Pain Management – Why Doctors Don’t Get It
In this blog, we have written often about pain management because so many patients come to us desperate for help. Pain seems to be one of the most misunderstood aspects of patient care. A recent New York Times article sparked a lively debate among fellow advocates about the failure of most doctors to understand pain and to treat it appropriately. I invited Ken Schueler to share his thoughts as guest editor today.
“I had the privilege of participating some years ago in Dr. Russell Portenoy’s successful initiatives in making “pain” the fifth vital sign. Dr. Portenoy is considered the father of the Pain Management movement in the U.S. He is at Beth Israel Hospital in New York.
There are multiple problems with regard to pain management in the United States. First, we have a puritanical history that has contempt for suffering which can’t be measured scientifically or associated with an organic disease (e.g., Reflex Sympathetic Dystrophy, also known as Complex Regional Pain Syndrome).
In other words, with the exception of some investigational functional MRI’s, doctors can’t verify a patient’s subjective report of pain. So they begin by under-dosing a patient’s baseline pain, allowing continual breakthrough pain. Gradually they will dose to effect unless they dismiss the patient and refer them to the psychiatric service believing the patient is malingering or that “it’s all in your head.”
Second, for many years, pain management physicians had no Board Certification; they were composed of neurologists and anesthesiologists. Now, there is the American Board of Pain Medicine which is fostering education among all physicians.
Third, there is an enormous misunderstanding and lack of knowledge about addiction and three characteristics of pain management:
1) Dependency – if you suddenly stop taking an opioid you’ll go into withdrawal. Note: one wouldn’t say that a diabetic is addicted to insulin, one would say a diabetic is dependent on insulin. Therefore, dependency is NOT addiction;
2) Tolerance – needing a higher dose to achieve the same effect, as often happens in advanced cancer: that is NOT addiction;
3) Addiction is properly defined as “drug craving behavior where a patient is obsessively seeking to score opioid drugs through doctor shopping (paying cash) and even forging prescriptions.”
For many years I was on a list service with Dr. Russell Portenoy, and the stories of suicides by pain patients unable to receive adequate treatment were/are heart-breaking. The Drug Enforcement Agency’s witch hunt tactics contributed to these suicides. There is an irony that the most widely used addictive substance in the U.S., tobacco, is not even FDA regulated.
Many patients are not sufficiently educated to know that once there is breakthrough of their baseline pain(managed with long-acting opioids), it make take considerable time to get the plasma concentration high enough with a short acting opioid to get the pain under control. Often, good pain management Nurse Practitioners are the best educators for pain patients.
Chronic pain requiring an opioid cannot be managed solely with acupuncture, but we know from research that acupuncture stimulates the body’s own endogenous opioid system, such that it may be possible to reduce the dose levels of opioids. One problem here is that insurance companies limit the number of acupuncture sessions, just as they do with physical therapy sessions. Fortunately, a number of compassionate acupuncturists have lowered their prices for pain patients.
I’ve often said that if all medical services were run like hospice we would have a much more humane health care system, notwithstanding the abhorrent insurance system we have. You never see the DEA harass a hospice physician over their opioid prescriptions because admission to hospice requires the primary physician’s certification that the patient has less than six months to live.
Many years ago I did a study of “physicians who became patients.” Several observations: if the physicians experienced pain they become much more sensitive to their patient’s pleas for better pain management. Second, if they had a serious illness or surgery, their colleagues were less likely to refer new patients to them, in other words, once you’re seriously ill, you diminish in value and the institutionalized impact of this on patients is seen when a doctor making rounds with residents says, “that’s the pancreatic”- NOT SEEING THE WHOLE PERSON.
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Guest Editor: Ken Schueler