When is the treatment worse than the disease?

There’s a quotation by famed 19th century doctor Sir Robert Hutchinson which has resonated with me throughout my life and medical career.
 
‘And from making the cure of the disease more grievous than the Endurance of the same, Good Lord, deliver us.’ 
 
The quote came to mind again when I read a recent article, ‘Prescribing wellness: Comprehensive pain management outside specialist services’ in Australian Prescriber by addiction specialist GP Dr Simon Holliday, et al.
 
I came away from the paper feeling like we have come to a crossroads with opioid use in chronic non-cancer pain. The decisions we make now, the skills we learn and the conversations we have with our patients will have major ramifications for all of us going forward.
 
Opioids are cheap and easy to prescribe. While they are essential drugs for specific conditions, and while they may be useful for some people with chronic pain, it has become increasingly clear that they are a high-risk option for chronic pain sufferers.
 
Why? The drugs may in fact make the chronic pain worse and, if they don’t make the pain worse, may significantly decrease quality of life and indeed cause death due to opioid poisoning.
 
Dr Holliday and his co-authors discuss how opioids fail to wholly manage chronic non-malignant pain and show that the simplistic ‘quick fixes’ that opioids promise can ‘never untangle the many strands of suffering contributing to chronic pain’. 
 
While GPs do most pain management, we lack the resources of the multidisciplinary tertiary centres. It is absolutely true that, as the paper in Australian Prescriber states, we are the ones most likely to be in a position to assist patients with chronic pain, but as a group we have varied skill and experience in the area and we are poorly supported by the current system.
 
It is very clear that multimodal active management with an emphasis on non-pharmacological treatments will result in better outcomes for people with chronic pain. But many of our patients cannot easily access such therapy, as there are limited options available through Medicare.
 
In addition, supporting patients to change their approach to their pain takes significant time in an environment where we are not only very busy, but we are not rewarded financially for spending more time with our patients. This leaves GPs in a bind.
 
The Pharmaceutical Benefits Scheme (PBS) makes medicines cheap, which is an essential pillar of our excellent health system. But it also drives ongoing use of pharmaceutical opioids because they’re cheap and available and, for many of us, all too ‘moreish’. The promise of being pain-free and euphoric at the same time is very enticing.
 
It seems to me that another important factor is our desire to assist our patients, and our distress at their distress, and how this discomfort at times drives us to make decisions – such as opioid prescription – that are ultimately not in the best interests of a patient. It is hard to sit with someone in their distress and be unable to offer a quick solution.
 
What I liked about the Australian Prescriber paper was that it suggests new ways of looking at the management of chronic pain in the general practice setting. It focuses specifically on areas where time-poor GPs can provide better outcomes.
 
After I read it, I was reminded of one of my patients. Let’s call her Sascha.
 
Sascha is a 42-year-old woman with a complex past history of interpersonal trauma and drug and alcohol dependency, who presented to my surgery with severe shoulder pain. After investigations it became clear that she had cervical spinal stenosis.
 
My colleague referred her to a neurosurgeon where her stenosis was corrected. However, Sascha was left with ongoing pain sufficient to disturb her sleep and make her feel very depressed and overwhelmed.
 
With her history, on paper, Sascha was at high risk of not being able to safely manage opioid use for her ongoing pain. She had been discharged from hospital on long-acting oral opioids with minimal explanation of the risks and benefits of this treatment. She was told that physio would be a good idea, but left to organise that herself.
 
Prior to seeing me after her hospital discharge, Sascha had seen a number of GPs at other practices for repeat prescriptions and the opioid flow continued. By the time she came to me, Sascha was escalating her dose of opioids and was feeling more and more out of control.
 
I felt my heart sink listening to her story, wondering how I was going to work with her.
 
Matters took an interesting turn when I said, ‘You know this pain you’re feeling doesn’t actually mean that your body is being damaged?’ She seemed surprised, so we looked at a video describing the process of chronic pain. 
 
Sascha thought about it and asked, ‘So I can move, even if it is painful, without causing damage?’ I nodded and her eyes lit up. ‘Jeez, doctor, I can manage that. Help me get off the pills and I’ll get moving.’ 
 
Sascha did exactly that. She started walking her dog again. She joined a tai chi group in the park. She did aqua aerobics in the local pool, meeting ‘some amazing women’ in her classes. She diligently did the exercises and strengthening the physio gave her.
 
I have to say, she impressed me here – she is one of the few people, including myself, to actually do the physio’s exercises. And, most importantly, Sascha slowly weaned herself off all opioids. She saw a psychologist who helped with her anxiety and low mood. She found that as she left opioids behind, her mood and anxiety actually improved.
 
To be honest, I feel I actually did very little other than cheerlead and support her. Given information and support, Sascha took control of her health, led her own multimodal recovery and created wellness for herself. And isn’t this what we want for all our patients?

addiction-medicine chronic-pain dependence multimodal-pain-management opioids