The Cost of Treating Pain
Kathleen Harder-Brouwer, MD
Ravalli Family Medicine
411 West Main Street
Hamilton MT 59840
The Cost of Treating Pain
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.
This week's health column is a collaboration between Ravalli Family
Medicine and Marcus Daly Memorial Hospital. For questions regarding the
health topic please contact Kathleen Harder-Brouwer, MD at Ravalli Family
Medicine, 411 West Main Street, Hamilton MT 59840 or www.ravallifamilymedicine.com.
Working together to build a healthier community.