To Treat or Not To Treat

One of the significant dilemmas physicians and prescribing practioners can find themselves in is dealing with the patient who claims to be in pain and who demonstrates significant drug-seeking/substance abuse behaviors. Whether you are a specialist or a general practitioner, you will at some point be faced with a patient that comes to your office requesting pain medications but clearly demonstrates behaviors that support a drug-seeker/substance abuser rather than a person who suffers pain and desperately seeks relief. Many practitioners may be asking how they should handle such a patient.

The fear of legal entanglement and the exhaustion of resources that can occur working with a patient population that is demanding and often unrealistic in expectations can be overwhelming. It is all too easy to become angry with these patients for their behavior as they appear to be goal directed and inflexible with the options you present to them. They want one thing and one thing only - drugs. To help with answering the question of how to handle these difficult patients, allow me to offer some suggestions to consider for your own practice.

• Develop formal policies and guidelines for handling these patients before you need to use them. If you have a plan in place, you will be better equipped to address patients if and when a patient fitting this description appears at your office door. These may include developing or implementing a comprehensive questionnaire to be filled out at the first visit, information release forms to be filled out and signed by the patient. You may want to incorporate a rule that only information coming directly from a physician's office/clinic/hospital will be accepted as written history of diagnosis and treatment of the pain syndrome.
• Be straight forward with potential patients about the approach your practice takes in the evaluation and treatment of pain and pain syndromes. These folks can then determine if they can and will be able to support and accept the treatment approach presented. Anyone who is in genuine pain should appreciate this approach to diagnosis and treatment.
• Make it clear that new patients who are seeking pain relief should not expect to receive prescriptions for controlled substances until the physician/practitioner has the opportunity to review all past history and perform a comprehensive assessment of the patient's chief complaint. Then, if the practitioner feels that strong narcotics are warranted, they will be prescribed within strict guidelines in terms of dosage, frequency and duration. This may not be completed at the time of the first visit. Also clearly outline how a termination of treatment will be handled, i.e.: patient non-compliance, or determination of practitioner of the inability to appropriately and effectively treat the patient. Having a formal plan that requires a systematic review before treatment will help decrease the event of walk-ins seeking medication refills and multiple scripts for heavy narcotic or addictive medications.
• Treatment contracts that clearly state the expectations of the patient and require signatures at checkpoints during the treatment process may help to keep the patient accountable.
• Provide resources to assist the patient who demonstrates addictive behaviors. Names, addresses and telephone numbers of substance abuse clinics and rehabilitation centers and counseling services may help a patient seek help in these areas. Although you are not able to control what patient does with information and resources you provide, at least you can feel confident that you have not released a patient without providing them with something to help them as they seek proper treatment for their problems. Providing patients with the definitions and symptoms of addiction and drug withdrawal will help to realize your awareness of these situations and how to properly treat them. This way if someone who is truly seeking drugs related to addiction and abuse appears, he/she will know ahead of time they will not be treated with narcotic analgesics for pain or discomfort when they present with these symptoms.
• Be sure to document all objective behavior and statements made by patients that you use to diagnose and treat the patient. Describing the patient's complaints along with the behaviors they present will help to support the reasoning behind the decisions you need to make. You will want to have a clear understanding of what are considered acts of negligence and abandonment so you can be sure your practice is performed properly and guidelines and policies will protect you from any false claims by your patients.
• You might consider hiring or partnering with someone who specializes in psychology/substance abuse counseling and/or treatment. What better way to perform comprehensive assessments on patients in a timely manner than to have the ability to do so within your practice. And what better way to have a ready resource for handling and assisting in the treatment of those patients who present with a significant addiction problem overshadowing any possible pain syndrome.

It is important to understand that addicts are people who can also experience pain syndromes. Although they are unable to control their behavior, and although they can and do anger many practitioners because of the very way they misuse the system to feed and support their addiction, they still have a right to reasonable comfort. The problem is the fact the addiction really needs to be addressed before pain management can be effectively addressed and treated.

