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Saturday, June 18, 2011

A Case Of RSD And Pain Treatment

According to Oxford Journals, Reflex sympathetic dystrophy (RSD) is a condition characterized by localized or diffuse pain, usually with associated swelling, trophic changes and vasomotor disturbance. Allodynia (pain due to a stimulus which does not normally provoke pain), hyperhydrosis (a condition characterized by abnormally increased perspiration), and nail or hair growth changes may also occur. Motor abnormalities have been reported, in particular, tremor, involuntary movement and muscle spasm. (A.T. Marshall and A.J. Crisp, "Reflex Sympathetic Dystrophy," Rheumatology Volume 39, July 2000)

RSD is a chronic, painful, and progressive neurological condition. It can occur in any part of the body, but it most commonly occurs in an arm or leg. Generally, the pain is intense and continuous. The pain gets worse over time, rather than better, and may spread.

The cause of reflex sympathetic dystrophy syndrome is not known, but it is often related to an injury (ankle fracture, broken leg, etc.) or infection, which may inflame a nerve. In rare cases, an illness, such as a stroke or heart attack, may be the cause. In some cases, no precipitating event can be identified. The pain of reflex sympathetic dystrophy syndrome is generally greater than the severity of the injury that caused it.

Carolyn Shelton and Dr. James Lundeen

49-year-old Ripley resident Carolyn Shelton has reflex sympathetic dystrophy. She was a patient of Dr. James Lundeen, a doctor who was recently decertified by the Ohio Bureau of Workers Compensation and, as a result, had his license suspended by the State Medical Board of Ohio.

Although the BWC recently rescinded its decision, it also has planned on decertifying Lundeen because he now has no medical license. (Frank Lewis, "Through the Cracks: Woman Claims She Suffers Without Pain Clinic Doctor," Portsmouth Daily Times, June 18 2011)

Shelton feels she has "slipped through the cracks" of the pain treatment system since action has been taken against Dr. Lundeen. When Lundeen was practicing (prior to the March 16 raid), she traveled from Ripley to Portsmouth to see him. Then, his practice was primarily handling Workers’ Compensation patients.

Shelton claims Dr. Lundeen had her in remission. “The only medications I was taking were Percocet and demerol. He was always checking to make sure you were doing what you were supposed to be doing.”

“I don’t have a doctor. No one will treat me because I have long-term RSD,” Shelton said. “Right now, since Dr. Lundeen has been out, they have overdosed me on morphine.

“They did it at a pain center that is taking some of his patients in Columbus. He gave me a medication (Opana). I told him I was highly allergic to morphine. He told me there was no morphine in it. And I told him they had tried me on it before and there was morphine in it. He said they changed the formula. I took it and while I was home alone, and I was going into antiphylactic shock.”

Who Is To Blame?

I do not doubt anything Carolyn Shelton says. I feel terrible that she received some very bad treatment in Columbus, but I do, however, have problems with the fact that she blames those responsible for taking action against Dr. Lundeen for contributing to her suffering.

I think Shelton must consider the facts. Here are a few that pertain:

1. The BWC acted against Dr. Lundeen because he needed to be punished. Tom Wersell, director of Ohio Bureau of Worker's Compensation investigations, said the agency was very concerned about the unusually large number of prescriptions being written to injured workers at Lundeen's two offices. The BWC suspected the doctor was responsible for 61 percent of all Scioto County narcotics prescriptions in the BWC system.

"I think it's safe to say that he is among the highest not only in the county, but in the whole state," BWC Administrator Steve Buehrer told reporters. (Cary Ashby, "Doc: Office Raids Were 'Swift Retaliation...,'" Norwalk Reflector, April 3 2011)

Involved in the action taken against Lundeen were the Scioto and Huron County sheriff and prosecutor, Ohio State Medical Board and Pharmacy Board, Medicaid, Department of Taxation, Ohio Department of Insurance, Ohio Alcohol and Drug Addiction Services, FBI, Drug Enforcement Agency and the U.S. Attorney General.

Melissa Vince, spokesperson for BWC, said there are five factors that led to the decision by the Bureau to decertify Lundeen.

