Family Medicine: Pain

The Family Physician cringed mentally as he wrote the prescription for Percocet 5/325 #240 (two hundred forty).  Take one or two every four hours as needed for severe pain.  The patient had five years of low back pain, two before the surgery and three after, with numerous therapies and medications initiated and many rejected as inadequate or overly generous with side effects.  Long acting opiates yielded unacceptable brain side effects for the patient, not noted with short acting opiates.  The patient lost jobs and insurance coverage three or four times during our five year engagement so far.  Three trials of physical therapy seemed to be thwarted by the low back pain, loss of insurance and missed appointments.

Allodynia, hyperalgesia, palpable muscle spasms quadratus lumborum and paraspinous muscles.  Mid line tenderness is minimal at L4-5 with right sided tenderness of sacroiliac joint.  Straight leg raise positive on right at 45 degrees.  Deep tendon reflexes - 2 plus and equal knee jerk bilaterally.

The physician reflected on the low back pain in the patient's father, also a patient in the practice, who followed a similar course with low back pain in 1995, including several years of opiate therapy and two years of total disability.  How did his father get out of the pain situation?  He experienced a sudden priority change when his father died and mom needed a caretaker in his family home of origin.  Within two months he was off the Percocets and into fitness, church, vitamins and supplements.

Many Family Physicians are frustrated by patients with chronic pain who become "energy vampires" or get stuck.  Many are also tired of doing the "tough love" by confronting the behaviors of patients like the first one above to finally get them into physical therapy or other supportive strategies or even terminating their relationship if appropriate.  How will the next era deal with these patients?  And these doctors?

What experiences have you had with either side of the patient-physician chronic pain relationship?  How can it improve?