by Dr. Charlie Reznikoff, MD
A few months ago while attending the general medical floor I met a 60-year-old patient in a tragic situation. She was holding her household together — cooking for, cleaning up after, and parenting her granddaughters, managing the family finances, and trying to reform her two twenty-something daughters who preferred partying to raising their kids. One day she just collapsed. In the emergency room she was diagnosed with widely metastatic cancer of unknown primary. Liver. Bones. Lung. She had less than six months to live.
She had pain. Prior to her diagnosis, her pain was unmedicated. She had dealt with the pain because she prioritized her family over her needs. With the diagnosis of terminal cancer, she learned she would never see her granddaughters grow up, or help her daughters mature. She was comfortable in the care-taking role, but the roles would reverse, as she would become dependent on others in her final months. Her grief was profound. She suffered tremendously, and expressed her suffering as pain from her bony metastases.
Within 24 hours of admission to the hospital she was on continuous intravenous hydromorphone. We had to lower the dose before family meetings so she could participate meaningfully. In my role as a hospitalist I believed the hydromorphone I prescribed was appropriate. But the Addiction Medicine part of me asked, “What happened?” She was living with her pain 24 hours before admission, and required heavy palliation 24 hours after. Her disease had not progress in that time. Only after she had knowledge of her cancer, or maybe its implications, did she report pain. Maybe losing her role as the caretaker, or leaving her home, full of cues to be the caretaker, caused her experience more clearly what was happening in her body. Or maybe we just pushed opioids on her.
Treating pain is rife with uncertainties like this. There is no biomarker for pain. Assessing pain is dependent on the communication skills of the patient and doctor. Pain is not one thing, but many, and all are in interplay. Opioids complicate, not simplify, the treatment of pain. Opioids powerfully relieve psychiatric symptoms, but they are not indicated for any such conditions. How could I tell if hydromorphine was relieving this patient’s nociceptive pain, or quelling her suffering? That is probably a false distinction because each cause of pain compounds the other.
Now if you consider patients with addiction, mental health issues, and pain, the picture becomes muddier. “Pain” in such a person is like “dyspnea” in a patient with heart failure and COPD. Pain warrants opioids like dyspnea warrants furosemide: sometimes, with caution, but not always, and not reflexively. Yet addicts suffer more than almost anyone with nociceptive pain. Patients with pain, addiction, and mental illness can challenge any doctor’s ability to deliver safe and compassionate care. Since I started lecturing on pain management, I’ve tried to furnish my audience with usable tools to better care for these complicated patients.
My first attempt to provide clear guidance through the quagmire of opioids, addiction, mental health, and pain was a talk called Ten Prescriptions Never to Write. My speeches have evolved a bit since then. Prohibiting behavior is less useful than offering solutions, which I hope to do in my talk at Hospital Medicine 2015. I left the title the same, as a reminder not get paralyzed by hopelessness so common for this topic.
I will not give you a David-Letterman-style countdown of scripts never to write at the lecture. I will give it to you, right now, below. Please react to these verboten prescriptions, question me, debate, and offer your own anecdotes on this topic.
1. Alprazolam (lorazepam is safer)
2. Methadone for pain, unless very experienced
3. Opioids, greater than 100 mg morphine equivalents daily
4. Carisoprolol or butalbatol, which are short acting barbiturates
5. Tramadol is not a safer option for high risk patients
6. Short-acting psychostimulants (amphetamine, methylphenidate)
8. Long acting hydrocodone “Zohydro”
9. Any opioid until you’ve assessed addiction and mental health
10. Any prescription under duress
See you in National Harbor on April 1st to continue the discussion in person!
Dr. Charlie Reznikoff MD completed his internal medicine residency at Hennepin County Medical Center, after which he stayed on for a chief year. He then completed a two year fellowship in addiction psychiatry at the University of Minnesota. Since that time he has been on staff at Hennepin County Medical Center as a general medicine attending physician and addiction/pain consultant. Dr. Reznikoff sits on a hospital committee that monitors and reviews the most challenging pain patients in the hospital system. He has opioid, tobacco, and alcohol addiction clinics, including 10% of his time in a small rural Minnesota community stricken with heroin addiction. He is appointed to the state medical cannabis task force. Dr. Reznikoff is also an assistant professor of medicine at the University of Minnesota, teaching medical professionalism to first year students. In his spare time he plays ultimate frisbee.