The Great Pain Jack

AuthorHouse

Contents

Acknowledgments......................................................................vPreface..............................................................................xiChapter 1: A Brief History of Pain...................................................1Chapter 2: Definition and Types of Pain..............................................3Chapter 3: Introduction to a World of Pain...........................................5Chapter 4: Dependence, Addiction, Tolerance, and Pseudoaddiction.....................9Chapter 5: So, You've Got Headache Pain?.............................................20Chapter 6: So You've Got Facial Pain?................................................33Chapter 7: So, You've Got Abdominal Pain?............................................44Chapter 8: So, You've Got Obstetric Pain?............................................54Chapter 9: So, You've Got Pelvic Pain?...............................................60Chapter 10: So, You've Got Neck Pain?................................................71Chapter 11: So, You've Got Back Pain?................................................83Chapter 12: So, You've Got Knee Pain?................................................97Chapter 13: So, You've Got Shoulder Pain?............................................105Chapter 14: So, You've Got Fibromyalgia Pain?........................................116Chapter 15: The Psychology of Pain...................................................128Chapter 16: New Frontiers of Pain Treatment..........................................140

Chapter One

Regardless of race, sex, social status, geographical location, and other factors that divide and separate humanity, pain is something we all experience at one point in time. Thus it is no surprise that since the dawn of time humans have invested so much effort into alleviating and treating pain. Pain is not a unique experience only specific to humans.

In almost all of the animal kingdom, we see pain-generating output as a protective mechanism for survival of the species. For example, if a dog is walking with its owner and accidentally crosses its paw under the foot of the dog owner, the dog will let out a yelp and pull its paw away. This is reflexively accomplished within seconds as a protective mechanism for the animal. The next sequence of events (after the dog realizes it is not mortally wounded) may entail that the dog begins to lick its paw. This action then tells the dog's brain that everything is okay and that the "stomp injury" is merely a flesh wound and not something that needs long-term attention. This extremely adaptive yet simple sequence of events is repeated in the animal kingdom often. The message is that the repair or rejuvenation process is already initiated almost at the time of injury, ultimately to shut down the pain signal. This is one example of how the "great pain jack" occurs in nature.

Unsurprisingly the history of pain management goes back to ancient times. A lot of the early pain relief methods involved religious rites, including prayer and exorcism. Egyptians, for instance, thought of manifestations of pain in a person as possession by spirits.

In China a large contribution to medicine was made by Huang Ti, in 2600 BC, who explored the use of acupuncture in pain treatment. The use of opiates such as opium, for example, due to their anesthetic properties, goes back to ancient times as well, with uses documented in the Trojan Wars in 1220 BC.

Hippocrates, a Greek after whom the Hippocratic Oath is named, focused not on the disease but on the patient—a focus that is prevalent in modern chronic pain treatment. All medical students take the Hippocratic Oath and commit to doing "no harm," though in many chronic pain treatments the opposite can seem to be the case from the patient's point of view.

During the Middle Ages, many of the texts documenting advances in pain management made by the Greeks and Romans were buried and/or destroyed in Europe. However, medical studies flourished in the Middle East, where some of these texts were preserved. During the Renaissance, many of these texts resurfaced in Europe.

Opium was a popular prescription form of pain relief until it was diluted into laudanum, a painkiller used until well into the nineteenth century. Also, during the eighteenth and nineteenth centuries, major leaps were made in reducing pain during limb surgery, resulting in the use of cocaine as an anesthetic. In 1817 pharmacist F. W. A. Serturner made a significant contribution to pain management by creating morphine.

Ether was introduced as an anesthetic in surgery, and by the end of the nineteenth century it was replaced by chloroform. Karl Koller, an Austrian ophthalmologist, explored the numbing effects of cocaine, which led him to discover local anesthesia; that is, instead of the patient going under completely, only the region in need of treatment could be numbed. Koller's contribution to pain treatment was revolutionary and paved the way for the emergence of nerve-block techniques and other modern pain treatment methods.

The twentieth century is marked by many significant medical discoveries and inventions with the sole goal of preserving life and easing pain. Sir Alexander Fleming's discovery of penicillin in 1928, John Hopps's invention of the pacemaker in 1950, Willem J. Kolff's invention of the artificial heart, and the invention of HIV protease inhibitors in the late 1980s and early 1990s, as well as recent advances in genetic engineering and stem cell research, are all milestones in pain management.

Despite all these advances, millions of people all over the world experience acute and chronic pain every year. Their lives often take the form of a struggle from one day to the next, with no hope of relief in sight. Modern medicine has solutions for many of them, but these solutions are useless without a proper diagnosis. The case studies and analyses in this book stress the importance of accurate diagnoses in successful pain-management treatment. If the correct diagnosis and proper treatment is not initiated, "the great pain jack" may be initiated.

