Letters to the Editor: March 2013

Functional Abdominal Pain Syndrome in a Nonagenarian

I believe something important was missing from the December 2012 article “Functional Abdominal Pain Syndrome in a Nonagenarian” (Clinical Geriatrics. 2012;20[12]:32-34). The case patient was being treated with large doses of narcotics with no benefit, and for an inappropriate diagnosis, which is noted at the end of the article. Therefore, action should have been taken to get him off these medications. Although it is not mentioned, these medicines were probably slowly added and increased over time, suggesting he was becoming habituated to them. I don’t know why it is “of note” that he was a “well-respected healthcare professional” with a “distinguished career.” This does not make it unthinkable that he had a substance abuse problem; in some ways, being in the medical field is a risk factor for substance abuse. I believe part of this patient’s follow-up should have been a drug treatment program, with some thought given to the concept that he is continuing on these narcotics mainly to prevent withdrawal. It is even possible that the patient’s current situation was aided by his “distinguished” status; providers may have found it difficult to refuse his increasing demands for narcotics.

Kevin R. Dmytriw, MD, FAAFP
Board Certified in Family Medicine
Cumberland Medical Center, VA
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The authors respond: We very much appreciate Dr. Dmytriw’s comment regarding the approach to the use of narcotics in the treatment of our elderly patient who had a diagnosis of functional abdominal pain syndrome (FAPS).  We agree that, in an ideal world, the removal of narcotics and the placement of our patient in a drug treatment program would yield an optimal outcome. However, the mainstay of FAPS treatment relies on a biopsychosocial approach with a strong physician-patient relationship at its base.¹ As such, referral back to the patient’s primary care physician (PCP) with information on the syndrome was deemed best. The PCP worked with both the patient and the daughters to find an optimum treatment regimen to both decrease his pain, decrease his use of narcotics, and increase his quality of life. This was accomplished over time. In this context, immediate referral to a detoxification program would have undermined the doctor-patient relationship and, in our opinion, would have worsened the outcome.

David Espino, MD
Ughanmwan Efeovbokhan, RN, PhD
Theodore T. Suh, MD, PhD
Neela K. Patel, MD, MPH
Yangping Ye, MD
S. Liliana Oakes, MD
Robert W. Parker, MD
Drs. Espino, Efeovbokhan, Suh, Patel, Ye, Oakes, and Parker are from the Division of Community Geriatrics, Department of Family Medicine, The University of Texas Health Science Center, San Antonio, TX. Drs. Efeovbokhan, Suh, Patel, and Oakes are also from the Acute Care of the Elderly Unit, Christus Santa Rosa City Centre, San Antonio, TX.

Reference

1. Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology. 2006;130(5):1377-1390.