Dear Cynn and List(s),

The basic tenet remains; WE have medically come to an excellent place
with pain management; opioids have been shown through extensive research
to "increase the quality of life" for those who suffer NIP (nonmalignant
intractable
pain), and furthermore caused LESS COST to insurers, employers and those
thus afflicted by INCREASING the RTW (return to work) ratio et al.

The DEA has taken upon itself not only to unjustly to malign and
incarcerate
providers who treat NIP, but patients. We see MANY in prisons today, we see
MANY suicidal and some outcomes of suicide, DUE TO THE DEA the point
is very cognizant and well documented.

Then you have providers who are "sell outs" who are WILLING to be
bought by the DEA to testify against good providers; who know NOTHING at
all about RSD, and other pain disorders FAR more painful then end stage
cancer and the like MP (malignant pain) disorders.

With this in mine personal prejudices which in the "old school" of medical
thought become the byword; for instance:

1. Racial pain prejudice
2. The very young "cannot feel pain"
3. The elderly "do not have pain"
4. Pain is psychiatric craving for attention
5. Those with viable pain disorders are addicts

Mind you MUCH of this is grounds for "medical malpractice" a licensed
physician, D.O., RN, or LVN (LPN) who blatantly document such without
cause are open to lawsuits and damage awards; in short one can lose their
license for such bigotry.

It is simple.

1. Pain can be most safely treated for those with NIP long term
with opioids properly managed by specialists educated to treat
pain.
2. An addict is not a pain client; addiction is a serious illness and
can
be well treated by psychiatrists and trained NP's and psychologists
along with ADs (antidpressants) and the like and ongoing public
"interactive therapy" such as AA and NA.

Specific states offer legislation and "laws" to enact and portray what
and how
NIP is treated; the DEA has overruled the states. In America we used to
think the
IRS was "Big Brother" today we know it's the DEA.

Now personally I'm a big fan of George Bush; ya'll know I have maintained
a
residence in Midland, Texas and my husband's first wife even dated George.
The
Bush family are truly good folks; most West Texans are, but if HE DOES NOT
KNOW the truth (so folks let's start bombarding the President with literature
and
information) the current DEA witch hunt becomes bigger, harder, and more
invasive no matter who takes office the next go round....

The "price we pay for pain" well it's LIFE. We deserve ours don't ya'll
agree?

Much love,

Karen G.



In a message dated 5/19/2005 11:22:48 AM Central Daylight Time,
cynnyc@... writes:
The following is available in Pdf and Rtf formats at Ocpm's Sitemap under
"Pain Management".

