“The patient’s pain is still 9/10, doctor. We’ve already given morphine IV and then changed to Dilaudid IV and then we increased the dose of Dilaudid. Can we give it every two hours instead of every three hours?” the nurse asks me over the telephone. I sigh heavily into the receiver, unsure what to do, feeling more like a drug dealer than a doctor. The patient is on horse-sized doses of oral pain pills at home for chronic back pain, complicating efforts in the hospital. The prescription painkiller epidemic has changed the face of medicine in America, and the health care industry, doctors included, is partially to blame.
The statistics are sobering and growing worse. According to the Centers for Disease Control, there were 16,917 deaths and 420,040 emergency room visits due to prescription painkiller overdoses in 2011. Drug overdose death rates have risen steadily since 1992, including a 118 percent increase from 1999 to 2011. The epidemic has huge implications for the costs of care as well — about $55.7 billion annually as of 2007.
While narcotics are essential for those with acute pain from surgery or chronic pain due to cancer, there is no scientific evidence that they help alleviate pain in chronic, non-cancer pain. Doctors in the U.S. are now stuck occupying the awkward position of denying a patient medication for pain, rarely certain whether it’s real or imagined. On the pain scale, a 10/10 allegedly represents the worst pain imaginable, something akin to childbirth or torture. Inexplicably, patients report scores of 11, 15, or up to 50. Doctors and nurses must attempt to discern the primary motivation for the patient’s complaint — whether it’s real and severe pain or a psychological or physical addiction to narcotics.
I spend half of my time directing a cancer treatment program in Port-au-Prince, Haiti and half as a doctor in a hospital in Florida. The psychological impact of straddling the cultural and resource divide has led to many sleepless nights, but also to a different perspective on medical philosophy in the U.S. Even with all the patients who die due to insufficient resources in Haiti, the largest contrast between the two locations may be the manner in which each system addresses pain control.
Developing countries’ attitudes towards narcotics remain entrenched in the old school mentality that pain is something to be endured, not treated. Governments closely regulate the importation of narcotic medications, so much so that hospitals have trouble obtaining enough IV pain medications to treat post-surgical patients in the hospital. Oral pain pills are virtually non-existent, condemning many to suffering with chronic cancer pain at home. The World Health Organization has established a “pain ladder” to educate health care providers around the globe on the graduated approach to pain control, and to advocate for increased use of painkillers globally. Foreign doctors, myself included, haughtily describe the situation as archaic, disdainful of the notion that narcotics should be so closely monitored for fear fueling addiction.
However, we may have achieved that dubious distinction in the U.S. over the last 15 years. Since a landmark nursing article in 1999, the pain score has been considered the fifth vital sign, something that should be measured regularly by nursing staff, like blood pressure and heart rate. In 2002, professional medical associations, encouraged by the federal government, instituted a process which asks patients to self-report their pain intensity with verbal rating scales at regular intervals, and nurses are obligated to address higher pain scores with medications.
Further exacerbating the problem, Medicare reimbursement rates have been tied to patient satisfaction scores since 2012. Patients can also grade doctors and hospitals on websites where other potential patients shop for health care providers. With ratings and payment hanging in the balance, health care providers have a financial incentive to keep patients happy, which may mean increased numbers of narcotic prescriptions, both in the hospital and in the outpatient setting. Patient satisfaction scores, layered on top of pain rating scores, have resulted in a dangerous situation where the health care industry plays a role in driving the epidemic of narcotic addiction in the U.S. It might not be a coincidence, then, that there has been a 300 percent increase in painkiller prescriptions since 1999 and that deaths from prescription painkillers have doubled over that time.
On top of all of this, we may not be helping the patients despite our hypervigilance with the scoring systems. Recent studies have shown no change in long-term self-reported chronic pain scores regardless of whether medication dosages are increased or decreased over time. Other studies have shown that patients of doctors with the highest satisfaction scores are more likely to be hospitalized and more likely to die.
For developing countries, governments must allow increased importation or production of pain medications, especially oral formulations. Doctors and nurses must be trained in recognizing and addressing pain as outlined by the World Health Organization.
For the U.S., the situation is more complex and complicated by the financial interests of the parties involved: doctors, hospitals, and drug companies. Requiring patients to request pain medications instead of offering them on a scheduled basis would be an easy and effective first step. Any good bartender or waiter knows that the best way to encourage patrons to order more is to ask them frequently if they want anything else. Nurses should have the ability to rate the patients’ pain instead of relying solely on the patient’s self-reported scores. Outside the hospital, online databases of when patients fill narcotic prescriptions will allow doctors and pharmacists to see who is abusing the system. For those patients with chronic non-cancer pain, physical therapy and lifestyle modifications such as weight loss have proven to be more effective than narcotics, albeit more time intensive for both the doctor and the patient.
A happy medium between the dearth of pain killers for patients living with cancer and the overt medical endorsement of prescription drug abuse exists. For my patients in Haiti and in Florida, I hope that we can arrive at a sensible solution sooner rather than later.