The Patient With Complex Chronic Pain and the Busy Primary Care Physician Dr. Paul A. Farnan Prescribers Course – May 13, 2016

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Disclosures Disclosure

• I have no financial interests or affiliation with any pharmaceutical industry or manufacturer to disclose

Disclaimer

• Views expressed are my own

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Key points • Busy physicians

• Patients with chronic pain

• Sympathy, empathy, codependence?

• Impact of codependency on patients and physicians

• Getting help – healthy boundaries

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MDs and the house of medicine? • Qualities vs. vulnerabilities

• Competitive, controlling, perfectionistic

• Overwork is the norm

• Blurred boundaries

• What does the patient need?

• What does the patient want?

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The patient

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PAIN BEHAVIOUR

a PP “INJURY”

PAIN

SUFFERING

DISABILITY

Which patient does the CNCP get?

Loeser

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It is the patient who brings the CNCP • Complex

• Unhappy

• Dependent

• Fearful

• Angry

• Has not responded to or are made worse by pharmacotherapy

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Patient with complex chronic pain is psychologically vulnerable and subject to strong emotions

It is not surprising that physicians respond to these patients with emotions of their own.

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“I need you to fix my pain, doctor” “To write prescriptions is easy, but to come to an understanding with people is hard.” —Franz Kafka. A Country Doctor

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One-dimensional solution to multidimensional problem? “It has been the drug companies that have for years picked the message and the messengers while sponsoring much of the postgraduate education and all the major pain meetings.” —Ballantyne JC. Pain medicine: repairing a fractured dream. Anesthesiology 2011;114(2):243-6.

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New York Times, May 10, 2007 In Guilty Plea, Oxycontin Maker to Pay $600M “Three current and former executives pleaded guilty today in federal court to criminal charges that they misled regulators, doctors and patients about the drug’s risk of addiction and its potential to be abused.”

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Sullivan

Blame the drug, or blame the patient?

“Adverse selection”:

the pairing of high-risk patients with high-risk

opioid regimens...

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Dose threshold policies • 2007: Washington Agency Medical Directors’ Opioid Dosing Guidelines

– 120 mg MME/day threshold dose – Re-evaluation and pain management consultation if needed

• 2009: APS/AAPM guideline

– 200 mg MME/day “watchful” dose – Based on doses evaluated in trials and observational studies – Recommended re-evaluation for appropriateness of therapy, enhanced

monitoring, consider consultation

• 2010: Canadian Guidelines for Opioids in Non-Cancer Pain – Watchful dose 200 mg MME/day

• More recent, as low as 50 mg/day MED (ACOEM)

• CDC March 2016: Carefully when increasing dosage to ≥50 morphine milligram

equivalents (MME)/day, and should avoid increasing dosage to ≥90 ….. 75 MME

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High-risk patient for substance dependence and chronic pain • Dysfunctional/alcoholic family of origin

• Emotionally traumatized

• Past episode of SUD

• Stimulus augmenters – deficit in hedonic tone

• Lack effective coping skills

• Dependent traits

• Problems with relationships

Savage 1991

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Physician at risk? • Strong relationship with patient – “special”

• Pharmacological overconfidence

• Transitions

• Rescue fantasies

• Inability to set limits

• Denial about possibility of boundary issues

• Burnt out

• Doesn’t like “pain”

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Empathy? Sympathy? • Both involve sharing

• Empathy – share understanding… “as if”

• Sympathy – share emotion, feelings

• Sympathy – if excessive could interfere with objectivity in diagnosis and treatment

• An abundance of empathy should not impede patient care?

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Caring too much? • We go into the health-care professions so that we can care for people

• We don’t like pain

• Physicians who over-identify with patients and who have unresolved rescue fantasies are especially vulnerable

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Codependence • A psychological syndrome seen in people affected by someone’s

addictive/abusive behaviour

• Characterized by a need to meet the needs of, to fix or to control others

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Codependent physicians might... • be over-controlling, over-responsible

• need others’ dependence upon them

• derive self-worth from helping others

• have alexithymia

• avoid confrontation

• feel compelled to fix others’ problems

From Woititz 1983

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Codependent physicians might also... • feel anger when their help is ineffective

• have trouble saying “no”

• feel safest while giving

• attract, be attracted to needy people

• neglect own needs, feel stressed

• have difficulty accepting help

From Woititz 1983

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Enabling? • What happens when we prevent the patient from experiencing the

consequences of their unhealthy behaviour?

