ON READING HARRISON'S PRINCIPLES OF INTERNAL MEDICINE FOR THE LAST TIME

Pain and Its Management : An Old Doctor Reading Harrison's for the Last Time

Chapter 10: Pain Pathophysiology and Management

An Old Doctor Reading Harrison's Principles of Internal Medicine for the Last Time

"Given the choice between the experience of pain and nothing, I would choose pain'" William Faulkner. (Not certain if I agree, but hospice is very helpful here.)

This was a very interesting albeit challenging chapter. Early in my career we were advised to be careful when prescribing narcotic medication. Then in the late 1990's the "pain as the fifth vital sign" movement was forced on us by non-clinical regulating agencies. For a hospital to be accredited it had to address pain, and this ushered in the increased use of narcotics. To do otherwise was thought to be bad medicine. Previously we gave narcotics for a short period, say up to one week or so, but we were now instructed to prescribe narcotics for long durations. A common prescription for pain was Vicodin one-tab by mouth four times a day, dispense 120 pills with three refills.

It was thought that it was difficult to addict a patient. Once again contrary to what I'd been taught.

Then in 1999 Purdue Pharma and the Sackler family introduced OxyContin. The result was a large rise in opioid deaths and addiction.

Oops. The folly of pain as the fifth vital sign became readily and painfully apparent.

The Sackler's should be ashamed and imprisoned, but also the knuckleheads that promoted the policy of pain being the fifth vital sign. They are just as responsible, but will skate because they are the regulators.

Now there is a backlash and "many practitioners are hesitant to prescribe opioid analgesics."
Indeed, I only prescribe opioids for three days and refer the patients to a trusted pain clinic if a longer duration was needed. They are better at it than I am, and I don't want the feds on me.

I continued reading this chapter.

I was aware of the cardiovascular dangers of Cox-2 inhibitors but learned they were contraindicated in the post -operative period of coronary artery bypass surgery.

I read of the drug meperidine-Demerol. I'm not sure if Demerol was still available but very early in my career, I avoided this drug. I would never use it. It was touted to cause less biliary spasm and was used most often by surgeons after gallbladder surgery. I never used Demerol, there were too many complications with this narcotic, and it was ineffective when given orally.

A man, Mr. Smith (not his real name) came into my office. I recognized him. Now in his late thirties, he had been one of the best athletes to come out of my high school and was a senior when I was a freshman. He had it all. I wondered what became of him and here he was in my office.

He had kidney disease which I discovered was from a heroin addiction.

"I thought you went to college on a football scholarship. I remembered you could throw the football sixty yards."

"I quit the team. All they did was run the ball. Remember the Wishbone? I had an arm. They had me throwing punts in special team's practice. I quit school, lost my student deferment, and ended up in Vietnam."

"How did you get addicted?"

"Vietnam."

"What did you do in Vietnam?"

"I called in Napalm airstrikes. I was in the thick of things. It was horrible, the drugs helped."

"Are you clean?"

"Yep."

We developed a close relationship. We went to a college football game together. He knew the game and told me what would happen based on the offensive formations and defensive response.

I was proud to be able to help him.

He never asked for narcotics.

Months later, I got called in the early morning.

"Dr. Kroneman, your patient Mr. Smith is dead."

"What?"

"Mr. Smith is dead."

"What happened?"

"He cooked down Demerol pills and injected himself. He gave himself too much. He's dead."

I could hear his wife crying in the background.

"Who gave him the Demerol?"

"Your name is on the bottle. It looks like you did."

I never wrote for Demerol. Not only was it useless as an oral medication it was contraindicated for kidney patients. The metabolites caused seizures.

"I didn't write the script. He stole a script pad from my office and did it himself. I never write for oral Demerol."

I expected trouble but heard nothing from the police or the family.

I felt bad for him.

Two quotes from Thomas De Quincey's "Confessions of an English Opium-Eater" 1821

"Thou hast the keys of Paradise, oh, just, subtle, and mighty opium!"

Later he said," Nobody will laugh long who deals much with opium: its pleasures even are of a grave and solemn complexion."

Now we have fentanyl and drug cartels.

I found this quote written by Thomas Addis in his book "Glomerulonephritis" written in 1948. It is a reminder, through simile, of the importance of pain.

"Now it happens that through all the ages no pain no reflex mechanism has developed to warn us not to overwork our kidneys. In the initial stages of a glomerular nephritis when the kidneys are involved in a diffuse inflammatory reaction that is producing mass cell death, we find that a patient unless he is warned will continue his wonted protein consumption. This means the imposition of a quite amount of work on his grossly diseased kidneys. Observing such behavior and viewing the extraordinary distortions of the nephrons produced in glomerular nephritis, the bizarre deformities of the joints seen in patients with tabes are called to mind. There is a common factor in the pathogenesis of the renal and joint disintegrations. In Charcot's disease we see what may happen to a joint when trauma can no longer elicit pain and thus ensure rest. So it may be with overworked nephrons. If this is true it makes glomerular nephritis one of those diseases in which the deficiencies of nature have to be compensated for by the exercise of thought."

I really like that quote and I was lucky to find it. Comparing the destruction of a joint from syphilis with glomerulonephritis was interesting and thought provoking.

I found the writing style of a physician and scientist to be eloquent and a surprise.

It turned out that Dr. Addis' theory proved to be incorrect and protein restriction could not retard the progression of renal failure. But this had to be studied again in the late 1980's. The NIH funded a study of protein restriction and the progression of renal disease. Seven-hundred and twenty patients were studied for 2.2 years at a cost of 110 million dollars to duplicate the findings of Dr. Addis decades before.

Dr. Addis studied his patients for twenty years.

The only thing to come from the new study was the estimated GFR and its suspect race modifier.

I wonder how they got away with it.

Next Chapter : Chest Pain