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Chronic Pain (transcript)
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[clock ticking]

[music]

(Dr. Peter Salgo) 
Welcome to Second Opinion, where each week our healthcare team solves a real medical mystery.  When we close this file in a half-an-hour from now, we'll not only know the outcome of this week's case, you'll be better able to take charge of your own healthcare.  I'm your host, Dr. Peter Salgo, and our story today concerns Marlene.  Now you've already met our special guests who are joining primary care physician, Lisa Sanders, and health reporter, Christine Rogers.  Now no one on this panel knows the case, so its time to get to work.  Let's tell you a little bit about Marlene.  Marlene is 68 years old. She is in good health and only goes to the doctor when, and she says, "when there is something wrong".  The last time she went to the doctors was some time ago, six years ago.  She is described by her physician, in the chart, as a very smart independent woman who lives alone. The reason she has come to her doctor's office today is she is complaining of severe pain all over.  You're up. She's in your office.  Now what?

(Dr. Lisa Sanders) 
Wow.  Pain all over. 

(Peter)  
What do you want to do?

(Lisa) 
Well I want to get some more history.  When did it start?  How did it start?  What makes it better?  What makes it worse?  The quality of the pain?  I want to know all those things, its important.
 
(Peter)  
So you're asking for what?  The seven dimensions of her pain, right. But I can tell you a few things because her doctor's chart says that she said, "Her pain began about six months ago".  And the way she describes the pain is, "everything hurts".  She's tried aspirin, Tylenol, Advil, other home remedies with no success.  Do patients come in typically with vague pain complaints like this or do they come in with more specific stuff?

(Dr. Tom Campbell) 
Not as much as like this.  As a primary care physician my first reaction would be one of dread.  I have fifteen minutes with this patient whose coming in and she's giving me really not a typical presentation and its either something very unusual that's going to really challenge me or there's something else going on here.

(Peter)  
I heard Carmen sighing over there.  What's the sigh?

(Dr. Carmen Green)  
Well you know the corner stone of quality pain care is actually pain assessment.  And I think it actually goes back to hearing in place this entire story.  You've just given us snippets of, you know, how the patient presents.  With that being said, I think part of the reason why we dread these stories, is because we're not trained to hear these stories.

(Peter)  
Well let's back up for a second.  What causes pain?  What is pain?

(Tom) 
Well I would think of it as something, what's called a bio-psychosocial prospective.  And there's a biological or physical element to it.  There is a psychological element to it and there's a social family community element to it.  And assessing all of those and understanding how that affects the experience of pain is going to be critical of the patient.

(Peter)  
Is pain always a symptom of something wrong?  Is it always a marker that you got to pay attention to an underlying disease?

(Dr. Michael Clark) 
Well but that's part of the problem. Is that it's an experience and it's a word that is used to describe a symptom, suffering, diagnosis, findings that are provoked by an examination.  So you really have to understand the patient as a whole, as Tom was mentioning.

(Dr. Peter Salgo) 
But Marlene says, she's in pain.  Is it worthwhile trying to measure it or get an estimate of how much pain?  And how do you go about doing that?

(Tom) 
Well usually you can ask them, in simple scales to say, gee compared to other pains that you've had on a scale of one to ten or on a visual scale or there's smiley faces that you can use to do that, to say how bad is this pain compared to other ones. And sometimes that can be very helpful, particularly if you anchor it in something like have you had children?  How does this compare to the pain that you had during childbirth?  But its very variable because people respond, I've had patients come and say, my pain out of one to ten is always twelve.

(Carmen)  
But the part of that is due to the fact, I mean we don't have a good pain-o-meter, for lack of a better word.  I mean there are experimental pain, I mean things that we say, okay, we'll take Lisa and we'll put her hand in some cold water.  How long does she keep her hand in?  Okay, if that's one.  Sorry about that Lisa.  But, so we'll look at pain from that prospective but the problem is, is that those types of tests have never been correlated to the clinical experience of pain.  And so what we do know is that the pain complaints of women, the pain complaints of minorities, the pain complaints of the elderly are often under treated.  Now when you talk about a scale of zero to ten and a patient gives you a pain score of twelve.  That means that scale doesn't work for them.  Okay.  And for a long time physicians have sort of said, geez, you know, that means the patient says the pain score is twelve that means they're crazy.  Right.  They're crazy. They won't work with my scale. But actually part of it is that we are taught in a very logical fashion.  Zero is no pain, ten is the worst pain you can imagine.  Someone says its twelve, they maybe saying its twelve in response to one, they want you to believe them or they have a history of not being heard.  Or the scale doesn't work for them.