“Prescribing high levels of narcotics to injured workers; unsanitary conditions at practice locations; lack of proper medical equipment; lack of private examination and treatment areas where injured workers are seen; and improper disposal and care of injured workers’ confidential patient records,” Vince said. “This decision came down from our administrator and the Department of Medical Services Division,” Vince said. “We have an ongoing investigation, and our investigators have collected more than a hundred boxes of evidence. And they are currently reviewing that.” (Frank Lewis, "BWC Decertifies Lundeen," Portsmouth Daily Times)

2. Shelton, herself, made the decision to go to a pain center that took Lundeen's patients. Dr. Leak, the physician there, has his own problems. According to the State Medical Board of Ohio website database, Dr. Leak’s license was revoked by the Board in 2008, but he has been practicing, pending appeals. However, since a ruling upholding the revocation by the 10th District Court of Appeals in May, he has not been allowed to practice. He filed an appeal with the Supreme Court of Ohio.

3. Shelton, herself, refuses to have an operation that would involve installation of a nerve stimulator. According to Shelton, The Bureau of Workers’ Compensation is trying to force her to have such an operation.  She has refused to get the operation because she believes it would make things worse, and she believes that after such an operation she would still need the same amount of pain medication.

“With RSD, if they cut me it will make it worse than it is. The one thing I have had in my favor is that I didn’t let them operate on me. They told me when I got it I was in a study, and I even seen doctors from France. It was a very technical program. They told me, ‘You do not let them operate.’”

4. Shelton, herself, denies the need for treatment from a pain center. She has just come back from the University of Cincinnati, which she says has one of the best pain centers in Ohio. She claims that the staff at the pain center told her she didn't need their help.

“They told me I did not need a pain center,” Shelton said. “All I need is a doctor that will treat me, because the medications that I am on, it is obvious that I am not somebody that abuses medication.”

Sheldon says Workers Compensation has her employer believing that she is refusing treatment but she claims she is just refusing the stimulator and medication that will kill her.

I, personally, am at a loss for a logical explanation as to why such a prestigious center would tell Shelton that she didn't need their services. Evidently the center doesn't believe she meets their qualitifications? I would think they are in business to help every patient with RSD. What kind of treatment did they offer her, and why didn't she take it? These are questions I cannot answer.

Bottom Line As I See It

I understand the terrible plight of Carolyn Shelton. She suffers horrible chronic pain. She desperately needs help so she can live a decent, normal life. Also, I completely understand her frustration with the system. But, I don't believe the actions against Dr. Lundeen caused her problems. 

Shelton doesn't want to take potentially lethal doses of medications. I respect that so much. I pray she finds the help she needs from new, highly skilled, concerned doctors who can help her get relief from her terrible RSD pain. I trust these physicians will offer her effective treatment for her condition.

Here are a few treatments that do offer help to RSD patients:
  • Physical therapy: A gradually increasing exercise program to keep the painful limb or body part moving may help restore some range of motion and function.
  • Psychotherapy: CRPS often has profound psychological effects on people and their families. Those with CRPS may suffer from depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain and make rehabilitation efforts more difficult.
  • Sympathetic nerve block: Some patients will get significant pain relief from sympathetic nerve blocks. Sympathetic blocks can be done in a variety of ways. One technique involves intravenous administration of phentolamine, a drug that blocks sympathetic receptors. Another technique involves placement of an anesthetic next to the spine to directly block the sympathetic nerves.
  • Medications: Many different classes of medication are used to treat CRPS, including topical analgesic drugs that act locally on painful nerves, skin, and muscles; antiseizure drugs; antidepressants, corticosteroids, and opioids. However, no single drug or combination of drugs has produced consistent long-lasting improvement in symptoms.
  • Surgical sympathectomy: The use of surgical sympathectomy, a technique that destroys the nerves involved in CRPS, is controversial. Some experts think it is unwarranted and makes CRPS worse; others report a favorable outcome. Sympathectomy should be used only in patients whose pain is dramatically relieved (although temporarily) by selective sympathetic blocks.
  • Spinal cord stimulation: The placement of stimulating electrodes next to the spinal cord provides a pleasant tingling sensation in the painful area. This technique appears to help many patients with their pain.
  • Intrathecal drug pumps: These devices administer drugs directly to the spinal fluid, so that opioids and local anesthetic agents can be delivered to pain-signaling targets in the spinal cord at doses far lower than those required for oral administration. This technique decreases side effects and increases drug effectiveness.
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