http://www.cpmission.com/main/sitemap.html


Ethical Management of Pain in
the Real World--
Do They Deserve Drugs?
Neil Irick, MD
Clinical Associate Professor of Medicine
Adjunct Associate Professor of Nursing
Indiana University
Institutional Core Curriculum Grand Rounds
UT College of Medicine-Chattanooga Unit
January 13, 2004
Ethical Principles
• Justice
• Autonomy / Shared decision making
• Beneficence (Do good)
• Non-maleficence (Do no harm)
• Veracity
– Treatment options and expectations
• Fidelity / Advocacy
Fitzgerald, 1999
Attitudes and Consequences
• When patients have withdrawal from tricyclics,
corticosteroids, and other meds, we think nothing
of it
• Patients take many different meds chronically--
insulin, BP meds, and are not punished for that
• Twelve “cured” cancer patients committed suicide
because of untreated pain related to their cancer or
its treatment
Prescriber Issues
• Is this pain?
• Is this addiction?
• Is this pseudoaddiction?
• Is this diversion?
• Is this psychiatric disease?
Patient Fears
• Dying
• Being labeled a “bad” patient
• Isolation
• Loss of control
• Becoming an “addict”
The Drug Problem
• <2% of the American population are hard
core drug addicts, 3-4% are drug-abusers
" 94% of the population do not “do drugs”
• The incidence of addiction is the same
today as 100 years ago.
• The incidence of addiction is the same in all
groups and strata of the American society.
Biases
both patients and health care professionals
• Cultural
• Religious
• Familial
• Existential
Cultural Biases
• Young African-Americans or Hispanics will
receive ½ the total dose of analgesic given
to middle-aged whites for the same surgery
Morgan, 1988
• Pharmacies in predominantly African-
American and Hispanic areas in New York
City do not stock Schedule II opioids
Morrison, NEJM, 2000
Cultural Biases
• Females of minorities over the age of 70 years are
more likely to endure undertreated pain, even
untreated pain in SNFs
Bernabei, JAMA, 1998
• African-Americans in ERs, with solitary longbone
fractures, are 66% more likely to be refused
pain medicine
Todd and Deaton, Annals of Emergency Medicine, 2000
Cultural Biases
• Conservatively reared African-Americans look
down and to the side to show respect to doctors,
nurses, and the clergy
• Whites distrust persons who do not look them “in
the eye.”
Religious Biases
• Is pain redemptive?
• Does it wipe clean the slate of one’s sins?
• The most difficult aspect of this bias is that
religiosity that allows us to righteously
judge the worthiness of individuals
Familial Biases
• Stoics do not talk about pain
– They dislike listening to pain complaints
• The majority of health care professionals
are stoics
• Epicureans talk endlessly about their pains,
thinking it was nice of us to ask
– They quickly become “bad” patients
Existential Biases
Each of us can remember the first time that
we were “scammed” by a drug seeker.
Unfortunately, we resolve that it will never
happen again. This makes us feel right in
refusing requests for medication for pain.
True Addiction
• Compulsive use despite harm
• Quality of life is not improved by the
medication
Pseudoaddiction
the end result of undertreatment of pain
• Drug-seeking behaviors
• Drug hoarding
• Usually going to more than one pharmacy and one
physician
• Usually “cured” by increasing the daily dose of
opioid and monitoring the patient
Weissman and Haddox. Pain, 1989.
Physical Dependence
• Occurs in all patients on chronic opioids
• Withdrawal will be produced by the
administration of an antagonist agent such
as pentazocine, buprenorphine, nalbuphine,
or butorphanol -- or by stopping
medications abruptly
• Withdrawal is a sign of mismanagement,
not of addiction
Who is the Addict-To-Be?
• Regular, recent use of illicit drugs
• History of alcoholism or treatment
• History of drug-related treatment and
problems
• Loss of jobs due to drug use