Chapter Two

Let us begin with a definition of pain. The IASP (International Society for the Study of Pain) defines pain as: "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

The note at the end of the definition goes on to say that pain "is always subjective." Pain can also exist in the absence of tissue damage, where it takes a psychological form. This book will focus almost entirely on physical pain, though I do use the expertise of a psychologist specializing in "psychological aspects of pain" as part of my treatment team. The mind can often be stronger than the body, and research is bringing new insights into the role of mind over matter.

Physical pain, especially when severe, will often have a serious psychological component and certainly serious mental health issues, not the least of which is dependence, which can arise from untreated and chronic physical pain. For instance, surgery for a defect causing abdominal tissues to descend into the groin area, known as inguinal hernia, may result in a condition called "nerve entrapment." Consequently, pain may develop in the groin area, affecting the sufferer's sexual life and his family life, and in general, result in depression. If the necessary surgery to repair the condition is not preformed, the condition may worsen and lead to other complications.

Pain may be subdivided into a number of different categories. For example there is somatic pain, neuropathic pain, visceral pain, nociceptive pain, arthritic pain, pain from cancer, sympathetic mediated pain, nerve damage pain, mixed pain, and psychogenic pain.

Pain becomes chronic when it persists for more than three to six months. It is important to realize that chronic pain may be caused by an anatomical or correctable medical problem. The problem, when undiagnosed or untreated, may become chronic and cause additional types of pain, which may be worse than the original condition. An example would be the care of an inguinal hernia repair, which then could be complicated by the entrapment of small nerve fibers in repair mesh. The resulting condition is known as ilioinguinal neuralgia.

Case Study: Bob, a young painter and plaster handyman, fell off a scaffold and broke a small bone in his wrist. The bone, however, did not heal properly. Since the pain would not go away, Bob went to see his doctor. The doctor examined his hand carefully and found it necessary to perform a surgical procedure known as open reduction and internal fixation.

Yet, after the surgery, Bob continued to experience pain in his hand. In fact, the condition worsened, and, over a brief period of time, he lost all functionality in it. A complex regional pain syndrome developed in his appendage, and Bob was forced to go through several other surgeries as a result. While the fracture finally healed, the failure did not heal in a timely and normal fashion. This activated the nerves of the sympathetic nervous system and caused more damage. Bob developed severe limb and spinal problems that necessitated painful, extremely complex surgical procedures to treat.

Bob's story weighs on every doctor's mind, reminding us how crucial an early, correct diagnosis truly is. If Bob's condition had been diagnosed earlier, many of the aforementioned problems would have never occurred.

Of course, diseases and medical conditions don't always allow for an easy diagnosis. Many a rediscovered overlong periods of time, after a series of tests, guesses, and experiments. This book will offer tools that attempt to lessen the time between the manifestation of a disease or condition and its accurate diagnosis, by education of the patient about pain and by how to communicate this information most accurately to one's doctor.

In the forthcoming chapters, we will journey through the body, beginning with the head, and address some of the more common problems, diseases, and syndromes that can arise, as well as the various treatments available to combat them. I will touch on the unusual and some uncommon pain syndromes and their treatments as well. More information may be obtained from the website www.gotpaindocs.com, www.ThegreatPainJack.com, or www.ThegreatPainJack.org for specific treatment of complex regional pain syndrome.

It is always important to remember that pain is a signal that something is wrong. It is the body attempting to give us some crucial, and in many cases "lifesaving," information. Numbing it with drugs or pills or in any other way can obscure the cause of the pain. The idea is always to manage the pain while finding out the underlying cause or causes in order that the root of the pain can be discovered and treated.

Chapter Three

It's 5:40 a.m. on a Tuesday. I've already reviewed the day's agenda, which was culled from three days' worth of operative reports and office notes securely forwarded to me via Internet and e-mail. Despite the average four and a half hours of sleep, I feel quite energetic.

Even with the morning's preparation, the day has its share of surprises. I arrive at the pain management clinic at 8:00 a.m., and sure enough, I am informed that an emergency lumbar epidural steroid injection has been added to my schedule. The patient is now in the waiting room, nervously pacing in pain.

The phone starts ringing, and it will not stop. Today calls are being forwarded from two other office locations; the usual call volume is magnified. A patient with excruciating, steadily worsening back pain is asking for more Percocet. A hospital calls requesting an "emergency consult" for an unfortunate individual with an undefined pain phenomenon, who was admitted in the last twenty-four hours. A slew of ER and family physicians, neurologists, orthopedic surgeons, and other specialists are already debating how to help this patient. If the patient is already taking strong medication for his pain, like OxyContin or morphine, that usually triggers a call to me, a pain management physician.

While still on the line with the hospital, I get a call from another hospital about a patient in the emergency room with redness and drainage from his morphine pump implant site, placed one week ago.

