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From Luke’s Journal January 2018 | Vol. 23 No. 1 | Pain & Faith

A Pain Vignette 1:

A Doctor’s Work is Never Done

Ally is a 61 year old divorcee, admitted to a nursing home because of a diagnosis of memory decline in association with falls and failing capacity for self-care. Thereís also history of episodes of self-harm and mood instability. 

Other history features include:

1. Pronounced myoclonic jerks (thought by Ally to be epileptic)

2. Chronic headaches

3. Low back pain

4. Complex relationships with an only son

5. Very poor quality of sleep

Ally’s medications included:

1. Sodium valproate

2. Sertraline

3. Donepezil

4. Quetiapine

5. Atorvastatin

6. Oxycodone PRN

7. Paracetamol

On encountering Ally, I discovered a person who was very devoted to her four year old granddaughter. She was using an iPad competently. She says she uses it to keep lists and records to help her memory. She regularly attends a church associated to the facility.

Prior to the admission, a memory clinic had made the diagnosis of frontotemporal dementia in the context of depression and borderline personality disorder. Ally was also thought to have epilepsy. It soon became clear that Ally was very keen for pain relief for headaches and back pain, and her myoclonic jerks seemed to have a stress association. 

Ally’s presentation was very unusual, and it caught my clinical imagination. Was this really a case of dementia? Why was this lady needing pain relief in this overall context? 

In taking a “patient-centred” approach, I discovered that Ally was divorced in the context of humiliating domestic violence. 

I tried to introduce NSAIDs, regular paracetamol and adjusted the sodium valproate dose for her headaches. Requests for PRN oxycodone appeared to be escalating. Some questions were emerging:

When do primary care practitioners need to question established tertiary care diagnoses?

How should we go about further assessment and management of Ally, in this overall context?

I tried to read the memory clinic notes as carefully as I could, and became aware that a neurology assessment had not occurred. Ally confirmed this. She had had a normal EEG, and her movements, which were quite dramatic at times, were considered by some of the team as pseudo-seizures. I was beginning to form the opinion that PTSD in the context of domestic violence in association with a borderline type personality might be a better diagnosis for Ally. 

I continued to work hard at a good doctor-patient relationship. In this context, I asked her permission to arrange a neurology review. I put it to her that her headaches were becoming quite a problem. The neurologist repeated an MRI, and after seeing this and examining Ally, decided that there was no evidence of dementia and that PTSD and personality factors were indeed the most likely diagnosis. Another series of questions started to form in my mind. 

How difficult is it to manage pain in a context like this?

What are the options available?

I was now faced with breaking the bad news, that Ally didn’t have dementia. She initially took it quite badly, and was very concerned that she would be asked to leave the nursing care facility. I reassured her at this stage that this wouldn’t be the case, and that in fact, there was good news in the sense that she probably was going to live a much longer life than she initially expected. 

Around the same time, blood tests demonstrated that her renal function had declined, and Ally retained quite a bit of fluid. In retrospect this was probably due to the persisting use of an NSAID, but it allowed me to cease her sodium valproate, meloxicam and sertraline and introduce duloxetine and try to stabilise her pain request with Targin 5/2.5mg bd.

I continued to see Ally regularly. As she became more confident in my presence, she disclosed that her sleep disorder at night was due to very violent nightmares. She had memories of near death experiences on at least three occasions at the hands of the violence she received from her ex-husband. These memories tormented her at night.

What was also beginning to be clear was that Ally was no longer requesting PRN oxycodone, and that indeed we had begun to achieve much more stability. Her myoclonic jerks were reduced in number, and I encouraged her at this point to enter into a relationship with the nursing care facilities chaplain, to explore the pastoral care implications of her past violence, and to begin to pray for healing of her memories. 

My work is not yet done. While Ally is on Targin bd it means that there is still scope for getting her off narcotic pain relief altogether. But I think there is a good chance that with a holistic approach to her problems, she’ll come through this and indeed one day may leave the nursing care facility as she becomes healed and well again.

A Pain Vignette 2:

A Broken Heart

“Bill” is a 63-year-old truck driver who presented with recurrent chest pain. His pain was heavy, retrosternal and recurrent. He was an ex-smoker who was normotensive and had no signs of heart failure, and normal heart sounds. 

The pain had been recurrent over a few months, and he disclosed that he had presented to multiple emergency facilities in our city. He had been actively assessed for ACS on each occasion, and no diagnosis of MI was sustained. A stress echo was normal. There was no costochondritis. Bill was anxious and uncertain about his health status.

