I'm an ER Doc with Pain: September 24, 2016

  • @Drahuber Thanks, I really hope his doctor can help him through his journey to both pain management and not the KAOS of addiction (if that is possible), and, not give up on him and let him fend for himself. But it does lie with my son, hope he has the stregnth and will power.

  • @NE1 I totally agree with you, @NE1. All we can do is educate and in this regard, you might be interested to know that Pain BC and the Dept of Emergency Medicine at UBC just had a webinar for emergency physicians on this exact subject this week with a pain expert in the field of emergency medicine and chronic pain.

  • @Drahuber how do you avoid busy times if your in pain? I broke my back 8 years ago, have had 3 surgeries. It's been tough dealing with the pain and depression. I'm on suboxone for the pain to which I had to beg my pain doc at the Wasser clinic in Toronto. I live in BC now due to the weather. I think pain is very consuming. I get worried if I feel pain that's new something's wrong with my back, like my screws or broken or my disk has blown. It's been difficult finding a doc to prescribe the subs I almost had to return to Toronto luckily I found a wonderful one in my town who's very supportive. I have gone from 6 mg to 2 mg a day so hopefully one day I can get off but if I can't due to the winter months are much harder. I'll stay on them. It's a vicious cycle. Why isn't suboxone prescribed more for pain in BC?

  • @MisterW With my doctor hat on, @misterw, I will offer you some form of reassurance in the fact that very many people have gone down that road and managed to re-enter life having conquered their addictions. The road is not an easy one.

    With my patient hat on, my heart goes out to you and I wish you all the best as you struggle on that journey.

  • @Drahuber I am attending SMART recovery Friends and Family support groups (very helpful and accessible resource) and my son has attended some of their meetings as well. He is scared of both the withdrawl process and the migrainse returning. Fingers crossed. .

  • @Forum_Moderator [QUESTION FROM FACEBOOK] I would like to know what do I do if my prior pain medication is no longer working the same as when I started them 4 years ago. I don't wish to try different meds as some of them do work good when I'm having a good week. I've tried everything over the years. How do I approach my Dr about this matter?

    Well, this isn’t really in my area of expertise, and I’m not sure what exactly you are asking. It is true that lots of meds do lose their effectiveness as time goes by. Then your only choice is to increase the dose and deal with side effects or try something new. One thing I will say is that sometimes a med you tried a long time ago will act differently if you go back and try it. It might be worse, but sometimes your metabolism has changed and it can work well when it didn't before.

    There also might be new options. Certainly in the pain world there is new technology and procedures that might help that don't involve meds...e.g. I have a spinal cord stimulator implant that is like a pain pacemaker. It can help in some specific conditions. If your Doctor isn’t aware of these or doesn't know where to get you help, you can get a referral to a pain specialist or clinic. There are lots of different types of these, but the best is a multidisciplinary clinic that has Pain Drs, physios and psychologists. There are not many of these, and they have long wait lists, but do exist. The Provincial one is based at St Paul’s Hospital and they will take referrals from all over the province but be prepared for a long wait. The Pain BC website has more resources for you.

  • If I present in ER (or admitted) with a bottle of my pain meds, if for some reason the ERP or House prescribes me something other than my pain meds, is the hospital / staff allowed to take my previous RX meds and throw them away? Or do they have to give them back to me?

  • I've worked in emergency medical care for over a decade and just recently gave a presentation to my colleagues regarding opioid use in chronic pain. I highlighted the important distinction between addiction and dependence, and even after all these years, I was still shocked at how many think the two terms are synonymous. It's unfortunate, that given the pain stats in BC alone, there continues to be such ignorance. I congratulate and support all who work tirelessly to move the education forward throughout the system.

  • @drummergirlnancy That’s an extremely good question and I find it difficult to find a good answer for you. I agree that as in life, once these labels are put on, they are very difficult to have taken off. The only suggestion I would have is sitting down with a medical professional that understands your situation and trying to list the various aspects of your problem and separate them into distinct areas that can be discussed with caregivers. This way, one can have a session focusing purely on the aspects of pain, and another time a discussion can be had on coping mechanisms, and yet another time the issues around medication use can be discussed.

    It would be my hope that the separation of these components and a discussion around them might make your overall situation clearer to those offering you care. Obviously this is not going to happen in a busy emergency department and would have to happen in an appropriate situation with an understanding doctor. I empathize with your situation and agree that it is a very difficult one to be in, as I have experienced some aspects of it myself. I was fortunate enough to be able to see a pain specialist about my issues and we had this exact type of discussion. The pain specialist talked about “pain layers” - a layer being each aspect of your pain and how it affects your life.

  • @Drahuber Thx...yes I will havea look at Here to help. Its a complicated circle now that he finds himeself in. Anxiety is also at play. His doctor advised him that he has to taper off the opiates in 2 months. I am hopeful but scared of that because it could go one of 2 ways.

