The under-treatment of pain in the United States is a public health problem of great magnitude. (It is also a major problem
in several other countries as well)
It has been estimated that from
50 to 76 million Americans currently suffer from chronic pain. In the good majority of instances, the suffering is unnecessary, since
medical science has the knowledge to successfully treat the great majority of cases of pain. One example of this is
a study that showed that one quarter of nursing home residents received no pain medication at all for their persistent pain.
Another study showed that 70% of patients showing up in emergency rooms for the treatment of fractured bones received no pain medication while in the emergency room.
My involvement in a Wisconsin pain management projectIn the late 1990s I worked for the Wisconsin Peer Review Organization, which had a contract with the state of Wisconsin to encourage Wisconsin health care providers to provide better health care to its Medicare patients. In that capacity I became involved in a pain management project, which led to a research study, which was published under the title “
Evaluation of a Local Cooperative Project to Improve Postoperative Pain Management in Wisconsin Hospitals”.
More important than the specific results of this study were the conditions that led to it. The initial impetus for the project was the results of a questionnaire survey that showed that most Wisconsin acute care hospitals had no policies in place to ensure that postoperative patients received pain management consistent with existing standards of care. As one example, only 12% of hospitals had policies that required that postoperative pain management plans be developed in cooperation with patients prior to their surgery. And a review of 100 patient medical records showed that most post-operative patients did not receive adequate pain management.
Our research study concluded, in part:
This study demonstrated significant improvement in six of the seven indicators used to measure the quality of the processes used to control postoperative pain in 15 acute care Wisconsin hospitals after the implementation of quality improvement plans…
Why pain control is so importantActually, the reasons why it is so important to control pain should be obvious to anyone who has ever experienced severe pain. Chronic pain destroys the quality of life for tens of millions of Americans. And it is not just the pain itself. Severe pain also interferes with or eliminates the ability of people to perform myriad functions required in their work or their home lives.
When postoperative patients are inadequately treated for their pain they
tend to heal slower and end up staying in the hospital longer.
Nor is it sufficient to wait until pain becomes severe before treating it. By delaying treatment until it becomes severe, the patient ends up requiring more drug treatment to provide the necessary pain relief, and therefore acquires a greater risk of serious side effects:
Pain medication should be given on a regular schedule so that there is a stable amount of medicine in the body to keep the pain away. By taking medication before the pain becomes unbearable, the patient can get better relief with lower doses and fewer side effects.
The
under-treatment of pain in children is recognized as a world-wide problem that:
can lead to patient anger, frustration, depression, low self-worth, anxiety, mistrust, isolation, or even suicide… In an effort to quell this "public health problem," the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) developed standards that deemed… pain treatment to be a patient right.
Some personal experiencesMy mother, when she was alive, suffered from severe rheumatoid arthritis for the last 40 years of her life. My wife has long suffered from chronic back pain due to a condition called spondylolisthesis, which is a displacement of the lumbar vertebra. Consequently, they both required large doses of pain medication, including narcotics, for control of their pain.
So when they required surgery for various unrelated conditions, management of their pain presented an especially challenging problem. Not only did they have to contend with the chronic pain that they normally were plagued with, but added to that was pain associated with their post-surgical status.
On those occasions I don’t believe that their pain was ever handled adequately. Often or usually, for one reason or another, they were taken off even their routine chronic pain medication upon admission to the hospital. Because of their weakened condition, they were in a poor position to fight with the doctors and nurses to demand adequate pain relief.
These were some of the most frustrating periods of my life. Throughout much of their hospital stays I would have to beg the doctors or nurses to provide adequate pain relief. They would tell me that they wanted to see if lower doses of medication were adequate before going to higher doses, and I would attempt to assure them that the lower doses that they contemplated wouldn’t even begin to control their pain. It was always a constant struggle and a constant fight. And my mother and wife suffered great amounts of unnecessary pain in the process.
Reasons for under-treatment of painThere are
many reasons why pain is under-treated, and these reasons have been written about in great detail. One obvious reason is the lack of access to medical care. But even after medical care is accessed, pain is much too often under-treated. Here, I’ll address two reasons that I have found to be especially important in my own experience:
Systemic lack of empathyA certain high degree of empathy is often required to treat severe pain adequately. The treatment of severe pain requires spending a good amount of time with the patient – to evaluate the pain, initiate a treatment plan, and then follow the patient closely in order to determine the effects of the treatment.