(Peter)  
When I first mentioned these pain complaints.  And I'm not even going to call them vague complaints.  They're not vague to her. 

(Carmen)  
No.

(Peter)  
But there was a look on everyone's face that's oh, my goodness.  Here we go again.  And the reason I bring this up is when you talk about pain complaints to a group of doctors, isn't this the group of patients that many doctors would least like to meet?

(Michael) 
Absolutely.  These are the patients that are typically chronic.  Typically seen as frustrating by physicians.  And often times, don't respond to the therapies that are prescribed. 

(Peter)  
Now Helen you've been in this system, you've had chronic pain?  Right.

(Helen Dearman)  
Yeah.

(Peter)  
What was your experience here and does this sound familiar?

(Helen)  
Yes it does.  My experience with chronic pain was due to an accident, not an ailment or a disease or birth defect.  And I fell four stories snow skiing.  And had it not been on a mountain laden with snow I'm sure I wouldn't be here today. So I'm very, very grateful to be alive.  But I went seventeen years undiagnosed because I had a fractured spine in three places, in the lumbar area of my spine. And quite honestly, like you were saying, many people did not believe me.  I never once in those seventeen years had my spine x-rayed.  And I didn't even in the emergency room, when I had my arm set, which was the obvious outcome of falling off a ski lift.  You know, its quite interesting because the emergency room physician said to me after my arm was set, do you hurt anywhere else?  And I looked him and I said, I just fell four stories, my eyebrows hurt.

(laughter)
 
(Dr. Peter Salgo) 
Would you like to know some more about Marlene?  Marlene is still in her doctor's office after the initial, I suspect, horrified moment like Lisa's of, what do I do now?  She did the obvious.  She took a physical exam.  She took a look at the patient.  What she found is that this is a woman who looks much older then her stated age.  Her blood pressure was 136 over 88.  Pulse 96.  Lungs were clear and her abdomen was basically a benign exam but she was very tender everywhere she was touched.  Everywhere.  Does that help anybody with this?  Does this advance the diagnosis at all?  Again, deathly silent. 

(laughter)

(Peter)
And I will tell you that it went further.  Marlene needed help from the nurse to get off the examining table and finally ends her exam completely because she had extreme discomfort.  So what her doctor did was to order some tests and schedule a follow up appointment.  What's going through your mind at this point?  Listening to this whole doctor encounter?

(Tom) 
One thing that really is curious is this started six months ago and she's just coming in now?  What's that about?  Usually that's very unusual, particularly the degree of discomfort that she has.
 
(Lisa) 
I think I' d also want to know what she thinks is going on because that can often illicit some information that she might not have thought was important but will be illuminating. 

(Peter)  
Well there's nothing in the chart about that, that's an excellent question by the way.  She is sent home to wait the results of the lab results or actually to come back and get them fasting.  She's not given any medication at all. Does that surprise you?  She's in pain. She comes complaining of pain.  As a layperson, would that surprise you?

(Christine Rogers) 
Yes, it does surprise me.  If someone is expressing that degree of pain, even, I mean I would think there would be something to make this woman more comfortable, particularly if she's been dealing with this for this long.

(Michael) 
I'd like to make her comfortable, no question about it, but at the same time you'd like to try and get some more information and she's already told you that several basic therapies have failed her.  So....

(Tom) 
I'd give her some low dose narcotics.  I don't have any problem with it.

(Peter)  
You would.

(Tom) 
Yeah, because who's not, it's not like somebody who presents to the emergency room with abdominal pain where you think that you're going to disguise the symptoms of the like.  It sounds like that non-steroid inflammatories and Tylenol did not work.  And you might still want to have her continue those but also add a low dose of a mild narcotic. 

