Kathleen Harder-Brouwer, MD
Hamilton MT 59840
If you have been in the hospital anytime in the last 20 years, you have seen the signs asking you about your level of pain. Faces from smiling to crying were paired with a numerical ranking to help patients convey to medical staff the level of pain they were experiencing. Some would say that these pain rankings were a "vital sign" that needed to be recorded, followed and treated. It was in this culture that many of today's health care providers were trained. While it is important that pain be evaluated and treated, most of these ideas of pain ranking and pain as a "vital sign" should be applied primarily to the phenomena of acute pain. Acute pain is short lived pain related to a very specific medical event. If one breaks a leg, there will be acute pain that should be treated. If one has surgery, there will be some degree of discomfort that might call for the use of opioid medications. What we are seeing in the press and on TV is not attention to the treatment of this type of pain, but the more elusive issue of chronic pain. This is a long standing pain, much less easy to measure and infinitely harder to treat successfully.
Chronic pain has been defined in many ways, but according to the Centers for Disease Control (CDC) it is a pain that lasts greater than 3 months or past the point of normal tissue healing. To reference an example above, pain in a broken leg four months AFTER the injury, when x-rays show normal healing, would be quantified as chronic. The exact number of persons with chronic pain is difficult to determine.
Certainly large numbers of opioid prescriptions are written annually for patients. Like with many medications, pain relief has become a huge pharmaceutical business. In the approximately 210 years since morphine was discovered, we now have a plethora of medication options. These range from fast acting drops placed under the tongue to patches that last 7 days. The evolution of the treatment of pain mirrors the development of these medications. While the short acting medications were the first used, the medical community switched to longer acting medications with the belief that they were safer long term and had a much lower abuse potential. However, that belief was inaccurate. Now the medical field will need to find a way to reverse prescribing that is unsafe while still being sensitive to the needs of patients who genuinely are in pain.
There are numerous reasons for this current epidemic of opioid overprescribing. A few of these reasons must be acknowledged before any plan can be developed to tackle the issue. First, it is very important to acknowledge how opioids act. In addition to blocking pain at the level of the receptors in the brain, they act as sedatives and have the potential to cause euphoria (a feeling of intense excitement and happiness). If you as a patient have chronic pain after an accident that affected your ability to work productively, you will likely also experience some degree of anxiety about your future and depression about your predicament. The opioids treat this anxiety and depression almost as much as they treat the pain. It is quite possible that a patient would feel terrible if the medications are stopped, even if the pain is not necessarily being effectively treated. Second, most physicians have empathy with patients who are suffering and wish to relieve that suffering. If the presenting complaint is pain, it has been the norm to try and relieve that pain with whatever medications are available. Lastly, there has been a reliance on patient satisfaction as a measure of the quality of the medical provider. Failure to treat pain effectively may lead to dissatisfaction of patients and impact the provider's ability to work.
If we are to turn the tide of opioid overprescribing without harming all parties involved, we need to work together to find a healthy approach to treating chronic pain. Patients need to understand that chronic pain needs to be treated to improve function and not necessarily to lower an arbitrary numerical value. There are times when opioids are useful, just as there are times when antidepressants, physical therapy and counseling are necessary. Medical providers need to help patients transition off unsafe levels of medication with compassion and understanding. Providers also need to make use of prescription drug registries and urine drug testing for identification of abuse. The answer is not to stop the usage of all of these medications, but to do a better job of caring for patients. This is the challenge of medicine with regards to all disease processes.