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History of enabling behaviour? • Taking too much responsibility

• Embellishing sick notes (stress leave)

• Failing to confront with feedback

• No accountability for “contracts”

• Prescribing to treat emotional consequences

• Continuing to supply drugs when they are not achieving therapeutic goals, or doing more harm than good

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Codependency • Is not about a pathological relationship with an addict patient, it is the

absence of a healthy relationship with self

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Codependency… • Is not about a pathological relationship with an addict patient, it is the

absence of a healthy relationship with self

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Codependence: emotional status • Emptiness

• Low self-esteem

• Shame

• Anger

• Confusion

• Numbness

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“Universal Precautions” • Establishing defined boundaries from the outset

• Treatment takes place within a structural and conceptual place defined by certain parameters

• Boundaries exist to prevent harm to the patient

• May also prevent harm to the physician

• Doesn’t mean being defensively inflexible

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“If I work hard(er), I will be loved” • Roots of Physician Stress

Explored

Lynne Lamberg JAMA 1999;282:13-14

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Boundaries? • Who negotiates them?

• Who is primarily responsible?

“The onus for boundary safeguarding is primarily on the physician, him or her being the only professional on duty”

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Sleep

Eating

Intimacy

SocializingHobbies

Work

Exercise

Sexuality

Spirituality

The PIE of LIFE

Chart1

Sleep

Eating

Intimacy

Socializing

Hobbies

Work

Exercise

Sexuality

Spirituality

11.1

11.1

11.1

11.1

11.1

11.1

11.1

11.1

11.1

Sheet1

Sleep11.1

Eating11.1

Intimacy11.1

Socializing11.1

Hobbies11.1

Work11.1

Exercise11.1

Sexuality11.1

Spirituality11.1

Sheet2

Sheet3

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Controlling the epidemic: a three-pronged approach • Prevent new cases of adverse events/opioid addiction • Treatment for people who are already addicted • Supply control – provincial colleges and law enforcement efforts to reduce

over-prescribing and black-market availability

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More important than “drugs” • Give the patient hope

• Demonstrate therapeutic confidence

• Engaging the patient in their treatment plan

• What would you really like to be able to do?

• Provide an exercise and lifestyle prescription

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SELF-CARE SELF-EFFICACY

Behavioural therapies

Pharmacologic treatment

Physical activity

Employ multi-modal approach

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Summary • Tough patient population

• Qualities and vulnerabilities

• Empathy and sympathy

• We all have codependent traits

• “Codependence”: the syndrome

• Interferes with boundaries, relationships

• Causes enabling rather than empowerment

• Sets up patient for somatization and MD for burnout

• If identified is remediable

• With help, we can make change

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How to stop acting and feeling codependent • Read some literature: e.g. Woititz, Cermak, Beattie

• Go to some meetings: Al-Anon, CODA, ACOA

• Study and practice health boundary setting (Boundaries, Cloud & Townsend)

• Learn and practice meditation/mindfulness

• Get a mentor

• Take a prescriber’s course, FME

• Schedule fun into your life

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Thank you • Questions?

• farnan@mail.ubc.ca

The Patient With Complex Chronic Pain and the Busy Primary Care PhysicianDisclosuresKey pointsMDs and the house of medicine?The patientWhich patient does the CNCP get?It is the patient who brings the CNCPPatient with complex chronic pain is psychologically vulnerable and subject to strong emotions“I need you to fix my pain, doctor”One-dimensional solution to multidimensional problem?New York Times, May 10, 2007Blame the drug,�or blame the patient?��“Adverse selection”:�the pairing of high-risk patients with high-risk opioid regimens...�Dose threshold policiesHigh-risk patient for substance dependence and chronic painPhysician at risk?Empathy? Sympathy?Caring too much?CodependenceCodependent physicians might...Codependent physicians might also...Enabling?History of enabling behaviour?CodependencyCodependency…Codependence: emotional status“Universal Precautions”“If I work hard(er), I will be loved”Boundaries?The PIE of LIFEControlling the epidemic: a three-pronged approach�More important than “drugs”Employ multi-modal approachSummaryHow to stop acting and feeling codependentThank you