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H Rex Greene, MD

Note: Cancer Care: 50-60% who die of cancer have significant pain; 90% direct effect greater than 60% bone metastasis

1. Culture of Pain Management

   Hospice Terminal care 90-95% Commitment Family = unit of Rx Patients values affirmed Treatment by the clock Pro-life: Rehab Model Flexible job descriptions Patient seeks meaning No Code 50% die at home

   Hospital Curative 0-5% Technology Family = alien intruders Patient learns to beg or suffer in silence Demerol 25 mg IM q 6 prn Death is the only way out Silos, hierarchies and autocrats Staff seeks meaning (pejorative labels):   Crock, Gomer, 10 7-2 (metonymy),   The Gallbladder (synechdoche) Death = failure Full Court Press

   
   
   
2. ECOG Study (Cleveland NEJM 3/94)
   • 1308 CA patients at 54 outpatient sites
   • 67% pain causing decreased function in 36%
   • 597 "completely evaluated"
   • 42% adequate treatment

3. Predictors of poor control:
   • Minority (3x), old, female, benign pain, MD/Patient disagreement
   • 15-38% of MD's would not prescribe strong opiates regardless of indication

4. Medico-legal Issues:
   • Clath and Sees. JouL of Symptom and Pain Management 1993
   • 1/3 of MDs unwilling to prescribe opioids
        56% of California MDs either don't have or don't use triplicates
   • Harrison Act (1914) Taxation under Treasury Dept
        Ended Maintenance treatment
   • Comprehensive Drug Abuse Act (1970)
        Five schedules of drugs per "abuse potential"
   • Federal definition of addiction
     1. "Habitual use that endangers public morals, health, safety and welfare.
     2. Use to the loss of self-control.
     3. Use of "Narcotics." Physicians must prescribe in "good faith" for a defined "pathology" for a defined period of time.
   • California Intractable Pain Act (SB 1802)
     • Chronic, incurable pain, verified by second opinion
     • Treatment of Addicts with opiates (Sect. 2241, H&S Code)
     • May prescribe opiates "in emergency treatment in the presence of incurable disease."

5. Barriers to Pain Control:
   • Regulatory:
     • Triplicate Rx Hassles
     • War on Drugs
     • Oversight/Quotas
     • MBC-25% disagree with the use of opiates for CA pain
   • Attitude:
     • Suffering is redemptive
     • Avoid "strong" drugs until the end
     • Fear of Addiction
     • Culture of care (hospice vs. hospital)
   • Understanding the Medical Illness of Addiction:
     • Triad-antisocial behavior plus compulsive drug-seeking plus abstinence syndrome
     • Very low risk of addiction in medical illnesses:
     • Boston Collaborative Study 4/11,892
     • Burn Center 0/10,000
     • Headache (Medina 3/2,369
     • Cancer (MSKCC 2/1,000
   • Refined Understanding of Addiction:
     • Tolerance, dependence, withdrawal and anti-social behavior
     • Complex primary illness with genetic/familial risks
     • Onset in adolescents and young adults that results in dangerous behavior despite consequences
     • Two sub-types:
       1. Self-medication for symptoms of early mental illness
       2. Recreational use that gets out of control
     • Pseudo-addiction:
       • Drug-seeking behavior due to under-treatment of pain
   • Ignorance:
     • "The relief of pain awaits no scientific breakthrough." (B. Ferrell)
     • "Prescribing Demerol is prima facie evidence of incompetence in pain management"(B. Ferrell)
     • Morphine is "God's own medicine (GOM)." (Osler)
   • Wrong Drugs:
     • Demerol: The Perfectly Wrong Drug—Short acting, irritating, toxic metabolites
     • Stadol/Talwin: Mixed agonist/antagonist
     • Darvon: Aspirin with lethal side-effects
   • Wrong dose/schedule:
     • "PRN" orders
     • "The Magic of Needles"

6. Pain Management
   • Quality of pain:
     • Acute > Recurrent Acute > Chronic
     • Localized/generalized
   • Cognitive:
     • Perception
     • Threshold
     • Intensity
     • Tolerance
     • Tachyphylaxis

7. Pain Modulation System
   • Endogenous opioids
   • Affected by emotional state
   • Chronic pain unverifiable
   • Pain vs. Suffering
   • Spiritual
   • Psycho-social
   • Existential

8. Clinical Approach
   • Detailed investigation with each episode
   • Family/Social History (explore expectations)
   • Attributes of pain
   • Physical Examination
   • Diagnostic Studies

9. Treatment
   • Local Modalities;
     • Radiation
     • Surgery
     • Orthopedics
     • Anesthesia
   • Systemic
     • Drugless
     • Specific Rx
     • NSAID's
     • Other Rx

10. Opiates "God's own Medicine" (Osler)
    • Treat by the clock
    • Anticipate side-effects: Nausea constipation sedation itch confusion paradox
    • Monitor results closely:
      • Objectify the subjective (pain scales)
      • Diurnal variation
      • Constant blood levels
      • Break-through medication
      • Cross-over to other opiates

11. Route of Administration
    • IV—Trans-dermal
    • Sub-lingual—Oral
    • Rectal—Delivery systems: PCA

12. Pain Crisis
    • IV medication
    • Start high and work down
    • Sleepy for 48 hrs (warn family)
    • Special Problems:
      • High dosage requirements
      • Sudden Decompensation in stable patient
      • Constipation Self-withdrawal
      • Psycho-social

13. Adjunctive Medications
    • Steroids "Dr. Greene's Tonic"
    • Anti-depressants
    • Anti-convulsants
    • Anxiolytics (not TM)
    • Phenothiazines Pamidronate

14. Rex's Rules of Caring for the Dying
    1. Touch the patient (talk with comatose patients)
    2. Treat pain no matter what.
    3. Do Not Resuscitate!
    4. If in doubt, send the patient home.