• History of mental illness
– Major depression--five times as likely to abuse
medications
Reasons for Poor Pain Control
• No accountability for poor pain
management
• Failure to routinely assess and document
pain
• Lack of practical treatment protocols
• Perception of pain as insignificant symptom
in face of disease
Dahl, 1999
Acute Pain Treatment
Guidelines
Agency for Healthcare
Research and Quality
1-800-358-9295
www.ahrq.gov
Federal Guideline Compliance
Pre-op discussion of pain relief options 13%
Regular evaluations of pain, operative day 51%
Use of pain assessment tool, operative day 46%
Use of behavioral techniques 11%
Use of medications to maintain baseline control 55%
Use of Demerol. as first-line analgesic 51%
IPRO, 1997
JCAHO Standards
“The patient’s right to pain management is
respected and supported.
The HCO plans, supports, and coordinates
activities and resources to assure the pain of
all patients is recognized and addressed
appropriately.”
JCAHO Standards
• Every patient will have a “screening” interview
about pain on admission
• Pain as the “5th vital sign” -- only if pain is a
problem before our procedures
• “Dedicated” pain professional available for all
patients
• Pain management protocols in place
• All staff will have in-services twice yearly
Assessment
• Believe the patient
• Listen to the patient
• Have the patient rate the pain
• Do a good history and physical exam
• Give the patient pain relief while
completing the workup
• Reassess frequently to assure the best
outcome
Foley, NEJM. 1985
Pain Treatment Options
• Spiritual
• Psychological
• Physical
• Surgical / Anesthetic
• Pharmacological
Spiritual Interventions
• “Ministry of Presence”
• Listening
– Average length of “opening statement” by the patient is
only 3 minutes
• Planning
• Sharing
• Prayer
Am I a Good Listener?
• 77% of patient opening statements to the
physician are interrupted (Beck and Frankel, 1984)
• 94% of interruptions conclude with the
physician obtaining the floor (Frankel, 1984)
• Only 1 of 52 patients went on to complete his
statement of concern
• Patient/Physician agreement of presenting complaint
was 76% for somatic complaints, but only 6% for
psychosocial problems
Psychological / Psychiatric
Interventions
• Biofeedback
• Relaxation
• Imagery
• Hypnosis and self-hypnosis
• Group and / or individual therapy
Physical Interventions
• Manipulation
• Massage
• Acupuncture
• Topical preparations applied by the patient
and family
• Self-directed exercises through physical
therapy
Surgical / Anesthetic
• Use with greatest caution
– Chemical
• Blocks, Ablations
– Surgical
• Peripheral Neurectomy, Rhizotomy,
Methylmethacrylate
• Be aware of the long-term effects of some
interventions
Pharmacological Interventions
• Antidepressants
• Anticonvulsants
• Anti-inflammatories
• Analgesics
Antidepressants
Tricyclics
• amitriptyline, nortriptyline
• imipramine, desipramine
• doxepin
• trazodone
Anticonvulsants
for membrane stabilization
• Gabapentin (Neurontin)
• Oxcarbazepine (Trileptal)
• Topiramate (Topamax)
• Lamotrigine (Lamictal)
• Valproic acid (Depakote)
• watch for hepatic toxicity
• Carbamazepine (Tegretol)
• watch for hepatic and bone marrow toxicities
Anti-inflammatories
Use with great caution!
• NSAIDs caused 16500 deaths in ‘98 and ‘99
• 107000 admissions to hospitals
• Use non-acetylated salicylates if intolerant of
traditional NSAIDs
– choline magnesium trisalicylate
– salsalate
• Consider Cox-2 inhibitor or
misoprostol/diclofenac combination tablet
Opioid Analgesics
• Use long-acting opioids for the baseline
level in scheduled doses
• This achieves nearly constant blood levels to treat
the constant level of pain
• Use short-acting opioids only for preemptive
or rescue dosing
• This permits patients to participate in activities that
would otherwise be too painful, e.g. physical
therapy, shopping, etc.
