Monday, September 07, 2009

Coming to Know the Limits of Healing -

As I pondered postgraduate choices in medical school, I divided the medical specialties into joyful ones like obstetrics (congratulations, it's a healthy baby girl), grim ones like oncology (better get your affairs in order) and faceless ones like pathology (in which the good or bad news is delivered via an impersonal report).

I recognized I didn't have what it took to be grim. And because I love dealing with people, faceless was out. I landed in pain medicine by chance, and surprisingly, I've found that it fits in the joyful category: there are few better feelings than easing a patient's suffering.

Still, after a demoralizing recent constellation of patients, I was left wondering which is worse: informing people that they are going to die, or that they are likely to spend the rest of their lives in pain.

I've followed one older patient for five years now. He is a lovable gentleman in his 80s with chronic back and leg pain. Over the years, we've been through successive trials of different medications and treatments — some of them quite unconventional. Despite our best efforts, he continues to suffer moderately severe chronic pain.

My patient and his family are habitually early for clinic appointments, always exquisitely polite, forever compliant with my treatment recommendations. That he is never demanding, only grateful, makes it all the harder when my efforts fail.

Then there are the young veterans, frequently in their 20s, freshly back from combat. Chronic pain is often complicated by traumatic brain injury, untreated post-traumatic stress disorder, and sleep and mood disorders.

The challenge here is to find a balance between pain relief and side effects; to ensure that opioid painkillers like Percocet and Vicodin are being used to treat pain, not mood or sleep. I find myself in the unenviable position of limiting access to pain medications if their use will lead to functional decline.

The American Pain Society and the American Academy of Pain Medicine recently published their joint Opioid Treatment Guidelines. They include some sobering facts — for example, that nearly all the highest-quality trials evaluating the value of opioids for chronic noncancer pain were short-term efficacy studies, just 16 weeks or less. In clinical practice, patients are often maintained on opioids for years or decades.

Moreover, the studies generally excluded patients at higher risk for substance abuse or with significant coexisting medical or psychiatric problems; that, too, is unrealistic in clinical practice.

And trials suggest that on average, patients given opioids experience an improvement of only 2 to 3 points on a pain scale of 0 to 10. Side effects and risks abound: chronic constipation, sedation and somnolence, a worsening of mood, opioid-induced hyperalgesia (a paradoxical phenomenon in which pain medications actually increase pain), hypogonadism (impaired endocrine function) and addiction. Recent studies also suggest an adverse effect on immune function.

Still another slap in the face came in an article from The Journal of the American Board of Family Medicine that a colleague helpfully placed on my desk. The title — "Overtreating Chronic Back Pain: Time to Back Off?" — and the introduction said it all: "Innovation has often outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments. Complications and even deaths related to pain management are increasing."

The downward spiral, the authors wrote, begins with inappropriate imaging, which may reveal irrelevant and incidental findings that lead to unnecessary treatment. Echoing the new guidelines, the authors called for judicious use of opioids to treat chronic low back pain. And they advocated more careful selection of candidates for spinal injections and spine surgery, pointing out that such interventions can actually make matters worse.

"First do no harm" is the guiding principle we learned in medical school. But one skill that is not taught is an easy way to say, "There is nothing more I can offer you."

I've learned that my specialty, like every other, has its limitations. I've learned not to take those limitations personally: they are not a reflection of my inadequacies, merely the current state of the science. (Mastering this is where science becomes art.)

I've learned, too, that it is important that I come to terms with these therapeutic gaps first, so I am effectively able to convey realistic expectations, not perpetuate medical myth. At last, I've grown more comfortable with two of the hardest words in a doctor's vocabulary: "enough" and "no."

Colin Fernandes, a physician and writer, is director of a pain clinic in Northern California.

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