Everybody Hurts: California Medical Board recommends compassion, caution in pain management

On Monday, the Medical Board of California’s Prescribing Task Force will meet in Sacramento to talk about the board’s new draft guidelines for prescription pain medicines.

At 48 pages, the document is a little longer than your average magazine article, but it is also a surprisingly engaging read. Here are four takeaways from the guidelines as they stand now.

1) Pinpointing the type of pain leads to better treatment. The document attempts to break down the different types of pain a patient may experience, acknowledging the subjective nature of the divisions. The guidelines argue that physicians should shift away from talking merely about “acute” or “chronic” pain. Those have been the most commonly used distinctions. The guidelines talk about categories that will be unfamiliar to many health writers: nociceptive and neuropathic pain. Nociceptive pain is caused when the unspecialized nerve cells in your body – known as nociceptors – are activated, by a cut or an impact or an underlying medical condition. As the guidelines state, “Nociceptive pain is a symptom.” Neuropathic pain, in contrast, stems from damage or dysfunction in the central nervous system.

Differentiating between nociceptive and neuropathic pain is critical because the two respond differently to pain treatments. Neuropathic pain, for example, typically responds poorly to both opioid analgesics and non-steroidal anti-inflammatory (NSAID) agents. Other classes of medications, such as anti-epileptics, antidepressants or local anesthetics, may provide more effective relief for neuropathic pain.

2) Paternalism just comes with the territory. Health care has been shifting more toward a model of shared decision making between providers and patients. Gone are the days of “Take two pills and call me in the morning.” Patients want more information and more power to control their own fates. When it comes to painkillers, though, the medical board recommends that physicians be vigilant for ulterior motives. Patients in emergency rooms may “take advantage” of the chaos of emergency departments in order to get access to their favorite drugs. Doctors may want to count their patients’ pills “to minimize diversion (selling, sharing or giving away medications).” And then there are those who are receiving workers’ compensation payments.

Conflicts of motivation may also exist in patients on workers’ compensation, such as when a person may not want to return to an unsatisfying, difficult or hazardous job. Clinicians are advised to apply the same careful methods of assessment, creation of treatment plans and monitoring used for other pain patients with the added consideration of the psycho-social dynamics inherent in the workers’ compensations system.

3) Documentation is key. The list of things doctors should write down when treating pain is perhaps obvious. But it’s not obvious enough to make it automatic. That’s why the guidelines spell out things like “the patient’s medical history” and “results of the physical examination and all laboratory tests.” If you read about physicians who have been disciplined for prescribing too many pain pills, you’ll see that many of them never bother to obtain a medical history or complete a physical exam of the patient. The board also recommends that physicians document “patient consent,” presumably in nursing home settings, too. And it recommends that physicians check the state’s California Controlled Substance Utilization Review and Evaluation System (CURES) to see if patients have been obtained addictive drugs from other providers (prescription drug addicts routinely visit multiple doctors at different locations to maintain their supply).

4) Cutting off drugs isn’t the only option. Physicians are under increasing pressure to watch for patients who may be using painkillers to feed an addiction, not to treat actual pain. But the California Medical Board urges doctors to actively participate in managing these patients, not merely to cut them off from painkillers or other drugs. The guidelines state:

A patient’s failure to adhere to a pain management agreement is not necessarily proof of abuse or diversion. Failure to comply may be the consequence of inadequate pain relief, confusion regarding the prescription, a language barrier or economic concerns. A physician should arrange for an in-person meeting in order to have a non-judgmental conversation to clarify his or her concerns. If abuse is confirmed, minimally, consultation with an addiction medicine specialist or mental health specialize trained in substance abuse disorders and/or referral to a substance use disorder treatment program that provides medication-assisted therapy (MAT) should be immediately facilitated.

I corresponded with Medical Board Member Barbara Yaroslavsky and Medical Board Executive Director Kimberly Kirchmeyer about the new guidelines. I’ll let you know what they said in my next post.

Photo by Chris Yarzab via Flickr.