Intramuscular Opioids
• Interpatient variability
– Peak plasma level: 2-5 fold variability
– Time to peak level: 3-7 fold variability
• Intrapatient variability
– Peak plasma level: 2 fold variability
• Pain cycles
Austin, Pain, 1980
“Patient Controlled” Analgesia
Concentrations
• Morphine - 1 mg/ml
• Fentanyl - 10 mcg/ml
• Hydromorphone - 0.2 mg/ml
• Meperidine - not recommended by
federal guidelines
“Patient Controlled” Analgesia
• Loading dose - repeat until patient
comfortable
– morphine - 50 mcg/kg q 5-10 minutes
– fentanyl - 0.5 mcg/kg q 5 minutes
– hydromorphone - 10 mcg/kg q 10
minutes
“Patient Controlled” Analgesia
• Maintenance dose
– morphine - 20 mcg/kg q 5 minutes
– fentanyl - 0.2 mcg/kg q 5 minutes
– hydromorphone - 4 mcg/kg q 10
minutes
PCA at Night
• At 2200h, add up the total mg of PCA
opioid given since 0600h that same day.
Divide this total by 16 to give the average
hourly dosing with the PCA.
• Set the PCA to run at this rate continuously
during the night
• At 0600h, resume regular PCA settings.
Changing from PCA to Oral
• What was the total dose of PCA opioid used
during the previous 24 hours?
– Convert to oral morphine equivalents, then use
morphine or oxycodone in 1:1.5 dosage
• Patient used 40 mg PCA MS (or 8 mg Dilaudid) on
day before switch
• Convert as 120 mg ORAL MS
– CR oxycodone 40 mg q 12 hours with 15 mg rescue doses
– OR CR morphine 60 mg q 12 hours with 15 mg rescue
doses
What’s Wrong with this
Order?
• Morphine, 2 mg IV per hour. Titrate to
comfort.
• Patient is a 47 years old male with terminal
pancreatic cancer. His dose of MSContin at
home was 300 mg q 12 h, roughly 8 mg IV
per hour.
• 48 hours after admission, his dose of MS IV
was 98 mg/hr. Patient had respiratory arrest
How Best to do it?
• The order should read “nurse/pharmacist to
determine hospital dose based on home
dose.”
• DO NOT TITRATE IV RATE
• Offer rescue dose q 20 minutes that is equal
to the hourly dose to titrate for comfort.
• Basal rate of IV infusion can be adjusted on
a daily basis
Mild to Moderate Pain
1-3/10 on visual analog scale
Adjuvant Analgesics
– Acetaminophen 650 mg PO or PR q 4 h
– Ibuprofen 400-600 PO q 6 h
– Choline magnesium trisalicylate 750-1500 mg
PO bid
– Ketorolac 15-30 mg IV q 6 h (Maximum 3
days)
Moderate Pain
4-7/10 on visual analog scale
Opioid +/- adjuvant
Scheduled Long-Acting Agents
• CR oxycodone 10-20 mg PO q 12 h
• CR morphine 15-30 mg PO q 12 h
• Levorphanol 2 mg PO q 6 h
• Methadone 2.5-5 mg PO q 6 h
• Transdermal fentanyl, 25 mcg/hr
Moderate Pain
Opioid +/- adjuvant
Pre-emptive or Rescue doses for breakthrough
• IR oxycodone 5 mg, 1-2 PO q 4 h prn
• IR morphine 15 mg, 1-2 PO q 4 h prn
• IR hydromorphone 2-4 mg PO q 4 h prn
• Hydrocodone 10 mg/APAP 500 mg, q 3 h
prn (Not recommended)
Severe Pain
7-10/10 on visual analog scale
Stronger opioid dose +/- adjuvant
Longer-acting opioids, scheduled dosing
Titrate up as necessary every 24 hours for comfort
• CR oxycodone 40-80 mg q 12 h (No ceiling dose)
• CR morphine 60-100 mg q 12 h (No ceiling dose)
Titrate up as necessary only very slowly
• Methadone 5-10 mg q 6-8 h
• Levorphanol 4 mg q6 h
• Transdermal fentanyl 50-75 mcg/hr q 72 h
Severe Pain
Stronger opioid dose +/- adjuvant
Titrate up as necessary every 24 hours for comfort
Shorter-acting agents for breakthrough pain
• The rescue dose of the immediate release
agent should be approximately 15-20% of
the total daily dose.
Potential for Abuse
• EVERY opioid has the potential to be
abused by those determined to do so
• Sale or diversion to street market
• Altering the mode of delivery
– Removing the CR coating of OxyContin
– Cutting the corner off Duragesic patches to
suck out the fentanyl or making “chiclets”
– “Dope on a rope” to produce “Liquid Gold”
Can opioids be prescribed for
any chronic pain?
• The Controlled Substances Act of 1970
specifically states that opioids may be prescribed