(Carmen)  
Often the diagnosis is in the story. And for instance, it's not uncommon that she would have depression or have a sleep disturbance; so I would probably, in addition to the things that Tom and Michael have added, add an antidepressant to her, because of the fact that an antidepressant can actually help her with her sleep and that should help the pain.

(Peter)  
You'd do that right off.  Right on the first visit?

(Carmen)  
You'd better believe it.
 
(Peter)  
Well they didn't.

(laughter)

(Carmen)
Well they didn't do it right.

(Dr. Peter Salgo) 
All right.  But does anybody, I'm sorry to interrupt you but there's an 800 pound gorilla among us here, which is, is anybody worried that she's making all this up?  That this is fake?  I mean I know that doctors discuss this; does it cross your mind?

(Dr. Tom Campbell)
No, not in this patient.  I mean she doesn't have the history for that.  She doesn't have any of the background for it. 

(Peter)  
Would you characterize this as chronic pain anybody?  Six months.

(Dr. Carmen Green)  
Well she's had pain for six months and that's, you know, by anybody's definition that's chronic pain.

(Peter)  
Anything else right now that you guys want to know to make this diagnosis that you don't have yet?

(Lisa) 
Oh everything.

(Peter)  
Everything.

(Lisa) 
No you should have more.

(Peter)  
Oh that's right.  An executive health screen, maybe?

(Dr. Lisa Sanders) 
No, no, no.  I mean Carmen is right. We don't have enough of the history.  The history is going to tell us so much more then an x-ray or a Chem 7 or a CBC, none of those tests are really doing anything except giving the doctor a couple of weeks to think about this and what they could be missing.

(Dr. Peter Salgo) 
Sort of a pacing maneuver.  He's getting the labs.

(Lisa) 
Exactly.  I mean none of those tests are going to offer, I don't think any real answers. 

(Peter)  
I have one last question here before we sort of sum things up.  How long do you think it's going to take to get to the bottom of this?

(Michael) 
Oh it's going to be a while, I'm afraid, because things are so vague and we have so many unanswered questions.  What you would hope is that you would be able to find somebody or some of these tests are going to come back positive and narrow it down for you. 

(Peter)  
But is a fasten your seatbelts moment; this could be a bumpy ride.

(Michael) 
It could be.

(Peter)  
All right.  Let's pause then for a moment and go over some of the things that we've covered already.  Identifying the source of pain can be a difficult and long process, and sometimes pain is not a symptom of a problem it can be the problem itself.  This is a very, very difficult thing sometimes to parse out.  We've got some of the labs back.  Her white blood cell count is 6.8 with a normal differential.  Her hematocrit rate is 35 with a little microcytic.  Her ESR, her sedimentation rate is 23.  Her B-Rem is 19, creatine 0.9.  Her blood sugar is 128.  And nothing else on the panel is remarkable. 

(Lisa) 
So she's got a little bit of anemia.  She's got some sort of inflammatory process going on from the sed rate.  And she's got diabetes based on her glucose.

(Peter)  
What's wrong with her?

(Lisa) 
Well I don't know.  I can just tell you what the tests show and.  I mean to me it suggests.

(Peter)  
But I thought the test was supposed to tell you what's wrong.

(Lisa) 
No.  I told you they weren't going to tell you what's wrong.

(Dr. Peter Salgo) 
Helen, these guys and ladies are thumpering around looking for a diagnosis, was that what you experienced?  What was it like in the system when they tried to pin down what was wrong with you, and get to the heart of the your pain problem?

(Helen)  
Oh it was always my fault.

(Peter)  
Well how so?

(Helen)  
Because something couldn't be found.  It was in my head.  And it was my fault.

(Lisa) 
Can I ask you a question?

(Helen)  
Certainly.

(Dr. Lisa Sanders) 
Carmen was suggesting that this woman, Marlene might have sleep problems and she might be depressed.  How would you have felt if on your first visit to your doctor they had suggested antidepressants?  Would you have thought that was a good thing?  I mean because I think that this comes to a lot of doctor's minds but you're afraid that if you do that the patient might not feel like you were taking them seriously. 

