comPASSION Fatigue

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When was the last time you heard a colleague express genuine excitement about learning anything new regarding pain therapeutics? If a game-changer were to emerge, would it matter if no one is still playing the game? For people with pain it’s the bottom of the ninth, two outs, two strikes, bases loaded and the team is down by 3.

The onslaught of media negativity and their sensationalism about the realities of pain management is daunting for patients and professionals alike. The cherry picking of data, the pseudoscientific shortcuts, the political bully pulpits to gain favor, the collective self-serving rhetoric is simply too much; getting to the point where even those warriors committed to answering back to the dishonesty are exhausted from correcting the false portrayals. When lecture after lecture at major medical and pharmacy meetings are on “risk management” surrounding opioids or some semblance of that in the lecture tagline, the game is over.  How can we remain passionate about attending meetings in which all anyone is expected to learn is how not to kill anyone? Most pain clinicians entered this field of study with a desire to apply themselves for the betterment of humanity and the relief of suffering. As each days passes, it seems that instead it’s about careful documentation and avoidance of liability.

Before readers begin assessing whether the authors of this post (a senior and junior clinician) are suicidal, please recognize that there is a certain degree of compassion fatigue that can come with this territory. Compassion fatigue has been defined as essentially a form of burnout common to those of us who actually care; it’s not simply the burnout of too long hours, too much stress, too little camaraderie, too much witnessing of pain and suffering – it’s all of those things but if you have thick enough skin and/or were born without the caring gene, you might be less susceptible.

One of the hallmarks of compassion fatigue or caregiver burnout is that it distances you from the source of the stress – either through numbing or avoidance – in this case the people you want to care for and the subject matter that reminds one of the stress. What is a very obviously vicious cycle then takes shape as you distance yourself from the very source of joy, hope and inspiration that led you to the pain clinic to begin with. The human richness could flea away with diminished hopes to learn and grow and rekindle passion for relieving pain and suffering.  

We continue to demand ingenuity from the drug makers. Whether it is abuse deterrent products, new opioid innovations or non-opioids, is there enough enthusiasm for those who have been beaten into keeping a low profile to stand up and take notice. In the world of opioids, if there were a safer opioid product for the day, is their enough therapeutic wiggle room, backbone and commitment to recognize it as such or will the absence of evidence taken to be the evidence of absence cut off treatment so dramatically that it then drives more absence of evidence from this time forward?

If there were an efficacious opioid drug with less abuse and diversion potential; less potential for overdose due to a ceiling effect on CO2 accumulation; untapped possibilities for the relief of certain psychiatric comorbidities that frequently accompany pain; all of which could be used to help patients avoid traditional opioids, would it be used?  That’s the million-dollar question!  Let’s take a look at what’s available.

Three buprenorphine products are FDA-approved for pain and do in fact represent a safer alternative.  These include the newest formulations indicated for chronic pain, Belbuca Buccal Film (12-hour dosage formulation) and Butrans Transdermal (7-day topical patch).  Then there’s the oldest formulation, Buprenex Injection (generally for acute pain and institutional use).  For an overview of all available buprenorphine dosage forms, see A Brief Review of Buprenorphine Products. Irrespective, the lack of pharmacological understanding of this drug is mindboggling as it seems always to be associated with opioid abuse or inaccurately likened to methadone.  Those in the addiction community who are more familiar with buprenorphine’s clinical benefits have recognized its potential in their group of patients who have both pain and addiction but can sometimes sound almost too enthusiastic – of course the addiction community is having its day in the sun now, though, so they have not been robbed of their passion.  And of note is that Subxone and rehabilitation clinics have turned millions of dollars in profits which might even incentivize certain anti-opioid zealots to spin the rhetoric of opioid overdoses out of control.  Consider for example that annual NSAID-related deaths from gastrointestinal bleeds are about equal to that of prescription opioids – but alas, there is no black market, profitability from NSAID-rehab clinics, or sexy media initiatives to push that fact to the edge of a cliff.  Nevertheless, we continue as a society unable to hold two thoughts in our heads, the suffering of the addict now that rules the day and the suffering of the pain patient has been relegated to a bottom dweller. Both pain and addiction are obviously of equal importance and it shouldn’t matter that the addiction community is resurgent and the pain community downtrodden.

Whether a young aspiring clinician or a more seasoned aficionado, we intend to remain in the game.  Grand slam? Perhaps not.  But, in this new residency year we will both take that chance and together swing for the fences even if we miss? If either of us gets called out looking with the bat on our shoulders, we’ll be back next time.

Is anyone out there still playing the game?

PLEASE comment and tell us if you’re still in the game, and if not, why not!

