Treating pain a little too well

(My column from this month’s EM News)

Second Opinion: Treating Pain a Little Too Well

Leap, Edwin MD

The Centers for Disease Control and Prevention report that prescription pain medication abuse and deaths are at an all-time high in the United States.

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The numbers in the November issue of the CDC’s publication Vital Signs, are impressive. (See FastLinks.) Prescription pain medication deaths numbered 3,000 in 1999 but 15,000 in 2008. The CDC report is shocking … to everyone except physicians and nurses in the real world of the emergency department.

How many of us in the day-to-day practice of medicine have been predicting this sort of cataclysm for years? We’ve seen too many young people die from accidental overdoses from abuse of prescription pain medications. But why is it happening?

Part of the problem is the very real, very miserable problem of chronic pain in those with legitimate illnesses and injuries. Pain sufferers need help, and the overwhelming majority of physicians want to ease suffering and often prescribe narcotics.

It’s partly the result of efforts by large organizations like the Joint Commission, the Institute of Medicine, the American Medical Association, and advocacy groups (physician- and patient-driven). They have told us for years, in no uncertain terms, that we are doing a poor job of treating pain.

Those well-meaning but influential groups have systematically pressured physicians and midlevel providers. They’ve endlessly harassed nurses about pain scales. They have forced unnecessary pain policies on facilities.

In time, practitioners, good little followers that we have become, started using more and more potent medications. We began to ask everyone about his pain scale. It was even dubbed the fifth vital sign. “What is your pain today? On a scale of zero to 10?” Sadly, it’s rather subjective. And the number of people with a pain-scale of 10 is always high. They mutter, with slurred speech, “My pain is a 12,” even as they drift off to sleep in ED beds, and we watch the oxygen saturation nervously.

Of course, the epidemic of narcotic abuse was worsened by the financial possibilities, recognized and quickly abused by a minority of physicians who opened “pill mills” where narcotics were obtained with startling and fatal ease. Appalachia, my home, has suffered enormously from this sort of activity. I have seen patients who were the devoted followers of a local provider who notoriously gave out narcotics like Halloween candy. His patients would say, “Dr. X is the only doctor ever smart enough to diagnose my problem!” When he lost his practice and license, the weeping was audible across the county.

Obviously, the economic prospects did not go unnoticed by patients, or those calling themselves patients, who realized (with incredible financial acumen for jobless individuals) just how much their prescriptions were worth on the street. In short, a lot.

State medical boards nationwide muddied the water by punishing doctors for prescribing too many narcotics (in the endless attempt to justify their nebulous roles and necessity). Physicians were left confused between a national campaign and their local regulatory bodies.

Another grave problem, seldom mentioned, is the customer service model of medicine. Physicians, as we all know, often receive negative patient satisfaction scores from patients who feel they didn’t receive the pain medicine they desired or deserved (or, as they now say, was their right). Hospitals, eager to please “customers,” eager to curry favor with certifying organizations, reprimand those physicians who learn all too quickly that if they want a happy workplace and a secure job, they should give the patient what he asks for, science be damned.

Not to be excused, our country has an enormous population of individuals whose lifestyles are based on entitlement living, who come from fractured families, who grew up with alcoholism, and who consume many other drugs of abuse. And not all of them are poor. Prescription narcotics may just be the lowest hanging fruit of all in the endless attempt by humans to anesthetize their lives.

As we struggle with the economics of health, I suspect we have no real grasp of the amount of money spent on prescription narcotic abuse, not only in treatment of overdose or rehab but in the enormous costs as physicians sift through confabulated complaints and outright lies, ordering tests for chest pain and abdominal pain, believing the complaints of headache, backache, and all the rest, hoping to alleviate suffering but finding no objective evidence of anything except a history of drug abuse and likely drug diversion.

Physicians obviously share in the blame. Sometimes we’re lazy and give in too easily. Sometimes, we’re afraid to challenge authorities or cause arguments. And the medical education establishment has educated away the idea that humans are fallible and may not be truthful so that in our newfound relativism every truth is a kind of truth. Thus, every pain needs a pill … why would anyone lie?

What can we do? The CDC recommends monitoring programs, alternative treatments for pain, improved education of practitioners, and access to rehab. But the reality on the ground, at least in most emergency departments, is that pain specialists are seldom available after 5 p.m. and only for patients with insurance. Likewise rehab, without insurance, is all but impossible. And the best drug seekers know the drill. They’ll endure Motrin a time or two, but all too quickly they develop allergies or ulcers, just as they do with any drug or therapy that lacks the desired euphoria (or monetary value) of a proper narcotic.

Prescription narcotic abuse is killing Americans, casting in a negative light those truly in need of pain medication and crushing the health care economy. The complexities of the problem, as policies flow down from on high, make regular folks like us complicit in a terrible social tragedy. There are no easy solutions. But there’s plenty of blame to go around, that is, if anyone of influence is willing to listen to regular physicians and nurses, slogging through mountains of pain scales and prescription requests, day after day, night after night, and sometimes, far too often, giving tragic news to the families of the dead whose pill bottles lie empty at their bedsides.