Doctors and patients cannot win when it comes to chronic pain

Doctors and patients cannot win when it comes to chronic painThe following op-ed was published on September 18, 2011 in USA Today.

A fellow physician recently shared a frustrating clinic visit with me, in which a patient had left by saying, “You doctors need to wake up and realize that patients (who are) in pain are in a no-win situation.”

The patient was absolutely right. This summer, the Institute of Medicine released a report, “Relieving Pain in America,” which found that 116 million Americans suffer from chronic pain, costing the U.S. up to $635 billion in treatment and lost productivity. Chronic pain even increases the risk of depression and suicide.

But when it comes to treating pain, doctors also face no-win situations. While chronic pain is effectively treated with opioids — a class of medications that includes morphine and OxyContin, as well as heroin — close monitoring of the patient is essential because the drugs can be addictive.

Sales exploding

In a column in TheNew England Journal of Medicine last fall, physician Susan Okie noted the explosion in the sales of pain medication, as well as a marked increase in emergency room visits for pain drug overdoses. In fact, according to the Centers for Disease Control and Prevention, deaths from unintentional drug overdoses in the USA, primarily driven by opioids, are the second-leading cause of accidental death.

To combat prescription drug abuse, the Drug Enforcement Agency has gone primarily after rogue doctors, pain clinics and wholesale drug companies. Still, highly publicized federal raids can discourage honest doctors from prescribing pain pills. In TheNew England Journal of Medicine, physicians Timothy Quill and Diane Meier said “concerns about regulatory oversight have led some physicians … to avoid prescribing opioids entirely and have rendered others … fearful or hesitant.”

Doctors face a conundrum. On the one hand, chronic pain drugs can lead to abuse, which could draw the attention of law enforcement. On the other, chronic pain patients are often inadequately treated. It’s not because doctors don’t care. Robert Rolfs, state epidemiologist at the Utah Department of Health, calls prescription drug abuse “an unintended consequence of an intent to treat pain better.”

States taking action

One answer to the dilemma is to regulate pain management, as Washington state is doing with new rules to be fully implemented by Jan. 2. Opioid prescribers will be required to use a patient and drug monitoring program and to practice under uniform pain management guidelines.

Another answer lies in better education of both physicians and patients. According to the American Society of Interventional Pain Physicians, 80%-90% of physicians have no formal training in prescribing controlled substances, such as pain pills. Primary care doctors, who encounter chronic pain patients more frequently, need to be fluent in dosing and monitoring the use of pain pills as well as recognizing the signs of abuse. A proposal by Sen. Jay Rockefeller, D-W.Va., would require physicians to participate in specialized pain management training before being licensed to prescribe controlled drugs, such as pain killers. That is a step in the right direction.

And pain management needs to be incorporated into medical education. Only five of the country’s 133 medical schools today have required courses on pain.

More patients suffer from chronic pain than those with diabetes, cancer and heart disease combined. Similar attention and resources that we use on those better known conditions should also be spent on better educating doctors and patients about chronic pain.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Andrew Schutzbank

    “A proposal by Sen. Jay Rockefeller, D-W.Va., would require physicians to participate in specialized pain management training before being licensed to prescribe controlled drugs, such as pain killers. That is a step in the right direction.” 
    Would that not have the effect of drastically reducing the number of doctors prescribing pain medication?  

    • Anonymous

      Exactly.

      Most docs will quickly decide it isn’t worth the hassle, and adopt an “If you need opiods for ANY reason, go to the ER” policy.

      That will really make things better

      • Easton Jackson

        This is exactly what will happen. I’m a family doctor. I write almost no long acting opioids (MS Contin, Oxycontin, Duragesic, etc.). But I work in an urgent care clinic and occasionally in the ER. I write plenty of scripts for 10-20 hydrocodone or percocet for people with injuries and acute pain. 

        It’s more likely that the Government will require further education for the long-acting opioids first. If this occurs, I will simply not do the training. My response to patients will be, “Sorry. I’m not licensed to prescribe (choose a long acting opioid here). So, here’s your 20 Lortab. You’ll need to go to the pain clinic for anything further. 

        While education is a good idea, it WILL have further unintended consequences, like all of the government’s drug policies.