He seemed to be a defeated man. 

How would you proceed at this point?

From a GP point of view, something is missing in this presentation. We could continue to explore the cardiac status with a coronary artery CT angiogram. We could establish a disciplined medical treatment programme. My internal search process suggested further history taking to establish a bio-psychosocial context. 

I started with the question: “Was anything important happening in your life around the time the pain started?”

Bill burst into a flood of tears. Between sobs, he shared the crushing grief he was experiencing after the sudden loss of his wife. She had died of a sudden heart attack. 

We stayed “in this moment” for some time. I was now in time deficit with the appointment schedule. 

Bill agreed to get grief counselling and return for support. His pain quickly resolved. His broken heart was beginning to heal. 

What would Bill’s doctors have missed if they didnít inquire into his social circumstances? How important is a holistic history in your practice?

Are reframing skills helpful in patients like Bill? “Is it possible you have a broken heart Bill?” could be a useful question. 

A Pain Vignette 3:

Resistant to Change

“Scott” is a 55-year-old invalid pensioner. He has an aggressive persona and is heavily tattooed. Scott is a new patient. He had been seeing a kind, Christian GP who had retired. A State Health approval for prescribing oral morphine (Kapanol) 100mg bd was in place. He requests his “usual” script. 

How would you manage this consultation?

If you suggest a dose reduction because the morphine use is for degenerative cervical and lumbar pain, Scott is very resistant. You feel his aggression and anger. 

A good physical review is indicated. If the pain is correctly diagnosed, this dose of morphine is excessive. If the correct diagnosis has been slow to emerge, this is an opportunity for a careful review. Psychosocial and spiritual issues are highly likely. In terms of the “cycle of change”, Scott is firmly a “pre-contemplator.”

With these thoughts I am able to negotiate a physical examination in his next visit, providing the script today and asking for blood tests to exclude an inflammatory condition. 

How important is developing a healthy doctor-patient relationship in this context?

Scott agrees to this plan, but indicates he is highly likely to resist change and is prepared to complain to the medical board if change is forced on him. 

Should Christian doctors continue to see patients who pose professional risk?

Primary care medicine faces the full force of narcotic overprescribing. There are multiple factors:

• Rising complex pain rates in a world with only “imminent” significance. 

• Associated rising levels of narcotic use (both prescribed and illegal). 

• Pressure for early discharge from hospital leading to poorly planned pain pathways. 

• The despair of failure to achieve self-mastery and success in life. 

Without spiritual hope, narcotics are now the “real opiate of the people.” Many primary care doctors are ill-equipped to manage these contexts. All doctors are aware of the undesirable consequences of long term, medically prescribed, narcotic use. However, on the ground support for individuals and practitioners through the cycle of change to de-prescribe is weak.

Scott’s bloods are normal. X-rays confirms degenerative changes without operative solutions. Scott re-presents for his next prescription. He remains aggressive. Your heart is sinking. 

What are the options for a Christian GP?

1. Recognise personal limitations and involve a pain service to do the hard work of rationalising narcotic use. This may mean an interim time period where you agree to simply provide monthly scripts. A State Health approval needs to be obtained. It can be made clear a zero tolerance option applies and Scott has the 100% responsibility to manage his monthly supply. You may suggest weekly pickups. 

2. Accept that as a person made in the image of God, Scott needs healing in his life.

Is it appropriate to simply offer a gospel witness and decline further prescribing? Where would this leave the caring/witness of the previous senior colleague?

3. As in (2.) but recognise this will be a long journey. Serving Scott will mean respecting his integrity, creating the space to openly disclose the forces that have made “pain” such a powerful force in his life. It will mean ridding the bumps of “lost” tablets. It will mean keeping an eye on all the medical issues relevant to Scott, and always responding with integrity and compassion. 

In a person so resistant to change, looking for authentic opportunities to move forward in the cycle of change are important. Both relational and professional roles need to be maximised. 

Opportunities for “education” around pain, and the problematic use of narcotics long-term should always be accepted. Scott should be aware of the legal contractual nature of such an engagement. Developing a robust, dynamic pain management plan will be a priority. It may be useful to develop a treatment contract. 

If Jesus made friends with tax collectors and sinners, can a doctor develop a “professional friendship” relationship with someone like Scott?

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