Do Not Stay Ahead of Your Pain!

I often hear the mantra – “you must stay ahead of your pain, or else.” The president of the American Academy of Pain Medicine, states a common mistake people make, is waiting too long to take pain medication. By the time you’re in pain, you’re starting from behind the eight ball. "It takes a lot more medicine to control pain after it’s started as opposed to starting it ahead of time," he says.[i]Is this true, if I don’t pre-empt my pain I will be doomed to a never ending cycle of playing catch up? There are a lot of smart people and prestigious organizations espousing this theory of staying ahead of your pain so maybe we should move on and accept it as settled science, right?

Well as it turns out, there is a lot more to treating acute pain than sending patients home with a prescription of an opioid mixed with acetaminophen and telling them to just take what you feel you need so that your pain never gets “severe.” Do patients have any idea what this means? Of course no!

Since non-opioid analgesics should be used as the foundation of acute pain management, sending patients home after surgery, for example, with a combination opioid defeats the purpose. 

Rule # 1: Assuming you have no renal or liver disease, you should take close to the daily maximum of acetaminophen and a non-steroidal anti-inflammatory agent around the clock.

Rule # 2: Opioids should only be used in their pure form; they should be taken only when the patient feels their pain is intolerable and then stopped as soon as possible.

Rule # 3: The 24hr opioid prescription dose should be calculated so that the morphine milligram equivalents (MMEs) are less 50 for all opioid naïve patients.

Let’s unpack how these rules fly in the face of current medical management. Most patients are prescribed a combination opioid for acute pain. This means that you will always max out on the opioid component prior to the non-opioid – not good. Most clinician do not calculate the MMEs they prescribe and have no idea at what level an opioid naïve patient is at increased risk for respiratory depression – not good. Patients are not told to take a pure opioid if their pain becomes intolerable while on scheduled non-opioid multimodal treatment – not good.

When patients are coached to stay ahead of their pain they invariably overtreat with opioids due to fear of what “may” occur. By overtreating, you end up suppressing your ability to make endogenous opioids thus causing an amplification of pain once the prescription ends. Post-surgical pain is expected and when treated in keeping with the above rules most patients will be managed with tolerable pain. This tolerable pain allows you to progress with the healing and rehabilitation process, but more importantly, allows your brain to manufacture endogenous opioids – very important. Central sensitization of pain, opioid induced hyperalgesia, the progression to chronic pain, and persistent use of opioids after 90 days, are all the results of overtreatment.

So, the next time you hear the phrase, “stay ahead of your pain,” remember to “stay ahead of the pack” and utilize a non-opioid multimodal foundation first, followed by a pure opioid only when the pain becomes intolerable. This may fly in the face of current medical management, however, last time I checked, this philosophy was a main driver for our current opioid epidemic.

Myles Gart, MD

Dr. Gart is an anesthesiologist 

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[i]https://www.webmd.com/pain-management/features/managing-pain-after-surgery#1

The Fallacy of Patient-Centered Care

I often wonder what it was like before patient-centered care became a mainstream catchphrase. Was there a poor relationship between the patient and physician in the out-patient setting? While is the hospital were patient’s feelings, desires, goals, and therapy options ignored? It amazes me that we were able to care for patients more than ten years ago without using a “patient-centered” approach.

Patient- and family-centered care encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.[1]Under patient-centered care, care focuses more on the patient’s problem than on his or her diagnosis. Patients have a trusted, personal relationship with their doctors. 1Historically, patients have had a better relationship with their physicians than they do today. Today office visits are short to fit in as many patients as possible and during the visit the provider is too busy typing into an electronic medical record than looking the patient in the eye. Years ago, physicians made house calls, spent more time discussing what interested their patients and in smaller communities, patients even called their physicians at home of they had a question.

Marcus Welby, MD has been replaced with UltraSuperSpecialized, MD. Our knowledge of medicine, genetics, pharmacology, and immunology has exponentially expanded, but it has come at a great cost. Fragmented care is what we have today. Patients are referred from one specialist to another often with little education regarding how all the pieces of the puzzle fits together. Patients are supposed to take ownership of their healthcare under this new model. As a physician, I have watched my father go from nephrologist to cardiologist to urologist and then the hospital with urosepsis. Now there was a hospitalist on the case who tried to piece together what had happened with multiple specialists over the past two years. Needless to say, multiple tests were repeated, new specialists were consulted and new medications were added. 

My dad was finally discharged but not before I had spoken to each specialist to coordinate his care and come up with a treatment plan. He had no “ownership” of his healthcare, he trusted in his physicians to treat his condition and get him home as soon as possible. When a patient is admitted with sepsis or appendicitis or an acute myocardial infarction, how are they expected to play an “active” role in their care? Maybe they should google their condition and review the current treatment options with their care team? 

Patient-centered care is a form of value-based care. Governmental agencies and insurance companies are using these new care models as proxies for quality. Since quality is difficult to measure, a patient’s experience or satisfaction with the care provided serves in its place. Unfortunately, we are focused doing what makes the patient and their family “satisfied” as opposed to treating their condition. 

As healthcare providers we are not in the hotel and restaurant management business, we are here to heal. The fallacy of patient-centered or value-based care is that it forces us to allocate resources on an outcome which has little to do with the true quality of care provided. Is the patient a customer and as a customer, is the patient always right? One has to merely look at the current opioid crises to see the error in that logic.

Myles Gart, MD 

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[1]https://catalyst.nejm.org/what-is-patient-centered-care/