for pain, but not for addiction
• To be precise, encourage the prescriber to put “for
pain” in the sig. of the prescription. This will help
avoid calls from the DEA
• Remind the prescriber to write “chronic pain
patient” or “terminally ill” on the prescription
blank
Medication Management
Agreements
• Medication is the responsibility of the patient
• No use of illicit substances is allowed
• Only one physician prescribes opioids
• Only one pharmacy and one pharmacist is used
• Patient waives right to privacy regarding
medications
• Unannounced urine drug screens are used
Do These Things and
Stay Out of Trouble
• History and physical examination
• Treatment plan and objectives
• Records
• Consultation
• Periodic review
• Informed consent / Medication agreement
• Compliance with controlled substance laws and
regulations
Pain Treatment Goals
• Restoration and maintenance of hope
• Helping the patient grieve for the “former
self” that has been changed forever
• Reduction of the pain experienced by 50%
• Becoming strong advocates for the wellbeing
of our patients
Pain Treatment Goals
• Restoration and maintenance of hope
• Helping the patient grieve for the “former
self” that has been changed forever
• Reduction of the pain experienced by 50%
• Facilitate continued employment
• Becoming strong advocates for the wellbeing
of our patients
“Re-medicalizing the problem”
Spanos, 1998
• Patient with a pain problem
• Subjective report
• Objective findings
• Assessment
– Pain? Pseudoaddiction?
– Addiction?
– Diversion?
– Psychiatric disease?
Case Study
• 37-year-old male with intractable pain in
the epigastrium
• Six months post “cure” of esophageal
carcinoma
• Patient referred because of refusal to be
tapered off opioids (CR oxycodone, 80 mg
BID)
Case Study
• Referral to original surgeon for reevaluation
of the nodule
• Recurrent carcinoma
• As disease became worse, eventual dose of
CR oxycodone 720 mg q 12 h
• Patient maintained control of his company
until two days before his death
Aberrant Behaviors
Less Predictive of Addiction
• Aggressive complaining about need for
more medication
• Drug hoarding during periods of less pain
• Requesting specific drugs
• Openly acquiring similar meds from other
providers
Aberrant Behaviors
More Predictive of Addiction
• Selling prescription medications
• Prescription forgery
• Stealing or “borrowing” from others
• Injecting oral formulations
• Obtaining medications from “the street”
• Concurrent use of alcohol or illicit drugs
Case Study
• 42 years old single male lawyer admitted with
spontaneous rupture of diverticulum of sigmoid
colon
• Post-op received 180 mcg/hr epidural fentanyl for
48 hours (equivalent to 1800 mcg/hr IV)
• After epidural out, switched to Vicodin, 5/500, 1-2
q 3h prn
• Patient given Demerol, 100 mg IV with 1 hour of
relief, then confusion
• Toradol, 30 mg IV given QID x 6 days
Case Study
• After 8 days, patient referred to chronic
pain service by a cardiologist/friend of his
fiancée
• Pt started on OxyContin 80 mg BID
• Discharged 2 days later on OxyContin 20
mg, 1-2 BID with rescues
• Patient tapered off medications over two
weeks period
Case Study
• When patient admitted for takedown of
colostomy, he went home after 23 hours on
OxyContin 10 mg, 1-2 BID with rescues
• Patient returned to work 1 week after
surgery
• Patient tapered himself off the OxyContin
two weeks after the surgery
Post-Operative Pain
• 37 y o female with 22 prior surgeries to correct
congenital deformity of the right upper extremity,
last was 4 days prior to consult
• Pt receiving demerol 100 mg IM q 4-6 h
• Pain rating 10/10
• In getting ready for discharge, pt changed to
hydrocodone /APAP 7.5/750, 1-2 q 3 h prn
• Discharge prescription for 12 tablets in front of
chart
Getting Them Home
• Had been on CR morphine at home prior to this
hospitalization, 60 mg q 12 hours