It is also important to understand there are a tremendous number of patients out there suffering because of those who have abused the system. As difficult as it is, we as practitioners need to be careful about erroneously labeling our patients. It is important for us to have a solid understanding of the many facets of pain and its management. Understanding what the differences are between tolerance, physical dependence and addiction are critical and vital in developing the ability to better identify abusers vs the patient, who is truly suffering and seeking relief.

I have presented some food for thought and ideas that I feel might help with the concerns and frustrations shared by practitioners related to this difficult patient population.

Related Topics: Back Pain: Medication and Addiction, Recognizing Addiction

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Coping with Facial Pain and Pressure

There seems to be a lot of complaints about sinus headaches, sinus infections, and facial pain in the NJ area. Doctors are saying they are very busy these days with these being their most common diagnoses. I believe the weather has something to do with this. And I bet many folks who are suffering also suffer from allergies.

We have had higher than normal temperatures for extended periods of time. Someone told me they have flowers peaking through the ground in their garden already which will surely die off when the cold weather returns. In the meantime, I bet some of the allergens that plague folks are beginning to stir before their time.

Dry air can also irritate the nasal passages and sinuses. Depending on the type of heat a person has in their home, this can be an aggravating factor leading to their symptoms. And what about the heat in vehicles? If you often drive or sit in the front seat, chances are you have experienced air blowing in your face. If you have the air on high and sit close to the dash, you can irritate your sinus passages by the force of the air I have been told. I never gave that much thought but I have to say when I am driving with the air on high and hot, I do tend to get a little discomfort in my face.

How do you handle the pain and pressure you feel? Personally, I find using moist heat on my face helps. I did see a doctor and was put on antibiotics and antihistamines. It is very important to see a doctor if your symptoms become extremely painful and interfere with function or vision, etc. For instance, I had dizziness and visual changes with mine and it is believed to be caused from the pressure related to the congestion in the sinuses. And the treatment goal was to relieve the pressure quickly. This required the use of powerful antihistamines that at first made me fall asleep quickly. But they then had the opposite effect and I found myself wide awake all night for two nights in a row!!

I also found laying down was more comfortable than standing or sitting. So I rested with several pillows under my head until some of the pressure subsided. Sleep and rest are important when you are ill. The body needs to shift its energy to the processes that will lead to healing. Rest allows the body to focus and channel that energy so it can be more efficient at fighting.

Humidification may help you feel better and decrease the irritation often felt in the nasal passages. And while driving, keep the air from blowing directly on your face. Perhaps directing the air toward the feet, the door, or using the defrost will help decrease the force of the heat when it does hit you. You might also just keep the fan down on low as an option.

Tincture of time is probably the hardest to accept. Sometimes you have to ride it out and do the best you can until the meds take hold and you start feeling better. During this time, try to cut down on the demands on you if you can. Try to relax as much as possible. If you feel tired and the meds make you sleepy, go to bed and let them work. If your symptoms increase or change significantly, be sure to see your doctor for a followup.

Related Topics: Practical Tips For Allergy Relief, Pampering Your Nose

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Using Herbs

Many folks enjoy using family remedies carried down through the years. It's a way of hanging on to our pasts in a world that has become so impersonal. Others seek to go natural and avoid the many chemicals and preservatives that are often added to foods and substances during processing. Herbal and natural food stores are thriving because of this. There are some good reasons why taking these approaches can be very beneficial. However, I must warn anyone who is starting out to please be very careful when using herbs for these reasons. Always check with your doctor before taking any herbal supplements or remedies.

Many drugs are made out of herbs. Herbs can combine with these prescribed medications-leading to potentially dangerous and/or life-threatening interactions. If you are serious about using herbal remedies, I strongly suggest you pick up a good book at your local book store and read up on it beforehand. Be very careful. When it comes to making poultices or teas it is important to know what parts of plants are to be used and what parts are to be avoided. If your herbal book does not have sufficient information on drug/herb interactions, I suggest you get a drug handbook to go along with your herbal remedy book.

If you are going to mix your own herbs to make poultices and teas, be selective where you purchase your herbs. Make sure you know how to recognize quality products. Like cooking herbs and spices, they may lose their potency with age. This may or may not interfere with the way they react when mixed or prepared with other ingredients.

