Chronic pain management and the surgeon: barriers and opportunities.

“Oh great,” I thought sarcastically as I got off the phone with the answering service. The call was from Mrs. Daly, an elderly woman on whom I had operated 6 weeks earlier. She had presented with a large abdominal mass and obstructive symptoms. At the time of surgery I found a large pancreatic cancer that could not be resected, but I performed biliary and intestinal bypasses for what I hoped would be some degree of palliation of future symptoms. The answering service said Mrs. Daly needed me to call about “pain control issues.” It was 11 o’clock at night. I thought, “Where is her oncologist?” When I called the patient, I immediately sensed she was uncomfortable and desperate. “Doctor,” she said, “thank God you called.” “My stomach and my back are hurting and this pain is unbearable. I feel like I could climb the wall.” I asked her to tell me how long this had been going on and where she was having the pain. “The pain has become gradually worse over the last couple of weeks. The pain is in the middle of my stomach and my back. I can’t find a comfortable position.” When I asked her to rank the intensity of the pain on a 0 to 10 scale, she stated it was, “way beyond the scale, like 15.” Mrs. Daly went on to tell me she had recently seen her oncologist. The oncologist was aware of the increasing pain. The oncologist arranged for a CT scan and gave her a prescription for Percocet. The Percocet was to be taken as 1 to 2 tablets every 4 to 6 hours as needed. The patient had been taking two tablets around the clock without any relief. To complicate matters, the oncologist was out of town at a national meeting, and she did not know the name of the covering doctor. In addition, her primary care physician of 25 years had recently retired and she had not established any relationship with the new physician assuming her care. “I thought I’d call you because, after all, you operated on me and you know me better than my new doctors.” She went on to tell me the pain had become so bad that, despite the Percocet, her son had taken her to the emergency department. The emergency department physician gave her a “shot” of morphine which provided some relief. She was discharged from the emergency department with a prescription for Dilaudid, and the promise that “these are more potent than the Percocet.” Unfortunately, this occurred on a Sunday evening when all the local pharmacies were closed. She resumed taking the Percocet without any relief until the following morning when a friend attempted to fill the prescription, discovering none of the local pharmacies stocked Dilaudid. The patient’s friend, desperate herself, went to the new primary care physician’s office where a prescription for Oxycontin, 10 mg every 12 hours, was issued. Mrs. Daly told me, “I took that Oxycontin and it did nothing.” She added, “I am hurting so much but I’m afraid to take this medication. I’ve heard such horror stories on the television about people overdosing on this stuff.” I asked her, “How can I help? It seems that you need to talk to the oncologist on call to help your pain situation.” Mrs. Daly told me, “I remembered when I had my surgery 6 weeks ago how much attention you paid to my recovery and making sure that I did okay after the operation. I know that I don’t need any more surgery, but is there something you can do to help me?” A general surgeon, Erie, PA