• Home Rx--CR morphine 100 mg q 12 hours
PLUS immediate release morphine 30 mg q 3h if
needed for breakthrough pain
• Anticonvulsant, tiagabine 4 mg at h s with snack
added for “shooting, stabbing” sensation
• Scheduled for follow-up in office in 6 days
• Next surgery, patient went home 21 hours after
surgery
Keeping Them Home
• 33 y o female with post-op pelvic tumor
removal seen in ER on 3 occasions in 2
days for uncontrolled pain
• Admitted for pain control, had repeat
surgery, with nothing found
• Pt receiving Percocet, 2 tabs q 4 hours
• After 3 weeks in hospital, chronic pain
consult obtained
Keeping Them Home
• Pt sent home that day on CR oxycodone 40
mg q 12 hours with rescue dose of IR
oxycodone, 15 mg q 3 hours for
breakthrough pain
• Follow-up in office in 5 days
Non-Cancer Neuropathic Pain
• 28-year-old female with RUE “burning and
electric” pain as result of a 300 pound
patient falling on her
• 67 stellate ganglion blocks in 6 months
• Pain unchanged
• Medication--Vicodin ES, 1 q 4h prn
Non-Cancer Neuropathic Pain
• Desipramine, 25 mg daily
• Neurontin, 100 mg daily
• CR oxycodone, 10 mg 1-2 BID
• IR oxycodone, 5 mg, 1 q 3 h prn
• Referral to psychologist for evaluation of
secondary gain and possible marital
problems
Non-Cancer Neuropathic Pain
• 38 year old male referred by IPD Narcotics
division for phoning in his own Lortab
prescriptions
• Works for construction crew
• Married, two children
• No arrest record
Non-Cancer Neuropathic Pain
• Post-traumatic deformity of the right tibia
with distortion of the ankle
• No insurance
• Desipramine, 50 mg daily
• Methadone, 10 mg TID
• Working regular hours
• Pain scores have decreased from 7/10 to
3/10
Non-Cancer Neuropathic Pain
• 40-year-old-female referred by psychiatrist
• Non-functional, depressed, previous suicide
attempt
• Two children, ages 10 and 12
• Husband is a lawyer
• Taking 12-16 Vicodin per day
• Also on Prozac, 80 mg per day
Non-Cancer Neuropathic Pain
• Pain rating 10/10
• Seven failed back surgeries--last was
removal of fixation hardware
• Previous cervical fracture (MVA) with
foraminal compromise and neuropathic
symptoms
The Beginning
• See patient with husband to enlist his help
in monitoring her care
• Add small dose TCA to regimen--
desipramine
• Ask what is the MOST analgesic ever taken
in one day (16)
• INCREASE that by 50% (Give 24 per day)
• Use IR oxycodone to avoid APAP toxicity
Instructions to Patient
• Lay out 24 tablets every morning
• When you take a dose of medication, write
down even just one word to describe your
pain--at least one word per day
• Return in one week with pill bottle, written
journal, and husband
Is This An Addict? NO!
• Patient returned as scheduled
• Patient had pills left over
– Able to control use
• Patient had prepared two meals for her
family during that week
The Following Period
• On CR oxycodone 80 mg BID
• IR oxycodone 30 mg q 3 h prn
• Runs a carpool, chairs her parish committee
• In charge of St Vincent de Paul Society for
the parish
• President of Parents Association at the
school
Post Trauma Pain
• 92 y o female in auto accident
• Fracture of left ribs 2-5 and fracture of
sternum
• Darvocet N-100, 1 6 h prn for pain
• 36 hours after admission, patient begins to
be confused, disoriented, and disheveled
• Physical therapy started, but patient “not
cooperative”
Post Trauma Pain
• O2 sats 80, Rales in bases
• Son insisting that her pain regimen be more
aggressive (OxyContin 20 mg po q 12 h
with 10 mg IR Oxycodone q3h prn AND 1
hour before PT)
• Attending physician afraid that dose would
cause her death
Post Trauma Pain
• Patient home less than 48 hours after
regimen started. Home dose was CR
oxycodone 10 mg q 12 h with 5 mg IR
rescues
• Patient was able to drive herself to PT
• Two weeks later, patient was using only
topical ketoprofen for local pain and
sleeping on her “magnet” mattress pad