(Helen)  
Right.  I've actually had that happen, and it can be, if presented in one way it can be taken very well.  If presented in another, it can be totally disastrous.  So you have to be kind of patient, patient, but we'll work together as a partnership.

(Peter)  
Are there specific techniques that primary care physicians can use to encourage feedback and additional detail from a patient other then it hurts. Are there specific little tricks of the trade you could try?

(Tom) 
Well you know, you mentioned the most important one, is developing a partnership so that it feels like you're working together, that you're being what's called patient centered.  Trying to really understand what the experience is and share your uncertainty.  In this case, I would certainly say, you know, this is very unusual.  This is going to take awhile for us to figure out what's going on.

(Peter)  
Now Carmen you had something you wanted to add.

(Carmen)  
Well I think one of the key things for Marlene and for Helen is to actually have their pain validated.  And I think that going back to what Helen talked about and Lisa asked is, you know, what do you hear when I say an antidepressant.  It's all in the way you present it.

(Peter)  
Let me tell you what Marlene says.  Marlene says, you've given me the tests, you've listened to me, and you've examined me.  My pain isn't getting any better.  I want some action.  I want some action now.

(Lisa) 
Well you can certainly understand why they're impatient.  You know, they've been.

(Dr. Peter Salgo) 
They're an impatient patient. 

(Lisa) 
They're not the patient, patient.  And why should they be?  You know they've been alone with their pain for six months and then it finally got to be so overwhelming that this person who clearly doesn't like doctors was willing to go to a doctor.  That suggests already that it had reached a certain threshold.
 
(Tom) 
That's right.

(Lisa) 
Now you're, you know, you're fumphing around, you're talking, you're per cussing, you took blood, you're poking her.  Let's have some action here.  I totally understand that, but she has to understand that this is not a multiple-choice question where you look in the back of the book to get the answer.  This is a process.

(Helen Dearman)  
Many people in that situation are looking for the magic bullet. 

(Michael)  
Yes.

(Helen)  
And there isn't one generally.

(Carmen)  
And sometimes you have to tell people, there is a not a magic bullet.

(Helen)  
That's right.

(Carmen)  
There is.

(Helen)  
You have to be honest.

(Dr. Carmen Green)  
This is, there's an art and there's a science to the practice of pain.

(Peter)  
Well I'll tell you what her doctor's did.  Her doctor specifically gave her a tricyclic, an antidepressant.  And I am sure the doctor got the question, oh so you think I'm crazy.  Is it because the doctor thinks she's crazy that she's given her the tricyclic?

(Tom) 
No absolutely not.

(Peter)  
No.

(Tom) 
In fact that's a particularly good choice here because it's useful as a pain, for treating pain specifically at a lower dose generally. 

(Peter)  
What does all of this have to do with pain?

(Dr. Michael Clark) 
You're trying to intervene in a system that is very dynamic and very complicated but at least we have some pharmacologic tools as well as a few other things to try and do that.  And it sounds like the doctors were hoping that they would get lucky by using medicine that's commonly prescribed for this purpose. 

(Peter)  
Well you know I'm going to tell they didn't.  They did not get lucky and neither did Marlene.  Marlene comes back to her doctor's office and she said, the tricyclics made her feel, and this is a direct quote, "awful, terrible, I'm not going to continue I'm going to stop it," she says.  She has lost.  She gives you a little more history at this point.  50 pounds in the last year and she's getting weaker, her pain is getting worse.  And I'll advance this even more.  Her doctor goes ahead and gets some more tests.  And gets a post glucose loading blood sugar that is, gives her something sweet to drink.  Comes back in two hours and gets a blood test.  And here's the result.  Her hemoglobin A1C is 8.6 and this blood sugar is 368, two hours after her glucose load.  Now where are we?  What does Marlene have?

(Lisa) 
Well she has diabetes.  But we actually knew that before.  It's always good to get a confirmation but we knew that before when she had a fasting glucose of 128.

(Peter)  
What does that mean for her pain?  Does diabetes have a relationship to pain?

(Multiple)   
Oh absolutely.