Some people feel if a little is good then more is better. This is not often the case. Follow directions. Be careful to measure accurately, steep for the stated amount of time and strain when it is called for. Store appropriately and use within the allotted safe time frame.

When used appropriately and with care and attention, the use of herbal supplements and remedies can be very effective in decreasing pain and discomfort, and increasing health and wellness.

Related Topics: Folk Remedies Part of Child-Rearing Tradition, Massage, Chiropractic Top Medical Alternatives

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Hypnosis for Weight Loss and Comfort

Have you ever explored the use of hypnosis as an approach to stress and pain management? Many years ago, by chance, I learned how effective it can be. Up until about ten years ago, I believed hypnosis was the way it was portrayed in movies. People doing things they would never conceive of doing if they were in control of their mind. Well after talking to a hypno-therapist, I quickly learned differently.

My daughter has suffered from a weight problem since she was about a year and a half. When she was about 13 years old we decided to try hypnosis as a way to lose weight. So we found this prominent hypnotherapist outside of Albany, NY and we went to see him. After talking to him, we decided to go ahead with it.

Because my daughter was only 13, I went in during the therapy. I was allowed to listen with a set of headphones so I could hear everything being said to her. We both had comfortable recliners to sit in so I had all of the same benefits she had. She was given special tapes to listen to each night for a month. She was faithful to the program and the results were incredible. She was a donuts and French fries junkie before being hypnotized. Once she was, she had no desire to eat them. In fact I had a call from her teacher because suddenly she was giving away her donuts and cookies. It was so unlike her, the teacher was afraid she was ill or something. I reassured her she was doing fine and I applauded her sticking with the program.

I remember going to a fast food restaurant and ordering a big burger sandwich, fries and soda. She ordered a salad and a diet soda and was perfectly satisfied. In fact, I would eat the fries in front of her and it never phased her a bit. She stayed on the diet for about three months and lost weight consistently in small amounts. Then we had an argument and for spite, she ate a donut in front of me... and it was as if she was never hypnotized. She regained the cravings for these things and unfortunately before too long, she regained the weight she had lost.

The other thing I realized was that I lost weight right along with her...but I really couldn't say why except that I wasn't as hungry and I was able to eat smaller portions. I remember trying on clothes that started getting baggy on me and the clincher was when I was running upstairs with my slip on shoes and walked right out of one! Then I realized even my feet had decreased in size!! I could not say that I even tried to lose the weight but it did come off...and I was thrilled!!

Some of us carry around a little more weight then we should. And I have to admit I am uncomfortable and I suffer arthritic pain in my major weight-bearing joints. Losing weight for me is for health and comfort reasons and not for cosmetic ones-although I do want to look better and function easier than I currently do. I feel I might decrease the pain I experience and that would be a blessing. I am considering hypnosis for myself this time in hopes I might benefit as much as my daughter did way back when...I Will keep you posted if I decide to give it a try!

Related Topics: Weight Congrol Health Center, Diets A to Z

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Shoveling Snow: Guidelines

Here in NJ we experienced our first major snow storm of the season. I hated to see it coming. I was enjoying the spring-like weather we had so far and just loving it!

I heard different folks commenting on their weekend and how they spent it shoveling and plowing snow. Many of them were also complaining about painful backs and arm muscles they forgot they had!

Shoveling snow can be dangerous and should be approached with caution. If you have lifting limitations or back problems, then it might be best to hire someone to help you rather than take a chance of injuring yourself. If however you are unable to do that and you absolutely must shovel your own snow, keep these tips in mind:

• Select a small shovel with a curved handle that is ergonomically tested and proven to decrease strain and pain on the back.
• Lift with your legs and not your back keeping the load as close to the body as possible.
• Take small loads. Don't try to accomplish too much too fast.
• Avoid twisting at the waist as this can lead to back trouble. Stand in what archers call an open stance - with one foot facing ahead and one facing out to the side. This will enable you to pivot easier as you lift and dump the snow.
• If you can find a push shovel, this might be safer than one you must lift.
• When you finish shoveling, plan to relax and let the muscles calm down. Taking a nice warm bath might help you. The key is to try and break a spasm before it has a chance to develop into a painful condition. Massage, heating pads, muscle relaxants, etc. can all help in avoiding the development of muscle spasms.
• If you have a heart condition or high blood pressure, be sure to speak with your doctor ahead of time to determine if there are any precautions you should be taking.