10425387_10153363652926248_2898143228029211280_nThis post was collaboratively written with Dr. Erica Wegrzyn.
Erica Wegrzyn, B.A., B.S., PharmD is currently completing a PGY-2 Pain and Palliative Care residency at the Stratton VA Medical Center, Albany NY. Dr. Wegrzyn received her PharmD from Western New England University College of Pharmacy, Springfield MA and completed a PGY-1 residency at Maine General Medical Center, Augusta ME.  Prior to completing her PharmD, Dr. Wegrzyn also received her bachelors’ degrees in Biochemistry and Music (trombone) from Ithaca College.  Dr. Wegrzyn’s initial interest in pain management was sparked by her exposure to Dr. Fudin’s pain practice during her final academic year while completing an advanced practice rotation at the Stratton VA Medical Center.  In her new role as a PGY2 Resident she has already had an intense few weeks with three pending publications and is looking forward to some busy clinics starting next week.  Dr. Wegrzyn thrilled to return to the Albany area where she is will resume her roles as a volunteer firefighter with Selkirk Fire District and also with “Out of the Pits” pitbull rescue.  Dr. Wegrzyn is pictured here with her therapy certified and Selkirk FD resident fire dog, Blue.




6 thoughts on “comPASSION Fatigue

  1. I am grateful for the help I still receive although it is by far as good as it once was! How could I have been so naive to think when the government could see that patients were not going to multple doctors and multiple pharmasists by encouraging state’s to adopt this drug monitoring list: that things would get better for doctors and patients who had been doing it right all along! I care not to discuss all the hell I have been put through by a few doctors who are terrified of losing their medical license or the many pharmacists who have refused to fill my very legitimate prescription even when they could see that I was due or past due for prescriptions that can and have put me into withdrrawal because everyone told me they did not have my medications . Just last month I was told they had neither of my medications by the same pharmacy who had filled for me the month before; mind you I had just moved about 300 miles and changed my identifications address and got a new doctor. At 9pm when I could get to the pharmacy I was told they had neither of my medications … one due that day the other the next! I made a phone call to someone I know who cares about me … I was crying as I now know what it means to be without my medications for a day but for as long as a week. They got in their vehicle at 2 am so they could make the 400 mile drive and get to me about the time the pharmacys opened. He drove me right back to the pharmacy who said they did not have my medications; the same pharmacy he had taken me to the month before! He gave my prescriptions to the worker behind the counter at this chain pharmacy and told her they had to be verified by their pharmacist … who was different from the one before. A couple Mi sites later he was told that they would be ready in 30 minutes! Bow can this be? I am a 59 year old woman with multiple problems who can not get my own prescriptions filled!!! Why does my loved one have to drive many miles while I am in panic mode before I can get my script filled? Of course I said nothing at the pharmacy because I will need these same medications filled next month and the one after into infinity and it took us going to at very least 20 pharmacys before I got my first scripts filled by my new doctor which were less than I had been on but grateful for something. I can no longer go for a walk, I no longer go shopping unless there is a wheelchair. I no longer go to the beach or see my family. So many things I can no longer do because doctors have cut medications back so much because they fear losing their medical lisence. Believe me when I say I am in this not by choice but because my body has not held up like I would have expected considering I don’t not never did drink or smoke! My downfall appears to be the steroids I took on the advise of a specialist when I was suffering from what they called chronic urticaria; small hives that progressed so quick and so bad; it looked like I was beat with a belt. Oh yes, I may not be medical personnel and I am not here by choice but today I am here fighting for just a bit of life as I once knew it!

  2. Yes Jeff, I am still in the game. My wife will ask me “how was your day?”. From the practitioners I can converse with, they are frustrated treating pain patients and the changes in medicine. We seem to be losing control over the decisions we have to make. Yielding to insurance companies, the group practice “Partners”, and over zealous bureaucrats.
    I tell my wife I hit a single today, and tommorrow we will only be down by 2, and I will be at bat again.

  3. Tired here too. But will NEVER give up fighting insurance companies, yes, some pharmacists 😉 and OTHERS who out of ignorance, prejudice, and their own psychiatric issues, want to prevent pain patients from obtaining their needed opioids. It will never be over, till it’s over.

  4. Given what has been written about the “extinction of empathy”, this is a wonderful, timely column!

  5. I love this column. Can we maintain two thoughts in our heads at the same time? I would also ask, can we have two feelings in our hearts at the same time as well? It appears to be too much for many. The reductionist view limits us to choose one concern or the other but not both. Pitting people with pain against people with addictions is not solving either problem. We can address both problems but first we need compassion for both.

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