The fact of the matter is that there is only one good way to determine how much pain a patient is having: talking to the patient about it. That takes time and effort, and it is not encouraged or well rewarded by private insurance companies.
Furthermore, when I attended medical school there was very little time devoted to the subject. And then there are cultural issues. There are many who consider the endurance of pain, even when unnecessary,
to be a virtue. The end result is that patient pain is often not considered a high enough priority by too many doctors.
Over-concern about drug addiction or “drug abuse”I encountered this problem all through medical school and during my residency training. And I accepted the “common wisdom” at the time, as I didn’t know any better, or I just didn’t think about it enough. The general attitude seems to be in many quarters that it’s better to let a hundred patients suffer in pain than to risk the possibility that someone may “abuse” the drugs they’re given and become addicted to them. I find that authoritarian attitude abhorrent.
One thing that physicians generally are not taught in medical school, but which is very important to keep in mind is that drugs used for the relief of pain cannot simultaneously cause euphoric effects and the addiction that accompanies those euphoric effects. Is it possible that a patient may continue to demand narcotic drugs after s/he has no more pain? Sure. Is it possible that drugs taken for the relief of pain may continue to be needed for the relief of pain indefinitely? If the underlying cause of the pain continues, then sure it is. Do patients sometimes ask for pain medication when they have no pain at all? Sure they do. But do all these considerations justify 50-76 million Americans living in chronic pain for large periods of their lives? Absolutely not!
The role of the U.S. government’s “War on Drugs”A large part of the blame for this belongs with our government’s stupid “War on Drugs”. Some doctors live in fear that they could be arrested for providing large amounts of pain medication to their patients who need it. Efforts by the Drug enforcement Agency (DEA) to “crack down” on narcotic abuse have resulted in denying nursing home patients the pain relief that they need.
Senators Kohl and Whitehouse recently objected to that:
The lawmakers wrote to Attorney General Eric H. Holder Jr. this month, urging that the Obama administration issue new directives to the DEA and support a possible legislative fix for the problem, which has bothered nursing home administrators and geriatric experts for years…
The law "fails to recognize how prescribing practitioners and the nurses who work for long-term care facilities and hospice programs actually order prescription medications," Kohl and Whitehouse write. They conclude that delays can lead to "adverse health outcomes and unnecessary re-hospitalizations, not to mention needless suffering."
Katherine Addleman explains how drug paranoia in the United States has interfered with providing adequate pain relief to chronic pain patients:
Paranoia about prescribing opiates has been intense in the US. With the highly restrictive regulatory climate, many American doctors fear that they could be arrested as pushers if they prescribe opiates… US Doctors who treat pain aggressively risk investigations by state medical boards, police and agents from the Drug Enforcement Administration who sometimes pose as patients, as well as loss of license and criminal prosecutions….
The feds filed the
Lethal Drug Abuse Prevention Act, a law that made any physician prescribing a controlled substance subject to prosecution, unless he or she could prove the prescription was justified. But the backlash came swiftly. Fearing that doctors would be unwilling to take on pain patients, over 50 medical and patient groups got together and stopped implementation of the bill. They were right to worry. A study later found that after the feds threatened Oregon doctors suspected of assisting in patient suicides, pain under-treatment spiked in the state.
But… a directive on controlled substances was passed by the American Federation of State Medical Boards, after the American Medical Association and other professional medical societies put pressure on the government to stop harassing doctors who were prescribing appropriately. The new directive clearly declares that under-treatment of pain is just as unacceptable as overtreatment. Since then, medical boards in Oregon and California have disciplined doctors for inadequate pain management….
And of course, in addition to the chilling effect that our “War on Drugs” has had on the use of
legal drugs for the relief of pain, it has also criminalized some drugs that are quite useful in the treatment of pain –
most notably marijuana.
Some advice to pain patientsPeople have an unalienable right to have their pain treated. It’s in our Declaration of Independence. If your doctor doesn’t agree with that; if s/he doesn’t ask you about your pain and then talk with you about it when you want to talk about it; if s/he seems reluctant to prescribe sufficient pain medication because of a fear that you will “abuse” the drugs; or if s/he doesn’t seem to believe you when you talk about your pain, then it’s time to think about finding a different doctor.