The most obnoxious email my hand surgeon has ever received

I managed to badly break my thumb during judo last week. I'm having surgery to repair it this Friday. After spending all this time learning about pain/pain medicine, I've learned just enough about drugs to be dangerous. Today, that danger has manifested in what I'm guessing is the most obnoxious email my hand surgeon has ever received from a patient.

For your enjoyment:

Dear [Dr's assistant],

....The pharmacy has a prescription of Darvocet for me. But, I'd actually like to avoid both the propoxyphene and APAP in Darvocet. I'd appreciate it if you could ask Dr. xxxxxx to cancel that prescription and write me one for something different. He might find the following useful:

The Vicodin prescription [which I had been written for the initial pain of the injury] worked fine. Still, I had forgotten that there is some evidence of an interaction between acetaminophen and xxxxxx. See, for example, [3]. So I'd prefer something without APAP. It's not a big deal, but I'd prefer to keep on the safe side.

I'd prefer to avoid anything containing propoxyphene for two reasons. First, it's somewhat contraindicated with xxxxxxx (propoxyphene can potentiate the xxxxxxxxxx). Second, there are some concerns about its cardiotoxic metabolites. See [1] and [2]. I know it's a tiny risk. But, again, I'd prefer to stay on the safe side wherever possible.

To make things just a bit more complicated: I don't think anything with straight codeine will be very useful. I'm fairly certain that both my mother and my sister are poor metabolizes, so I don't want to trust my CYP2D6's any more than I have to. Moreover, according to Cochrane Reviews [7], with a NNT=12, codeine just doesn't seem very trustworthy.

Finally, just in case this is relevant, I'd prefer to use the narcotics to hit the acute pain hard for 1-2 days and then get off of them as quickly as possible. There seems to be evidence that early aggressive treatment helps cut the overall duration of post surgical pain and, more important to me, reduce the risk of chronic pain (see, e.g., [4], [5], [6], [8]). Thus I'd prefer very few doses of something strong to more of something weaker.

These are just some very weak preferences based on my rudimentary understanding of pain management protocols. I trust your judgment completely.

Thanks
Adam

References
[1] http://www.citizen.org/publications/publicationredirect.cfm?ID=7420

[2]http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm170268.htm

[3] Miners JO, Attwood J, Birkett DJ. Determinants of acetaminophen metabolism: effect of inducers and inhibitors of drug metabolism on acetaminophen's metabolic pathways. Clin Pharmacol Ther. 1984; 35:480-486.

[4] Leibeskind, J. C. (1991). "Pain Can Kill." Pain 44: 3-4.

[5] Merskey, H. (1999). Pain and Psychological Medicine. Textbook of Pain. P. D. Wall and R. Melzack. Edinburgh, Churchill Livingstone: 929-949.

[6] Harman, K. (2000). "Neuroplasticitiy and the Development of Chronic Pain." Physiotherapy Canada 52(64-71).

[7] Derry, S., R. A. Moore, et al. (2010) "Single dose oral codeine, as a single agent, for acute postoperative pain in adults." Cochrane Database of Systematic Reviews DOI: 10.1002/14651858.CD008099.pub2.

[8] Kehlet, H., T. S. Jensen, et al. (2006). "Persistent postsurgical pain: risk factors and prevention." Lancet 367(9522): 1618-1625.
Acute postoperative pain is followed by persistent pain in 10-50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2-10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain.

Another new paper by me: Privation Theories of Pain

Yep. More from me. This time in a philosophy of religion journal --guess I'm branching out.

Privation Theories of Pain

Most modern writers accept that a privation theory of evil should explicitly account for the evil of pain. But pains are quintessentially real. The evil of pain does not seem to lie in an absence of good. Though many directly take on the challenges this raises, the metaphysics and axiology of their answers is often obscure. In this paper I try to straighten things out. By clarifying and categorizing the possible types of privation views, I explore the ways in which privationists about evil are—or should or could be—privationists about pain’s evil.

International Journal for Philosophy of Religion (2009)
DOI: 10.1007/s11153-009-9202-4
http://www.springerlink.com/content/644751l635n21r71/

Super awesome paper: Pain's Evils

Okay. I'm lying. It isn't really super awesome. But it is a new paper by me in the latest issue of the journal Utilitas:

Pain's Evils

The traditional accounts of pain’s intrinsic badness assume a false view of what pains are. Insofar as they are normatively significant, pains are not just painful sensations. A pain is a composite of a painful sensation and a set of beliefs, desires, emotions, and other mental states. A pain’s intrinsic properties can include inter alia depression, anxiety, fear, desires, feelings of helplessness, and the pain’s meaning. This undermines the traditional accounts of pain’s intrinsic badness. Pain is intrinsically bad in two distinct and historically unnoticed ways. First, most writers hold that pain’s intrinsic badness lies either in its unpleasantness or in its being disliked. Given my wider conception of pain, I believe it is both. Pain’s first intrinsic evil lies in a conjunction of all the traditional candidates for its source. Pain’s second intrinsic evil lies in the way it necessarily undermines the self-control necessary for intrinsic goods like autonomy.

Utilitas Vol. 21 No. 2 June 2009
doi:10.1017/S0953820809003550

Pain's Evils

I just found out that my paper Pain's Evils will be published in Utilitas. Since this is my first major publication in a top tier journal, I'm quite a happy Adam. Once I figure out the copyright issues, I'll post a copy of the paper on my website. If you're interested in the interim, let me know and I'll send you a copy.

Dissertation coda

A friend liked this bit of my dissertation. So I'm sharing it with you. It's the very last section of the whole thing. It says what I've done and why I think my view isn't crazy.

§6.3

Coda

I admit that many of my conclusions in this dissertation are radical and counterintuitive. I have claimed, inter alia, that pains are not what we think, that all existing accounts of their intrinsic badness are wrong, that they have two distinct intrinsic values, that a privation theory of their intrinsic badness is correct, that this privation is found in their phenomenology, and that intrinsic value can have properties no one has thought to combine. Radical and counterintuitive are usually okay in small doses, but in this dissertation the dosage may seem lethal.

I suspect that much of what is worrisome here is due to the shadow of the kernel view. All of these conclusions flow from the rejection of the kernel view. If pain kernels [the raw sensation of pain] are not what we care about from the normative standpoint, then we can take a much more capacious view of what pains are and what we are referring to when we say that a pain ‘hurts’. That opens the door to progress and the conclusions of this dissertation.

Several years ago, in the middle of a judo match, I broke my collarbone. As is often the case with severe trauma, the immediate pain was surprisingly mild. In many parts of this dissertation I have been painting a picture of what I felt for just a few moments when I later attempted to get out of the car in the hospital parking lot. It’s true that my memories may be tainted by theory; and it has been several years since the accident. But it was not me whose body twisted and crumpled or me who shrieked.

As philosophers we must follow our arguments where they take us. But we must also be conscious of when they’ve taken us over a cliff. I, of course, believe my arguments. But it is my reflections on countless stubbed toes, headaches, and memories of pains past, as well as my research into pain science and the depictions of pain in literature, which convince me that we are still on the right side of the precipice.

Finally, even if some of my arguments have taken us astray, I hope that this dissertation’s approach has been suggestive. Working on pain, and just pain, can, I think, keep us close to the foundations of normative theory and illuminate many of their joints and fissures. Pain is both a window into and a microcosm of much of value theory. After all, if anything is intrinsically bad, pain is.