almost exclusively dependent upon the patient’s description. And in the pain world, there is too much potential for secondary gain, and unlike cancer, for instance, a patient can claim cancer and not die from it. And if the analogy held the intervention for pain is more pleasant than the daunting treatments for cancer, such as chemotherapy with all its very unpleasant side effects, irradiation and disfiguring surgery. And one did not die and can continue to receive a pleasurable treatment on their assertion of the existence of the condition alone. It is to be remembered that in almost in all other serious medical maladies we require the confirming ‘scientific’ tests such as imaging, blood tests, physical findings with examination, progression of symptoms, impairment of organ functioning and easily often demonstrable impairment of functioning. Of course genuine back pain is bad and challenging and impairs functioing. I know myself as I have chronic moderately severe back pain from crushed vertebral bodies from the decalcification of those from multiple myeloma 2 1/2 years ago. But I like the more responsible approach is for the long run, “management of the pain” through safe means, not narcotics. But so many less “gumptioned” persons as my late Texan father would say, do not take that stance and want the quick fix that leads to the predicable severe problems later down the road.

I remember a colleague psychiatrist in psychiatrist who devoted several years’ effort and research, with clinical trials, more ‘try-outs’ on his part, administering his self constructed “Pain Index” to countless patients in a community and university hospital to try to demonstrate a relatively reliable measure of pain for use in both research and measurement of the effectiveness of any newly research pain intervention. As we in medical care would say, if he had come with something valid, he really “would have had something.” He was so dedicated to this he put countless hours into integrating its administration to pai patients of kinds. He had others administer it trying for “inter-rater reliability” and consistency. He correlated it in those days, just as the original IBM PC came out to correlate the results of each patient’s test results before and after interventions with their clinical diagnosis and symptomatologies of all types. Nothing definitively emerged and his work on the psychiatry consult liaison service quietly stopped.

So we had nothing to work with objectively or scientifically for all intents and purposes. I remember some of us at Duke and UNC joking harshly about resorting to primitive discredited procedures as the galvanic skin response. and took the results and outcome studies which were dismal and discouraging as no discrete treatment really achieved pre-eminent success more than any other approach in this growing group of working persons in ALL walks of life, but especially concentrated in the physically demanding occupations that involve lifting and toting to quote a song…


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