Dr. Rosenberg, in collaboration with colleagues at University of Michigan and University of Texas MD Anderson Cancer Center, has published an article in Pain Medicine reporting a series of cancer patients whose pain was successfully treated by both intrathecal drug delivery (a “pain pump”) as well as modification of the pain processing system in the central nervous system through cordotomy or myelotomy. This study is important in illustrating the potential for overall pain control and improvement in quality of life by using a “toolbox” approach, in which all different clinical “tools” are considered and used. This can be far superior to the limited list of possibilities that is usually considered in treating cancer-related pain, both in terms of pain control and limiting the effects of pain medications (tiredness, nausea and vomiting, loss of appetite, etc.)
It is important for every cancer patient to realize that pain is not a necessary consequence of having cancer. The health care provider who is caring for the patient should continuous consider new options for pain control, sometimes revisiting options that had been previously ruled out. In addition, cancer patients who are in pain should expect their health care provider to work toward effective pain control WITHOUT unacceptable side effects. While this is not always achievable, it often is – if a “big toolbox” is used.
Dr. Rosenberg was recently appointed to the Education Committee of the American Society for Stereotactic and Functional Neurosurgery. The ASSFN is also the AANS/CNS Joint Section on Stereotactic and Functional Neurosurgery. The Committee’s first task is to review resident education requirements for functional neurosurgery. Dr. Rosenberg will be assisting in evaluating these requirements regarding the neurosurgical treatment of pain.
There are good data showing that the current over-emphasis on “rules” for clinical decision-making is not resulting in improvement in care. While some rules are helpful, even necessary, clinical medicine is too complex and “fuzzy” to rely on them. This is the problem with our current regulatory environment – the belief that medicine can be reduced to a set of instructions, which, if followed, will result in good care. In fact, for all but a few situations, good clinical judgement and experience is what is needed. And that cannot be distilled down to an list or guidelines. It’s hard enough to teach and really must be acquired over years of experience.
There are few areas of medicine in which this is more apparent than pain care. Pain is intrinsically difficult to understand and diagnose. Although the government and insurance industry are trying to simplify this care into a list of rules, it is not working. And people are suffering from the effort. What is needed is to foster interdisciplinary collaboration, help clinicians gain and share experience while keeping an open mind and remaining centered on the individual patient.
Stephanie had severe, debilitating, daily migraines for 16 years and tried numerous treatments without benefit. A peripheral neurostimulator (with leads just under the skin) gave her 80% relief and has allowed her to resume her life. She contacted Fox 4 News with the story and they decided to pursue it.
Clinical guidelines are very popular, as they should be, in trying to disseminate appropriate care. Unfortunately, these are often portrayed as clear-cut and indisputable. Unfortunately, the truth is that there is just as much debate and disagreement about them as most other things in medicine. There are numerous examples of multiple available guidelines for a given topic that are mutually incompatible. It is important to realize that these are products of a human process that is (1) imperfect and (2) in its infancy. Guidelines for Guidelines: Measuring Trustworthiness by David F. Ransohoff and Harold C. Sox.
The peer-review process in publishing scientific articles in health care is considered the gold standard, sacrosanct. Yet all who are involved with it know that it is highly imperfect, fraught with errors, biases and sometimes fraud. Yet, as pointed out in this article, the process itself has never been subjected to critical analysis. Dr. Adler, an experienced academic neurosurgeon, does so in this article with a fascinating suggestion for improvement.
The CDC has released new data suggesting a rise in opioid (“painkiller”) overdose rates in women. Clearly, the situation with prescribing opioids for pain control is serious and requires careful consideration. Nevertheless, good medicine mandates caution in order to prevent over-reaction with unintended consequences. The lesson is that health care providers have to be careful – as with most medications – and may, at times, have to make difficult choices and have difficult conversations with patients. But creating poorly considered legislation and/or mandating options that fail to recognize the very real potential good that these medications can do is not the right path. Many patients will suffer if there is not rational planning for how to provide the right medication, in the right amount, to the right patient.