Meanwhile, another patient is waiting for me in exam room one. Accompanied by his insurance company case manager, he wants to discuss the quantity of Vicodin pills that he should take for a minor work-related injury. He's been directed to me by his attorney because both his employer and his workers' compensation carrier do not believe that he is truly injured. His colleague ran over his foot with a fork lift, and he lost two and a half of his toes. He now has a substantial injury with a condition known as complex regional pain disorder of the lower extremity. The employer wants to know why this individual can't go back to work since his condition has improved (after amputation of the toes) and over eight months have passed since the injury. Another "great pain jack."

The gentleman in exam room two has run out of the OxyContin prescribed by his previous physician and is here for another dose recommendation. He was referred to me after being released by his doctor for "dereliction of duty" and failure to read the fine print of the narcotics agreement, which states that "under no circumstances can a person receiving prescription medication, intake any illicit or nonprescribed medication or medication of the same type prescribed at the same time by another physician into the body." Another victim of "the great pain jack."

As I pass by the exam room I pick up the strong, distinct smell of tobacco and marijuana. While he did not smoke in the exam room, I often find patients who have used nonprescription drugs before seeing their doctor, especially after running out of their regular prescription medication. Pain can be unforgiving. Dependence can be unrelenting. Addiction can be deadly. Chronic pain can really "jack" you and your brain

The operating room calls to let me know that the emergency lumbar epidural steroid injection patient is prepped, draped, and ready for her lumbar epidural and sacroiliac joint injections. I perform them. I finish the procedure. When I leave the operating room, I learn from my office manager that Medicare has requested fifteen charts for medical review and is threatening an audit if they do not receive the information by the end of the week.

I am stopped from attending my next appointment by a call from a doctor regarding a request for a radiofrequency nerve ablation (a treatment for spine pain) for a patient. I begin to feel slight withdrawal from the coffee I badly need; I try to persuade the doctor, who works for the patient's insurance company, that the procedure is necessary for her well-being. The smell of coffee from our kitchen seems awfully tempting!

My other office calls and informs me that the local police department has referred a patient on an urgent basis who held up a pharmacy using a utility belt tool. Apparently they needed the person evaluated on a timely basis because after holding up the pharmacy (while using a wrench) and succeeding, he ingested a large quantity of narcotic medications formulated into a patch. After becoming immediately intoxicated with the box of ingested narcotic patches, he managed to crash his vehicle into a utility pole. The police then rounded him up and pressed charges. He pleaded the "fentanyl frenzy" defense for his crime while undergoing treatment of an existing medical condition.

Sadly, this individual, who had clearly been "hijacked" by pain and addiction, was found dead two weeks later. Another somber, late "great pain jack."

The telephone conversation with the doctor that wants to disapprove of the radiofrequency ablation of the spine gets a little heated; the doctor clearly has not read the detailed reports I sent him along with my treatment-authorization request. It doesn't help that his mission is to turn down my request since his goal is to "preserve" the insurance company's money. In the end, he assures me that he will submit his report to the carrier and, in a routine maneuver, and pleasantly, reminds me of my right to appeal the carrier's decision.

While some doctors can be reasonable, the majority of these conversations can get very hostile and tense. It's easy to get caught up in the uphill battle that unravels regarding treatment plans over the phone with insurance companies. This is another example of the physician's version of "the great pain jack." Often, I want to simply give up. However, it's difficult to overstate the fact that often lives and well-beings are literally at stake during such talks. So when a report comes back to me classifying a necessary procedure as "noncertified," I have to prepare for verbal battle. It's part of my job and my duty to my patients. Such combat takes skill, nuance, tact, and persistence. You have to pick your fights well. You have to know when to hold or when to fold, and when to persist. And the good doctor will be hearing from me. It's a bit like poker in that sense.

I look at my watch. It's only 9:10 a.m. A medical assistant informs me that a well-known national insurance company is refusing to authorize a neural stimulator trial for a chronic pain patient, a possible life-changing treatment for this individual. I decide to return to this later and head for the operating room.

There I greet a patient of mine who has survived facial cancer. Unfortunately, the radiation treatments have left his neck, face, and spine in a distorted state. Our eyes meet and a broad smile comes across his face. I smile back at this calm but spirited seventy- six-year-old man and chat with him as I provide an anesthetic through an IV. Quickly, it takes effect. His eyes close.

I can sense the radiation-induced tension in his muscles subside. I perform a cervical epidural injection and, using a fluoroscope (a real-time x-ray machine), I watch the infused dye enter the cervical nerve roots of the epidural space. I now inject an anesthetic steroid, the drug that will keep my friend and patient off all of his pain medications for two to three months. His aged body does not tolerate pain medications very well.

The dye material dissipates with my second booster cocktail injection of anesthetic mixed with a steroid. The fifteen-minute procedure will save the patient from surgery. I may perform eight to twelve such injections on a daily basis.

(Continues...)

Excerpted from The Great Pain Jackby John F. Petraglia Copyright © 2012 by John F. Petraglia . Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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