Hear No Evil, See No Evil, Speak No Evil

The original Japanese origin of the infamous three monkeys was that of three wise primates also called the three mystic apes. These wise apes are comprised of Doctors Mizaruu, Kikazaru, and Iwazaru.

But in our culture it has come to mean a person who looks the other way, or as the idiom goes, “turns a blind eye”. In medicine, and in particular, pain management, it has become commonplace. While some believe there should now be a fourth monkey, “post no evil”, I’m going to ignore the latter and do just that. And here’s the thing – while many prescribers continue to see and hear no evil in terms of listening to patient pain complaints, they sometimes e no problem speaking evil if evil is restating intellectually dishonest information.

Let’s start with NSAIDS
“My doctor told me that inflammation and pain are needed for my bone to heal.”
“I have never prescribed etodolac; just use ibuprofen.”
“What’s etodolac?”
“I don’t have experience with that drug or know what it is, so I’m not comfortable prescribing it.”

These are real statements from orthopedic surgeons, maxillofacial surgeons, plastic surgeons, and general practitioners. They are statements relayed to me from friends and relatives that have contacted me in severe pain following a surgical procedure. Some of them couldn’t tolerate opioids (generally oxycodone or hydrocodone); some didn’t respond to opoids; and some had both problems.

Why etodolac? It is the most cyclooxygenase (COX)-2 selective NSAID, and because it is available generically which translates to insurance coverage and smaller copays. For a schematic on relative COX-2 selectivity see COX-2 Specificity. COX-2 specificity affords the patient less bleeding risk and prevents inflammation immediately following certain procedures. In the real cases above where the prescriber was willing to listen, the outcomes were far better in every case that I know about.

Just last week for example a relative contacted me because he needed emergency hand surgery for a deep laceration that involved two finger tendons and significant suturing. He was placed on hydrocodone/acetaminophen. It wasn’t helping much and his fingertip was becoming numb at 48 hours post-injury. I suggested he speak with his surgeon and recommended that he need an NSAID such as etodolac to reduce the swelling away from the nerves, that it would likely work better than hydrocodone for his pain type overall, and that a COX-2 agent would be most appropriate to avoid blood leaking around the injury (less bruising and fluid surrounding the joint and connective tissue). His doctor’s response? “I have never prescribed etodolac. Just use ibuprofen. It’s the same thing” The patient said to me, “what should I do?” Of course he is at the mercy of his doctor. What would I say? I would say that answer is unacceptable. I would say “You have a professional obligation and made a commitment to lifelong learning. I’m suggesting to you that there is a better option – don’t you think that you have an obligation to at least look it up?” But then again, when provoked I can get a bit rambunctious I guess.

In an earlier paindr.com blog entitled Is it safe to take NSAIDS following orthopedic surgery?, we point out that the standard amongst some orthopedic surgeons is to avoid NSAIDs because of a purported decreased healing risk. But the only data available are animal studies except for the 21 human studies for which the data was falsified. And in the animal studies, half say it’s a real issue and the remaining say that it is not. Then there’s the argument for not prescribing NSAIDs due to bleeding risk which wholly ignores the COX-2 specificity of certain NSAIDs. But in fact, some studies have looked at bleeding risk post-operatively in major surgeries using COX-2 specific agents even in the presence of heparin without increased significantly increasing risk.1

Consider that the risk of developing complex regional pain syndrome after a wrist fracture is high if the pain and inflammation are not well-controlled. Consider too that due to neuroplasticity, certain surgical procedures carry significant risk of developing a chronic pain syndrome if the pain is poorly controlled – these include amputation (30-50%), coronary artery bypass surgery (30-50%), thoracotomy (30-40%), breast surgery such as lumpectomy or mastectomy (20-30%), cesarean section (10%), and inguinal hernia repair (10%).2,3 So inadequate pain treatment clearly can have very real permanently disabling outcomes. So ignoring good pain care post-operatively is synonymous to seeing and hearing no evil (or in the case, pain).

As if chronic pain patients haven’t suffered enough following the renaissance of an opioid epidemic backlash, PROPagandists and supportive anti-opioid zealots, politics, state regulations, and third party payer policies, now it is bleeding into the acute and surgical pain space, literally.

