Every day in the emergency department I am confronted by pain.  In fact, the treatment of pain is one of the most important skills emergency physicians, indeed all physicians, possess.  For instance, I recently cared for a child with sickle cell disease who was having a pain crisis which involved severe leg pain.  His life is one of frequent, intense pain.  I gently, and repeatedly, treated his pain with morphine until he had relief.  I see hip fractures; all broken bones hurt.  I am thrilled to alleviate that discomfort.  Pain is one of the things I can fix, if only temporarily.  It makes me happy to see the relaxed face of a man or woman with a kidney stone or migraine, who suddenly smiles and says ‘thanks!’

But pain is also the source of so much subterfuge.  Emergency department are full of individuals who use controlled substances for recreation.  I know because they have pain that is entirely unverifiable.  They have terrible right flank pain with no gall-bladder, no pancreatitis, no kidney stone (documented by CT), no pneumonia or rash.  They have nothing to cause the pain.  And yet, dose after dose of narcotic later, snoring in their ER stretcher, they look up at me with hazy eyes and say, thickly, ‘cann I gettt somethinn elsss for paaiin…it hurtssss so…bad. zzzz.  Itzzz a tennn.’

So I began to wonder about science and the pain scale.  I admit that the pain scale has a place.  But I also wonder to what extent the pain scale has made everything worse.  Prescription drug abuse is epidemic.  And most of it isn’t stolen; it’s prescribed, then abused or sold by patients.

I’ve heard this old saying, ‘you can’t create an addict in the ER.’  Poppycock.  That might have been true in the days when the ER wasn’t an all-inclusive, shop-till-you-drop supermarket of medical wonders.  It might have been true when you could actually escort someone out of the ER and tell them to never return.  It might have been true when federal law and trial lawyers didn’t have us in a collective choke-hold.  But now, I’d venture to say that you can absolutely create an addict in the ER, or in the family medicine office, or in the pain clinic, or in the neurologist’s office.

Have we simply taken our own fear of under-treatment of pain and transferred it to the more dangerous over-treatment by the patient, who has the final answer to all pain questions, simply by saying ‘yep, it’s a ten,’ while texting his girlfriend about their trip to the lake?

It would seem that we could do a better job scientifically.  Aren’t there some indicators?  Can’t we develop a ‘pain-o-meter?’  For goodness sake, I’m carrying an Internet capable phone in my pocket, and this blog-post will be available around the world when I hit ‘post.’  The Hubble Telescope looks 10 gazillion light years into the past, and particle accelerators are about to look at the very building blocks of atoms!  And all we have is, ‘rate your pain on a scale of one to ten?’

I think we’ve gotten lazy.  In our cultural terror of ‘judging,’ in our obsession with the clearly false idea that everyone is always speaking the truth, in our post-enlightenment fantasy that every human, every patient, is basically good, we have simply decided to believe everyone, every time.

In the end, our rush to objective, rational science sometimes banishes common sense and self-evident truth as anachronisms to be ignored, rather than even evaluated for their intrinsic worth to medicine and to mankind.

What a travesty.  When I think about it all, it gives me a headache.  But don’t worry; it’s only a 4.

Edwin

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