Try to hang in there! Spring is just around the corner!!

Related Topics: Cold Weather Survival 101, Prescription for a Healthy Home

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Snowy memories

This past weekend we experienced our first major snow storm of the season. And although we have been very fortunate to work our way through to mid February with wonderful spring-like temperatures, it didn't change the way I felt about it. I remember as a kid growing up in the heart of the Adirondack Mountains, surrounded by Lake Champlain, Lake George, Schroon Lake and a host of neat little ponds and lakes. Summers were spent fishing and camping and winters included snowmobiling, ice fishing and ice skating on Eagle Lake and anywhere else we could get to. Those are fond memories.

My aunts, uncles and cousins used to come up from the city and we would all go riding snowmobiles on trips that took a better part of a day. We would ride out on secluded lakes and ponds and cook hot dogs and drink hot chocolate over the open fire. It was beautiful...Driving our sleds through woods and along back roads, we explored areas we never would have reached otherwise. I will never forget the laughter as my aunt so gracefully topple her sled -- causing her to roll off and into the snow...With heavy snowmobile suits on, everyone was rather rollypolly and we would all laugh knowing we could easily be the next one to do it!!

As I have grown older, I enjoy the memories of days gone by. Loved ones have since passed on and others have spread out and moved away. But all it takes is a ride north to be reminded of these special times.

Related Topics: Elders Reveal Keys to Healthy Aging, Regular Exercise Keeps Brain Young


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Self-Diagnosis: Know when to call the doctor

I know it can be difficult not to try and self-diagnose - especially if you are a nurse or someone else in the health care professions. We tend to do that naturally I believe. Well sometimes common symptoms can lead a person on a wild goose chase if they try to sit back and figure it out on their own.

Why is it health care professionals tend to be the last ones to seek health care when they need it? Perhaps it is because they are too busy to do so. Most health care professionals live very busy lives. They tend to work long hours and keep putting things off until they absolutely have to address them. I guess I have joined this group of folks.

I have been feeling dizzy on and off for quite some time. I felt maybe my blood sugars were fluctuating and that was making me feel dizzy and lightheaded at times. I really couldn't make rhyme nor reason out of it though. There didn't seem to be any real pattern.

This past weekend I woke up with a major headache that lasted much of the day. It felt like a sinus headache and a migraine wrapped into one. Well several months ago, I had similar symptoms that left me incapacitated and bed-bound. Finally I went to the doctor's office because I thought I was having a stroke. My blood pressure had been up lately and I thought the pounding in my head was from that.

The rest of my weekend was quiet and I just didn't feel well at all. Monday morning, I woke earlier than usual with severe dizziness, pain, facial pressure nausea and vomiting. I wanted to curl up and die. My face was swollen around my eyes and it hurt to look at anything. My forehead was bulging forward. I went to the doctors and he read the results of a recent scan. It showed I had thickened walls in my sinuses. The deep sinuses located behind the eyes were full of fluid that wasn't draining freely. I was treated with very large doses of antihistamines to help dry things up, antibiotics, and medications for nausea and severe pain.

The last time this happened, I pushed to get back to work. I didn't take the time to let the medications work as much as they could have. This time I was resigned to the fact I needed to get these symptoms under control once and for all. So I called my boss and told her the news and I took my meds and went to bed. I have followed my doctor's orders and have been pretty much asleep more than awake due to the side effects of the meds - but that is ok. I have a lot of work ahead of me when I return tomorrow but it will be good to be back to work.

So what did I learn from all of this? Stop putting off until tomorrow what needs to be done today. I needed to see a doctor. The dizziness had nothing to do with my blood sugars. I was way off in my self-diagnosis. The dizziness and other symptoms were from the fluid in my head that had no place to go. When it became too much, it put pressure on my eyes and caused visual disturbances. The dizziness and pressure caused nausea and vomiting. It was all a chain reaction.