(Dr. Peter Salgo) 
I'm sorry.

(Helen)  
Diabetic neuropathy.

(Peter)  
Diabetic neuropathy, what's that?

(Carmen)  
Diabetic neuropathy is very specifically the small vessels, the small nerves are sort of irritated and basically the patient develops a pain problem.

(Peter)  
Here's what her doctor told her.  Her doctor said, Marlene.  You've got diabetes.  You've got diabetic proximal neuropathy.  He puts Marlene on insulin and tells her its all going to be better now.  The pain is going to go away once your blood sugars are normal.  Again, the diabetes may or may not have been her problem but the insulin.  She comes back to tell her doctors, guess what?  Makes her feel terrible. 

(laughter)

(Peter)
Why do you think she wasn't put on a painkiller right away?  Mike.

(Michael) 
I think doctors are reluctant to do that in situations like this. They're finding abnormalities on the testing.  They're honing in or at least now naming new diagnoses and so the number one thing to do is to try to correct the underlying problem and treat the disease that's present.

(Carmen)  
The other thing that I would say is that here's a person.  And when you talk about, you know, whether or not she was not put on pain medications early. There are lots of reasons why you don't want to put people on pain medications.  If you think about pain medications they're actually closely scrutinized by the state.  And so we are, we have fears of a patient becoming dependent or addicted to different types of pain medication.  And certainly there are patients who are at risk for having their pain untreated.
 
(Peter)  
Here's a woman in whom you've clearly found something, which is associated with a pain syndrome.  She's not getting better.  What good did the diagnosis do?

(Michael) 
Well the diagnosis is ultimately, hopefully, going to direct you in specific therapies.  Without one or without an underlying etiology for her symptoms you're left trying things basically by trial and error.

(Peter)  
Let's pause then for a moment and go over some of the things that we've covered already.  Knowing the cause of the pain.  Getting a diagnosis.  Often will be able to let you predict the treatment that will be most effective in treating that pain, whether or not she's having success right away, the diagnosis is helpful.  Is that a fair summary of where we are?

(Tom) 
Absolutely.

(Dr. Peter Salgo) 
Well then let me tell you what Marlene is going through, because she's unhappy.  Her pain is still there. The insulin didn't work.  The tricyclics didn't work.  She's angry too, by the way.  And so her doctor says, I'm sending you to a pain clinic.  Michael what's a pain clinic going to do for her that Lisa couldn't do?

(Michael) 
Well it's going to provide her with additional people thinking about the case.  Now there are a larger number of individuals interviewing her, examining her, spending time with her, and hopefully getting more information.  So that, now you've got several people putting their heads together trying to formulate what's wrong.

(Peter)  
Did you go to a pain clinic?

(Helen)  
Support.  Support.

(Peter)  
Support.  Is that all?  Just people are going to be disappointed if they hear support.

(Helen Dearman)  
Well they're not going to hear support, but in fact they are getting support from a variety of areas.

(Peter)  
Christine what do you think?  The average person here's going to go to a pain clinic where they're going to talk to you a lot.  Is that going to satisfy the average person in pain?  What's your best guess?
 
(Christine) 
My best guess is maybe not, particularly somebody who's been suffering for a long time.  I mean once again, you know, everybody's looking for that magic bullet and you may not get it.  I mean I understand what you're saying; you want to feel like there's a team who's on your side.  You don't want to feel like your by yourself but...

(Helen)  
Well that opinion is not going to come at the very first time you go to a pain clinic, for most people.  But if the clinic is working together cohesively that message will eventually permeate to the patient and the patient, hopefully, will begin to feel like I'm part of a team.  I'm the most important part of the team.  And everybody here is concerned about all the aspects of my pain and my complaints. 

(Peter)  
Is the goal of the pain clinic to just eliminate pain completely?  Other than that, you've failed?

(Carmen)  
The real goal is improve someone's quality of life and their functioning.  And you know, going back to their point.  I mean a lot of patients, you know, Lisa, you know, the pressures of medicine are that she has to see a patient every twelve minutes or something along that line.  You come to a pain clinic and someone's going to spend a few hours with you.  And they come out saying that you know, this is the first time someone's actually heard my story.  And that in itself is actually validating for lots of patients.  And it really does go back to that physician patient communication, hearing the story.