        • http://twitter.com/okidoll821 Okidoll

          Could you at least refer them to a doctor that could possibly help them before just telling them to go to a pain clinic?

          This is getting ridiculous. Not every person that takes pain meds abuses them.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      Jay Rockefeller is a meddling fool with the intelligence of a pencil eraser.

    • http://twitter.com/okidoll821 Okidoll

      So then you have people in agony not being treated or helped properly. How humane.

  • http://www.facebook.com/people/Elizabeth-Mizioch-Crawford/1097779691 Elizabeth Mizioch-Crawford

    Once again the statistics are being distorted. The increase in accidental suicide is not just from narcotics but from a lethal combination of these medications with other substances. Pain patients who are indeed suffering are not abusing multiple drugs and dying. Also, how can there be uniform pain management quidelines when pain is highly individualized? Putting people into categories is going to have many falling into the cracks. The word abuse is blanketing all those that are dependent on medication. Dependence is very different from abuse. If patients become independent, active, contributing citizens when they take a medicine that makes them feel less pain why is that an issue? Researchers, the medical community and the government need to be held accountable for biased reporting and distorted statistics. Pharmaceutical companies skew data consistently to their benefit and it is time for the undertreated, chronically ill, chronic pain patient to be given the respect, dignity and medical treatment they deserve.

  • http://twitter.com/DICOMdb Don Peterson

    There is an effort to use fMRI for the assessment of chronic pain.  However, this effort is not making its way out of the lab and into the mainstream primarily due to a lack of funding.  Several patents have been applied for and issued, and the protocol is well thought out and easily implemented.  What is lacking is an effort by the industry to move non-pharma related research out of the lab and into the clinic.  At the moment there are only 6 or so adequately equipped fMRI sites in the U.S. although any existing 1.5T (or better) MR could be outfitted to perform the exam.  Given the ubiquity and cost associated with chronic pain, the risk doctors take in prescribing opioids and the need to establish clinical evidence of pain, it’s a wonder to me that the effort to measure chronic pain is still gathering dust in a lab somewhere. 

  • Anonymous

    Perhaps another question to ask is WHY 1/3 our of country (according to the above statistics) is suffering from chronic pain. In this modern age of technology, we have so many conveniences our forefathers could only dream about – advanced tools, safety regulations, etc. Yet, people seem to be getting injured more frequently. Maybe our ancestors never complained about their injuries and pain, or the documentation was poor in those days. However, I fear that our society is becoming weak, both mentally and physically. I hope I’m wrong.

  • Anonymous

    I, too, suffer from chronic pain. I have been fortunate to have a caring neurologist who is treating me for this condition with excellent results without using opoids. Using a combination of drugs, he has helped me tremendously, allowing me to work within my capabilities. I am so thankful for his treatment that allows me not to have the side effects that most opoid medications present. If more patients would be referred to neurologists who have the experience of dealing with the nervous system, I believe many patients would be helped. My two cents of opinion.

  • http://www.facebook.com/people/Jane-Overton/110000801 Jane Overton

    What I wish my Dr would see is that pain is your body’s way of telling you there is something wrong.  Find out what is wrong and treat that before just relegating the whole deal to chronic pain and prescribing a pill. The pill is the easy way out for the Dr and requires no diagnostic skills.

    • http://twitter.com/okidoll821 Okidoll

      There are some diseases and injuries that cannot be cured or fixed. Chronic pain is a very real and often and life changing situation.

       

       

  • http://www.facebook.com/paul.c.weiss Paul Weiss

    Narcotic prescriptions for chronic pain have exploded over the past several years, while there is little evidence to their efficacy in the management of chronic musculoskeletal and neuropathic pains. Often times, antidepressants and antiepileptics are far more effective.

    We need to look beyond pharmacological management. Health care providers and patients need to be better educated regarding the neurophysiology of chronic pain. Butler and Moseley have written an excellent book, titled “Explain Pain” on this topic. In my exam room, I have posters from this book on my walls that I use as teaching aids.

    People in chronic pain need to be taught how to appropriately pace their activities, and how their thoughts and beliefs about pain can influence their pain state. This type of education has been shown to improve physical measures (forward bending motion and SLR) in people with chronic low back pain. There has also been a case study showing that widespread brain activity (through areas known to process pain) was decreased during performance of an abdominal exercise as a result of this type of education. (The subject was a person with chronic low back pain. Brain activity was measured with fMRI.)

