Mr M. is a 58 year old man with severe, chronic neck pain. He has a history of hypertension, tobacco dependence, stomach ulcers, mild kidney disease, alcoholism (in remission for 10 years), and a "bleeding problem". He has no history of heart disease, stroke, depression, or diabetes. His family history is significant for heart disease in his father and alcoholism in his mother and two of his siblings. He was referred to you by a friend after expressing dissatisfaction with all his previous doctors.
His neck pain began nearly fifteen years ago after a minor traffic accident. He has had multiple imaging studies that show significant arthritis of the spine at the level of the neck, but no compromise of the spinal cord. There is some pressure on the nerves exiting the neck that supply the right arm. He has some pain in that arm, but has full use of it. His pain prevents him from keeping a steady job, and he often feels so bad that he doesn't bother to eat.
A surgeon offered to operate on several occasions, but warned the patient that the bleeding problem would increase the risk. He takes ibuprofen tablets by the handful throughout the day, which gives him significant relief. He says that he has been told that the ibuprofen caused his ulcer, which bled bad enough to land him in intensive care and required a transfusion of eight units of blood (that's a lot of blood). He saw a pain specialist who tried a few different medications, but would not use any narcotics because of the risk of "addiction". His previous family doctor also warned him against using any narcotic pain relievers.
Today in the office, he appears tired and thin. His blood pressure is elevated, and his brow is furrowed. He turns his head carefully when you walk in the room. He has full strength in all his extremities, except for some equivocal weakness in his right hand. The rest of his exam is normal. Laboratory examination shows mild anemia and some kidney dysfunction. His blood is negative for alcohol and for drugs of abuse. You review his MRIs which are consistent with what he has told you.
The patient tells you that you are the last resort; he practically begs you for help. He has heard so many good things about you. He has heard of some pill that starts with "V" that really helps some people.
How would you approach this case?