Post Operative Acute Pain
A colleague of mine recently needed medical management of pain following minor orthopedic surgery. This patient with a knife in his back also happened to be a learned scholar and clinician in pain management. But like so many others these days, he wasn’t offered a single dose of anything! In this case the doctor chose to see no evil and hear no evil. He didn’t see that the patient was or may end up with pain, and he chose not to hear or speak about the probability that medication could or should be needed when the local anesthesia wore off.

So, the former pain expert, tuned patient, walked out of an office following an hour long “mini-surgery” and never thought to discuss post-operative pain management with the doctor – who conveniently didn’t make an effort to discuss it with him either. Speak no evil, right?

This patient had a scalpel in his back for over an hour cutting through tissue at times a few millimeters below the level of the local anesthetic that had been applied, but he toughed it out. He knew his doctor was running way behind; he waited an hour to see him and was sure the difficulty encountered extracting his fibrous nuisance made it all take longer than anyone anticipated. But when his doctor left the room, my friend lay wondering about scheduling the next visit with his nurse/assistant, and was distracted and happy to be getting out of there. The local anesthetic was still working so that when the relief of getting off the uncomfortable table and being done with it combined with waning anesthesia led him to completely forget to ask about or even discuss pain management. It all seemed very simple, just antibiotic cream and band aids. How painful can something be that only needs a band aid? Just a minor boo boo. Albeit, one that required 4 internal sutures and 6 surface sutures to close….

By now some of you have gotten the pun – haha – knife (scalpel). Not so fast. There is a metaphoric use of this phrase that describes what he felt much more than that and it goes to the issue of betrayal. See, it doesn’t matter who you are, pain expert, neophyte to the wonderful world of office based procedures, or what, when your doctor doesn’t talk to you about post-operative pain and doesn’t even broach the subject and you trust him/her, the message you get is – THIS WON’T HURT VERY MUCH. And by the way, if it does, you’re on your own.

Not treating pain in this scenario and in others, it occurs to me, can be experienced by patients as a betrayal. Betrayal of trust; of purporting to care; of putting the patient first; of the Hippocratic oath even. Some may think that 2 days of opioids in this instance is absurd, while others believe it shouldn’t have been out of the question since it caused a moderate amount of pain. The point is, there was no reasoned thought process and discussion of the relative miniscule risk of 2 days of opioids (and I am not talking about 30 tablets where only 8 will be used, I am talking about 8) for this type of pain in a low risk patient vs. the relative miniscule risk of NSAIDs in an overweight person with hypertension (miniscule because again, it is a brief exposure). If you ask 10 people I figure at least 9 will say the risk is hands down less for NSAIDs – based on what? I am afraid this judgment is most often based more on fear, media saturation with anti-opioid messaging, regulatory concerns and the like than on the realities of an individual patient situation.

So now pain clinicians like myself and my colleagues are experiencing both ends of the spectrum in post-operative pain – opioids no questions asked one time and no discussion, no treatment the next. Even when procedures are not comparable on the pain, life alteration Richter Scale – not even close – what tends to be similar is that pain management is being based mostly on assumptions, preconceptions and beliefs about generalized people and drug classes and very little focus on the individual realities of each patient, their perceived pain, and overall medical and biopsychosocial risk level.

OOOOOOUUUUUUUCCCCCCCHHHHH. Sorry I might cry out over the horrible scenarios outlined herein. But what is far more painful than the aftermath of the knife in one’s back – the scalpel and the betrayal – is the pain of reconciling oneself to the fact that several decades as a career educator and expert made little or no impact and we are having the same discussions today that we had in 1990. More importantly, if this is what expert pain colleagues need to endure, what could a non-medical innocent surgical victim from any other walk of life expect? It’s horrifying to imagine, but more likely than not it’s a knife in the back from someone who sees no pain, hears no cry of pain, and only speaks the evil that medication is not needed while quietly typing a note for the medical record stating that the surgery was successful without complications.

So I ask you; has medicine evolved over time or have we regressed to more primitive times?

As always, comments are encouraged and welcome!

 

References:
1. Robert J. Noveck and Richard C. Hubbard Parecoxib Sodium, an Injectable COX-2-Specific Inhibitor, Does Not Affect Unfractionated Heparin-Regulated Blood Coagulation Parameters. J Clin Pharmacol May 2004 44: 474-480.
2. Perkins FM and Kehlet H. Anesthesiology. 2000;93:1123-33.
3. Kehlet H et al. Lancet. 2006;367:1618-25.