Chronic Pain
Jean asks about her chronic pain, meds and procedures.
Thanks for writing in such great detail Jean (nickname), it makes my job a lot easier - although in your case, there’s no such thing as easy, as you have found out. Here’s your question (edited by DrJ):
1. My GP was prescribing my chronic pain meds. He then sent me to a pain clinic to continue. I signed the contract with the pain clinic, but I was told I must first have a psych eval which I don’t mind. I’m not a druggy i’m there for help. Doc gave me new scripts for new meds he wanted me on. Told me to continue to take the percocet. I told him I was almost out and needed a refil. He then told me abt the eval. and that I needed to have my GP refill till after eval and they take over the prescription. I called my GP he refused. stating that the pain clinic was to now do it. I informed them I would be out of meds on sat. which I did run out friday night. Thursday I called the pain clinic and told them this. they said they’d call my GP, they did, he refused at their request also. I asked the clinic what I supposed to do for chronic pain, because of my glucose rises. they said go to the ER. so last night I spent 7hrs in the ER with a bG of 439 and walked out with a bG of my pumping own insulin and script for percocet.
was this ethically right for either of them to make me suffer like that? both physically and mentally? what recourse do I have if any? I don’t want anyone else to have to endure that. I was in the ER till 4am.
2. I’ve noted below my symptoms and diagnoses. My QQ is, the pain clinic wants me to have a series of SI Injections and facet injections. Will they help and if so how long? Another neurologist recommended a fusion from L3-S1 is that what I should do instead?
[DRJoshua] I’ve edited out quite a bit of the following for publication’s sake, but don’t worry, I’ve noted everything you listed.
Chronic Pain Problem: burning, stinging, kinda like a indian burn feeling, hot poker
stabbing pain in mid-lower back, down buttocks into thighs
Known conditions:
bulging disk at L5-S1, degenerative disk disease, chronic pain, radiculopathy, diabetes, scar tissue buildup at L4-5 (previous surgery site)
Meds: C: naproxen 1500mg 3x a day
D: percocet 325/7.5 3pills 3x a day
?
?
Dr. Joshua’s answer:
It is always vital to differentiate between “nociceptive” pain and “neuropathic” pain. “Nociceptive” pain is the “normal” pain signal telling us there’s something wrong somewhere. Lumbar disc herniation can cause nociceptive pain by compressing a nerve root. An MRI is needed to rule out compression of lumbosacral nerve roots. Nociceptive pain can be relieved by surgery. When the tissue heals, nociceptive pain resolves.
However, your description tells me your problem is chronic neuropathic pain, which is caused by lumbar disc herniation and/or failed back surgery. Neuropathic pain is caused by nerve injury, in your case L5-S1 nerve root damage. The problem with neuropathic pain is, even if you relieve the compression, the pain will not stop. Neuropathic pain can, in certain individuals, develop into a chronic pain syndrome. Who gets chronic pain syndrome and who does not? That’s probably determined by genetic factors, and perhaps by some environmental factors as well.
To answer your second question, I’m doubtful that the injections will help, but I couldn’t be sure, so may I suggest you give the injections a try, and discontinue if they do not help. However, in my opinion you should ABSOLUTELY NOT have the L3-S1 fusion done before careful evaluation by experienced spine surgeons. There’s nothing here that suggests pain due to L3-S1 instability, and an operation like that will make things worse for you. Fusion procedures do not relieve neuropathic chronic pain - 9/10 times the problem is worse after the operation. There are very rare instances where fusion might help, but as I said you should get a second opinion from an experienced spine surgeon (or, preferrably two)
There’s one more possibility - have you discussed spinal cord stimulation? Given your history there would be about a 50/50 chance of significant benefit from spinal cord stimulation for chronic pain. I’d suggest you discuss this possibility at your pain clinic. Since everything else has been done, I think you should consider it. It’s a reasonably low-risk operation.
About your meds: You are ABSOLUTELY taking WAY too much Naproxen. You should lower your dose to 500 mg twice daily. There’s no evidence of added benefit after a daily dose of 1000 mg, just added side effects, risk of gastric ulcer, and besides - you have diabetes, and naproxen is POISON for your kidneys. I suggest you discontinue naproxen altogether, over a month or so.
You are also heavily dependent on oxycodone (Percocet). Your daily dose is 67.5 mg which is quite high and it means you develop serious withdrawal symptoms if the drug runs out. The best thing that could happen to you right now would be to find a way to withdraw from Percocet. Spinal cord stimulation might help, and if all else fails, spinal (intrathecal) morphine pump might also be an option. I’m not saying you’re an addict - it’s a different thing - but pharmacologically speaking, there’s a significant drug dependence. This is often the case with chronic pain, and it leads to problems with prescribing and dealing with doctors. We doctors are (I hate to admit it) often keen to have someone else take care of the chronic pain patients who are dependent on morphine-like analgesics. It’s very demanding work, requires a specialist, and easily leads to conflict situations with physicians who are unaccustomed to treating chronic pain syndrome. You described a situation which faces thousands of chronic pain patiens every day.
My answer to your question is, no I don’t think it’s generally ethical to have you suffer like you did, but unfortunately this sort of thing happens very often, and physicians have their limitations, and their legal obligations, too. I think your new pain clinic acted properly in requesting psychiatric evaluation first. In my experience, physicians generally genuinely try to do the right thing. So I’m not going to try to judge your GP or the pain clinic here, as I am not in a position to do so. The real problem is - severe chronic pain is a very serious illness. It’s very difficult to treat, and there is no cure. What you need is a good, long-standing confidential doctor-patient relationship with a pain specialist, preferrably a neurologist. And, as you said yourself, a psych consult is in order as well - chronic pain is heavy on the psyche!
Have you tried gabapentin (Neurontin)? This may be effective for chronic pain, and could reduce your need for Percocet. Ask your pain clinic about Neurontin.
I realise that the drugs you are taking are there to help you deal with your chronic pain. A chronic pain syndrome like yours is a serious, life-threatening illness. But in the long run, you will need alternatives. Spinal cord stimulation may be one of them. I wouldn’t want you to spend the rest of your life worrying about whether your Percocet will run out or not.
I hope this helps, good luck!
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