President’s Message: When Was That Taught?

Harry J. Gould, III MD, PhD

It has been more years than I care to admit since I graduated from medical school. As most of us have realized, with time, advances are made, with experience, skills are refined and as practitioners, we adapt to change and challenge and improve in our ability to care for patients. An unfortunate corollary to the essential fine-tuning of the evolving practitioner, especially in specialty and sub-specialty practices, is that many components of our general training are infrequently called to bear in daily practice, are less well remembered, and suffer from lack of reinforcement. I have recently been more aware of this disappointing realization both in my own practice when confronted with patients suffering with problems involving infectious disease, endocrinology, hematology, pulmonology, cardiology, and gynecology and from a different perspective, in observing the practices of colleagues who consult me for recommendations to help care for their patients in pain.  Some problems require complex solutions, but surprisingly, most can be addressed simply by returning to the basic principles learned in those early courses when we received so much “irrelevant material”.

My reason for addressing this topic is that I have noticed, more recently, probably over the last 2-3 years, that well over half of the consults directed to our in-patient consultation service for pain management have inquired as to what else can we recommend to control pain and/or whether an additional opioid medication should be added to the analgesic regimen to improve pain control for a patient. Virtually all of the presenting analgesic regimens in these cases, regardless the type of pain or pain history, include gabapentin < 300 mg daily, a muscle relaxant, and not atypically, orders for multiple formulations of mu-opioid analgesics, e.g., hydrocodone PO as needed for pain between 3-6/10 in intensity, oxycodone PO as needed for pain > 7/10 and hydromorphone IV scheduled every 3-4 hours.  The total daily morphine milligram equivalents (MME) ordered is, not infrequently, less than that in the patient’s routine outpatient regimen for chronic pain. It is possible that the initial ineffective treatment regimens have been designed in an attempt to comply with published guidelines designed to minimize opioid use, but it seems more likely that the failed attempts reflect a prevailing assumption that complex problems require complex solutions.  Obvious to a specialist, but not so to the physician with medical school a distant image in the rearview mirror of life, is that simple solutions within recommended guidelines are more often likely to produce favorable outcomes because they are less likely to introduce complications that lead to confounding results.

More efficient use of the dynamic interaction between referring physician and consultant may be the best way improve patient care because the best learning opportunities seem to occur when therapeutic approaches are introduced or reviewed in the context of administering in real-time to an interesting patient or a problem situation (“When I was a resident, I had a patient that…”) and take less time out of a busy practitioner’s day than a formal course for review.  A referral for consultation provides a platform for the specialist to offer a focused review of basics from their specialty that reinforce optimum therapeutic approaches for managing a given problem and a platform for the referring team to provide feedback to the specialist as to the rationale for either accepting or declining to implement a given recommendation.

In the offered example, a good place to start might be to determine and establish an analgesic treatment base before embarking on diagnostic tests or therapeutic treatments that are likely to produce additional pain. The process of determination would be comprised of an assessment of the type of pain that is being experienced, a determination of co-morbid problems and whether the patient has had or is currently receiving medications, especially opioids, for a previous acute or a chronic problem, for which medications had been used and if current, what dose is being taken. It also would seem reasonable to take advantage of prior history and to start with a medication that has been shown to be effective for the particular patient and to anticipate that any new pain may require MME dosing equal or greater than the premorbid regimen to achieve adequate pain control and to prevent the onset of withdrawal symptoms. The pharmacologic principles that simple, monotherapy regimens are easier to administer, have higher rates of compliance and are more effective are generally good principles to follow when designing a treatment regimen.  Mu-opioid agonists due to chemical configuration and available routes of administration have different benefit potential and different side effect profiles that provide the basis of therapeutic selection.  Unfortunately, analgesic benefits of mu-agonists are achieved through a single mechanism of action, regardless the formulation precluding a hoped for reduction of daily MME by providing treatment with multiple mu-opioid agonist at low doses. Furthermore, the simultaneous initiation of treatment with multiple formulations complicates the recognition of which agent(s) might be responsible for any benefits or adverse effects observed.  Because of incomplete cross-tolerance between mu-opioid agonists, the concurrent use of multiple formulations, also effectively eliminates or greatly reduces any possibility for drug rotation, if needed. Thus, selecting a single mu-agonist formulation, determining the route of administration and the proper dosing allows for early identification of tolerance and dosing efficacy. Finally, the use and selection of potentially beneficial adjuvant agents based on pain type and benefits that may be realized from their otherwise adverse, side effect profile, e.g., drowsiness in patients with difficulties sleeping, are important components of the analgesic regimen that are likely to produce benefit without undesired adverse effects if they are prescribed in adequate doses. 

In the midst of the exponential growth in technology and continued advances in the era of information explosion that often lead to overwhelming increases in system complexity, it may be comforting to remember that the old, simple, basic principles that we learned as fledgling healthcare providers are still useful and may be our best means for caring for our modern day patients in a rapidly expanding and changing world of pain medicine.