    A lot of misinformation is being given to people in pain. Many are told “if it hurts, don’t do it”. Many associate chronic pain as a signal of ongoing tissue damage. Until we start educating health care providers, patients and the general public about why people are experiencing chronic pain this problem will not go away. The sooner we stop looking to narcotics as an answer, the better.

    • Anonymous

      I have rheumatoid arthritis. Are you telling me that the daily, constant, debilitating pain I feel is NOT a signal of “ongoing tissue damage”? If so, you are sickeningly ignorant. I infer you are a doctor or healthcare provider, since you have an exam room. Obviously provider education IS the key, if a doctor can blithely make a blanket statement like that with no exceptions.

      Of course arthritis patients are told to continue moving and exercising and doing therapy in spite of the pain. In many cases, effective pain medication can help us to do that. And in some cases, after 20 years of relentless joint damage, when a person’s foot bones have fused, tendons have snapped and been reabsorbed by the body, and she is walking on a bone never meant to bear weight, there is no “information” that will ever lessen that pain.

      The thoughts and beliefs that keep me going, as I maintain a full-time job, a children’s book-writing hobby, spending time with my family and volunteering for arthritis-related charities are thoughts about courage and perseverance, and about overcoming the stereotypes that so many people — including doctors, who should know better — assign to patients on long-term opioid therapy.

  • http://www.facebook.com/people/Karl-Hafner/100001398635141 Karl Hafner

    please, lets stop saying opiates are appropriate for chronic pain.  In 99% of cases they are not.  When we get that right then we can begin to treat pain effectively.  Paul Weiss you have it right.  Narcotics are good for one thing.  You have a patient for life.

    • http://twitter.com/okidoll821 Okidoll

      That is absolutely incorrect. You have no idea the pain other people go through. How dare you try to sentence me and every other chronic pain patient to agony for the rest of their lives. If you can find relief in other ways without medication then great for you, but do not make that decision for me.

      There is no cure fore my diseases – Lupus and Rheumatoid Arthritis. I’m 38 years old. Are you telling me I have to be in agony for the rest of my days because you don’t think I should take them? You have no right to decide that for other people.

      Notice you never see chronic pain patients trying to force other people who choose alternative medicine to try pain medication, but you certainly see people trying to remove the only relief those of us on pain medication can get. Until you can implant yourself into every pain patients body and feel their pain, then you have no right to interfere with other people’s treatment.

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    I too suffer from chronic pain. I have NEVER asked for a narcotic. All I have asked for is help finding the cause and then appropriate treatment. I can’t tell you how many alternative med folks I’ve tried in desperation (and I’m in the medical field by training). Finally had a neuro and PT tell me I’ve probably made the problem worse over the years using chiropractors (who by the way also take insurance). But at least they listen! Go figure. Is it so hard to get someone to listen and ask questions and work with you? Sometimes having that caring relationship is half the battle.

    BTW Muddywaterz, if you research some of the treatments they did a long time ago for pain, it was not pretty. Bizarre, barbaric, and downright deadly in most cases. While Bayer began selling Aspirin in the late 1800′s and the “good stuff” was around in various forms of use for those who aquired it, it wasn’t until the mid-1900′s that readily available pain medications came on board if you study up. So perhaps our documentation of CHRONIC vs. acute pain just wasn’t what it is now. Besides, insurance has changed dramatically in the past 20 years so obviously you are getting a better feel today of what is happening with today’s society thru ICD-9 codes and documentation vs. just 2-3 generations ago who all paid in cash or chickens!

  • http://pulse.yahoo.com/_GJCNF5QLKW7ROYAZZGB7HFH57Y jamesp

    What amazes me is the utter failure of modern western medicine to admit that we, in an effort to avoid opioid prescribing- can we use that medical term, not the legal term, “narcotic?”-  drives patients to endure invasive, costly procedures which often increase pain and disability. Failed back surgery syndrome is a recognized, codeable, diagnosis. It fails so often not because surgeons are incompetent, but rather because chronic low back pain- a common reason for  opioid use- is not nearly as scientific as we wish it were.

    Why is that little fact so poorly recognized?

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