The treatment has helped a great deal and I know I may need to eventually see an ears, nose, throat specialist if I keep having these problems. But at least I know what I am dealing with and I know how it is usually treated. It was a good thing I stopped trying to diagnose myself and went to see my doctor. As health care professionals and providers, we need to do that. We need to take care of ourselves so we can take care of others and tend to all of our other responsibilities besides.

Related Topics: Is Coffee a Headache Cure?, FDA Approves Clarinex 12-Hour

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Color, Imagery and Comfort

There are different types of imagery that people can use to assist in stress reduction and pain relief. There is the image that focuses on going somewhere and doing something specific that represents leaving something behind--usually the offending problem. There is another approach that can be used for stress reduction and pain control. That type of imagery requires a lot of concentration but when done successfully, it can lead to the relief of intense pain.

Many years ago, I went to the University of Vermont in Burlington to learn about biofeedback and self-hypnosis. I worked with a therapist for several weeks and learned several techniques that enabled me to rechannel my circulation and decrease the severe and debilitating pain of clusters and migraine headaches. It took a lot of practice but once mastered, I found I could use the techniques for a variety of painful conditions caused by arthritis and back injuries--to name a few.

• Give your pain a color
  Think about your pain for a moment. Think about the most distressing pain you have ever experienced. Now if you were to assign a color to that horrific pain, what color would that be? Well for me I usually choose black to represent the worst of anything. Now think about what it feels like to be comfortable. Notice I said comfortable and not pain-free because sometimes being totally pain-free is not a realistic expectation--think about this and assign a color to that like you did the horrible pain. I often choose my the color white for this one.



• Imagine an object
  Next, think of something--an object. A favorite fruit or a flower can work just fine.



• Strip away the color gradually
  
  When you are in severe pain, picture this object being covered by the color you assigned to represent the highest level of pain you can possibly endure--the ugliest and harshest pain you have ever experienced. With this type of imagery, you focus on removing the dark color from the object and replacing it with the color representing your comfort level. Now the trick of it is to focus on it as if you were scraping away the darkness little by little--paying close attention to the detail of the object and the location of the color around it.
  
  In the beginning, you might want to just hurry up and remove the "bad" color and go right to replacing it with the "good" or comforting one but what I have found to be key is taking a little more time and watching the change reveal itself gradually--just like pain tends to respond to comfort measures...Rather than go directly from black to white, I selected colors in between that I felt represented different levels of pain and comfort. As I moved closer to my comfort level, my colors progressed from the darkest to the lightest shades. As I carefully and methodically removed the black color from my object, I found a layer of a little lighter color waiting for me. I could not move onto the next color until I had completely removed the previous one.



• Imagine the removal of color as removal of pain
  
  Now it is important for you to equate the removal of color with the removal of pain or discomfort because remember--your color represents your pain at any given level. What I have found is this--as I progressed toward the white color, my pain levels would ease a little--sometimes more than others. Perhaps sometimes you will practice this form of imagery when your pain is moderate rather than severe.
  
  In this case, you might select a different color along your color spectrum and start the fading process from that point. And maybe you will change your particular object to other things when your source of pain differs. The neat thing about these skills is that you own them and if something specific works for you then by all means incorporate it. Some people imagine very large objects when they have "very large" headaches and they go about ridding of their painful color using a paint brush that has wide strokes. Others prefer to use an eraser and erase their pain away as if in layers until they reveal a perfectly clean and white object. If this works for you then use it!

The great thing about learning skills such as imagery, biofeedback, or self-hypnosis, is you can learn them and once mastered, you can use them over and over again--without having to pay for them over and over again!! And you may find these techniques helpful for a variety of conditions. How cool is that?!!

So if you suffer from a painful condition or just wish to reduce stress in your life, consider using imagery techniques as a tools to achieve your goals!

If you have found this type of imagery helpful in relieving pain or stress, consider sharing your experiences on the Pain Management and Migraine boards here at WebMD!! I look forward to hearing from you!!

Related Topics: Moving Meditation: Tai Chi for Arthritis Relief, WebMD Daily Video: Success Over Stress

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