Medication Management
Agreements
• Medication is the responsibility of the patient
• No use of illicit substances is allowed
• Only one physician prescribes opioids
• Only one pharmacy and one pharmacist is used
• Patient waives right to privacy regarding
medications
• Unannounced urine drug screens are used
Avoiding Problems
• Require picture ID at first visit
• Require Picture ID of anyone picking up a
prescription for a home-bound patient
• No opioids are prescribed on nights and
weekends
• Lost or stolen medications are NOT
replaced
Pain Treatment Goals
• Restoration and maintenance of hope
• Helping the patient grieve for the “former
self” that has been changed forever
• Reduction of the pain experienced by 50%
• Becoming strong advocates for the wellbeing
of our patients
Avoiding Problems
• Patient unable to urinate for drug screen
– “No pee, no prescription”
• If a male patient leaves the office to “get a
coke” to stimulate urine production, be
inclined to get estrogens checked on the
urine.
Considering an opioid?
• Patient may improve and want more of this
• Side effects may cause the patient to have an
accident or cause injuryVainio, Lancet,1995.
• Pharmacist may report you to the authorities if
s/he does not agree with the regimen
• If an opioid is started, and the patient improves,
what will my peers think of my prescribing and
treatment plans?
Tolerance
• Some of these patients are hard to tolerate
• Medication tolerance is not a great problem
– Sometimes it’s hard to get the patient up to the
best dose without losing your nerve
• The tolerance that develops is most often to
the side effects--sedation, pruritis, nausea
• Tolerance never develops to constipation
How do I deal with it?
• Learn to laugh with others and at yourself
• Conscious relaxation
• Rhythmic breathing
• Set aside time for yourself
• Limit caffeine and other stimulants
• Exercise
What exercise is the most
relaxing for you?
• Try to find an exercise that is enjoyable
– Use several different exercises
• Don’t try to be a champion
• Don’t try to lose weight
How to live a long life
• WEAR YOUR SEAT BELT !!!!!
• Choose long-lived parents
• Don’t smoke
• Watch your diet
• Don’t drink alcohol and drive
• Limit stress
Imagery Exercise
To be done before you leave the parking lot
• Write down mentally on a piece of paper
the things that are troubling you when you
leave the office
• Tear off that piece of paper
• Wad the piece of paper, roll down the car
window, and throw the paper outside
• Roll up the window
“Re-medicalizing the problem”
Spanos, 1998
• Patient with a pain problem
• Subjective report
• Objective findings
• Assessment
– Pain? Pseudoaddiction?
– Addiction?
– Diversion?
– Psychiatric disease?
Suggested Reading
• Fields H and Liebeskind, J, eds. Pharmacological
Approaches to the Treatment of Chronic Pain:
New Concepts and Critical Issues. IASP Press,
Seattle, 1994.
• Schultz, K. The Art and Vocation of Caring for
People in Pain. Paulist Press, New York, 1993.
• Cassell, E. Diagnosing Suffering: A Perspective,
Ann Intern Med. 1999;131:531-534.


--


Karen Hallenbeck-Sikorsky-George BS,RN,UM,QC

http://hometown.aol.com/anewplanforyou
http://hometown.aol.com/anewplanforyou/sb.html



Owner-Moderator
http://groups.yahoo.com/group/ADayWithoutPain/
"ADayWithoutPain"
http://groups.yahoo.com/group/AnAnGeLInPain
"AnAnGeLInPain"

Ya'll are special you truly are, and to be the
catalyst for this group is a miracle for I know
in my heart that God's will created this group(s)
and each of you are very very special to me, always
no matter what I AM SO PROUD to a "part of" what
this family has become..AND WILL BE!!!!
Interqual Certified
Published Psychiatric Researcher
Advocate for those in CIP, HIV, Psychologic Pain
"A Higher Power is necessary to find the ability to withstand self
destruction.."


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