(Peter)  
Well let me tell you what happened at the pain clinic.  Would you like to know?

(Multiple voices)
Yes.  Oh yeah.

(Dr. Peter Salgo) 
All right.  Well the pain clinic, she gets into an in depth discussion about painful diabetic neuropathy as a general concept.  It helps her with her expectations of what she can expect for pain in the future and how much she's going to be helped.  They prescribe a diet program to reverse her weight loss and they start her on Gabapentin, what's that?  What's Gabapentin?

(Dr. Tom Campbell) 
It's an anticonvulsant that has been found to be very helpful, recently developed to prevent seizures but has been found to be very helpful for neuropathic pain as a number of the anticonvulsants. 

(Peter)  
Well here's what Marlene did.  She took the Gabapentin and she also started the diet.  Over the next four months she gets much better. 

(Carmen)  
Great.

(Peter)  
Her pain is manageable.  It doesn't say her pain is gone, by the way. The pain is manageable.  Blood sugar is under control.  She's on insulin.  It's right here.  She's gained back twelve pounds.  She's got a lot more energy.  So how come the pain clinic worked where the PCP's office couldn't?

(Dr. Carmen Green)  
You know, I think that's a little unfair to my primary care colleagues.

(laughter)

(Lisa) 
Highly

(Carmen)  
I really do.  Because the pain clinic, you know, that's all we do is take care of pain.  And I think that a lot of our primary care colleagues do a great job of taking care of patients.  They're asked to do an awful lot in that ten, twelve minute interaction.  Not every patient needs to be seen in a pain clinic, but every patient who has pain should have the opportunity to be seen in a pain clinic.

(Peter)  
I want to come back to something else.  She finds that her pain is more manageable.  It doesn't say that her pain is gone.

(Dr. Michael Clark) 
I think it's unusual that somebody gets complete pain relief and as Carmen said, that may be the goal for us but it's a goal that may not be realistic in every patient. 

(Peter)  
Let me pause here for just a moment and sum up what we've been doing for the past few minutes.  I think its fair to say that the medical goal of pain treatment is to restore function in a patient's life. You are not necessarily going to find your pain gone completely.  And a pain clinic is probably more likely, if I heard you all correctly, to get you to a point where the pain is reduced and your function is better so that you can go forward.  Is that fair?

(Multiple Voices) 
Certainly.

(Dr. Peter Salgo) 
How are you doing after all these years?  Chronic pain and misdiagnosis or missed diagnosis.  What's your life like?

(Helen)  
My life is great.  I still have pain.  I don't believe at this point in time I will ever be rid of pain, of course, who knows what the future will hold.

(Tom) Did you go back to skiing?

(Helen)  
No. 

(Tom) 
No more.

(Helen)  
No I didn't go back to skiing but for many, many years I was depressed and angry and ugly to be around.  And I look in the mirror and my face was just etched with pain and I didn't like what I saw.  And gradually I began to realize that I'm not pain.  I have pain but I'm still a wife and a mother, a neighbor, and somebody who likes to garden and all those things. And why can't I still do those.  I just have to do them differently.

(Dr. Peter Salgo) 
I want to thank you so much for being here.  I want to thank all of you; this has been just an amazing discussion.  We've run out of time. But its tough to talk about these things in public and I really want to tell you how much we appreciate your coming.  Before we leave, I want to cover some of the ground that we've covered and summarize it as best we can.  There's been a lot of ground.  Let me just go over some of the key things to remember.  Identifying the source of pain can be a difficult and long process.  Sometimes pain is not a symptom of a problem, it can morph into the problem itself.  Now once you know the cause of pain you can predict the treatment sometimes, often that will be most effective in relieving it.  It's worth looking.  The medical goal of pain treatment is to restore function in the patients' life, not necessarily to completely eliminate pain.  And our final message is this, taking charge of your health means being informed and having quality communication with your doctors.  I'm Doctor Peter Salgo.  I'll see you next time for another Second Opinion.

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