  • [QUESTION FROM FACEBOOK] I would like to know what do I do if my prior pain medication is no longer working the same as when I started them 4 years ago. I don't wish to try different meds as some of them do work good when I'm having a good week. I've tried everything over the years. How do I approach my Dr about this matter?

  • @Forum_Moderator [QUESTION FROM FACEBOOK] What are the ways to avoid the ER and how can I treat a severe flare-up at home?

    Well, I'm not really a Pain Specialist as in the ER I was mainly treating acute pain, but I can tell you a few things. The ER really is your last resort and to be honest, many times not the ideal place to deal with a flare up, with its long waits and chaotic rushed atmosphere. The key to avoiding having to go is have a Dr who knows your situation and can help you draw up a flare up plan. In terms of medication, this means having what you need at home. This takes trial and error but oftentimes you can find a plan that tides you through the flare up. Some Family Drs have on-call coverage at a clinic, and if you have a plan you can bring it with you if you can’t manage at home.

    As for managing at home, I can only refer you to pain experts—websites like Pain BC's and the Pain Toolbox (https://www.painbc.ca/chronic-pain/pain-toolbox). Different things work for different people. My own experience is that I haven't had to go to the ER for my pain. I have a flare-up plan that is mainly an increase in medication and then getting in a dark room and either using distraction or meditating and sleeping. Sleeping is the one thing that resets my pain for a few hours and allows me to function.

  • @MisterW Yes, this is a horribly vicious circle—being in pain and addicted. I do understand though, that there are addiction services in place that can help, as this is not an uncommon situation to be in.

    Perhaps you could try Here to Help? This site provides comprehensive information on mental health and addiction issues and focuses on providing information that is based on the best research possible. With a number of partner organizations included in this project, like Anxiety BC and Canadian Mental Health Association, this website has a wide array of useful resources. Resources are also available in multiple languages. www.heretohelp.bc.ca

    You can also try Pain BC’s Toolbox for more resources.

  • [QUESTION FROM FACEBOOK] What are the ways to avoid the ER and how can I treat a severe flare-up at home?

  • How does one address 'pack mentality' in the medical system? ie being labelled as drug seeking or pain / illness being 'in your head'. Once labelled there ceases to be true 'care'. Doctors stop looking for what might actually be wrong.

  • @drummergirlnancy Hi @drummergirlnancy, that is truly a tragic situation and an extreme example of the terrible consequences of this stereotype. You can never look back and figure out for sure what you could have done differently. However, I am putting forward some ideas around how not to trigger this drug seeking stereotype. Moving forward with the situation that you described, however, I believe ER staff could gain important insights into the consequences of this stereotype if those cases were reviewed. It would be my suggestion to bring up these cases with the hospitals involved. That would trigger a discussion on how these patients were treated before these diagnoses were made.

  • @MisterW I am very saddened to hear about this tragic situation to do with cluster migraines. I never was involved with treating migraine patients on an ongoing basis. I will say that in addition to medications, there are treatments for migraines that do not involve medicines. These include procedures using ultrasound on the nerves at the back of the head, and would be accessed through a pain specialist. The family doctor could certainly call a pain specialist and discuss what procedures there are that don’t involve medicine for migraines.

    The only medicines for migraines that are addictive are opioids. It is my understanding that there are many different types of medicines for migraines that do not involve opioids, and this list is changing all the time. It is also my understanding that there are doctors, including neurologists, whose main practice is the treatment of migraines. And these migraine experts certainly could be accessed by your family doctor.

  • @MisterW My son is treated like a seeker in ER, but unfortunately, he has been. Its a vicious circle, he is both in pain, but also addicted.

  • @Drahuber Re stereotype .. my best friend and my son were treated as drug seeking for a year. Neither used drugs. Best friend had undiagnosed, terminal pancreatic cancer (she was pleading for pain medication because she was in agony) .. my son was in acute pain from his gallbladder (and ended up with a grade 4 bile duct injury).. Not sure what they could have done differently to be believed.

  • @NE1 NE1, I am very sorry that you had a difficult experience at the emergency room. Chronic pain patients face stigma in all aspects of their life, including with health professionals. Unfortunately, in the emergency medicine world, there is a negative stereotype involving chronic pain patients and opioid users. This is well documented and studied, and is consistent across all levels of caregiving. Patients with chronic pain have great difficulty getting empathy and understanding from caregivers and emergency rooms are no exception. All we can do is try to do as many things not to trigger this stereotype.

    Often a note that is brought in saying “this patient suffers chronic pain, she is not a drug addict” is viewed with suspicion, as some drug abusers and diverters bring similar notes in with them to try to persuade staff to give them drugs. I encourage chronic pain patients to discuss with their family doctor a diagnosis, followed by a flare-up plan. Then they should bring the flare-up plan to the emergency department. Then the ER doctor can see what steps have been taken on the plan already.

    If this isn’t sufficient, and if one needs to go to the ER frequently for opioids, the family doctor might need to discuss with the ER directly about this problem and a care plan created. There are educational initiatives directed towards family doctors and ER doctors on how to break down this negative stereotype. But in the meantime, we are left with its negative consequences.

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