Will the pendulum of pain management swing too far?

They say that the path to hell is paved with good intentions. Few things in medicine illustrate that as well as how we’ve approached chronic pain management in the past 10 to 20 years.

The advances that we have made in medicine in the past few decades have been truly remarkable. But, unfortunately, pain is one of the ailments we still do not treat well. One of the difficult aspects of pain is, unlike many other illnesses, there is no objective data — no lab tests or images — to verify or quantify pain. Pain is so multifactorial that we must trust our patient’s report on how they feel. That’s the only way.

When we took the Hippocratic Oath, we made a promise to prevent our patient’s suffering. In that vein, even just 10 or 15 years ago, when patients reported to us that they had pain, in the hopes of decreasing their suffering, we provided them with increasingly higher doses of prescription painkillers. Unfortunately, as recent data have shown, this intention to heal our patients has caused them overall an arguably greater harm. The CDC reports that each day in the United States, 120 people die from a drug overdose. Of the deaths related to pharmaceutical medications, more than 70 percent are due to opioids. More than half of the deaths attributable to narcotics are now due to legal, prescription medications.

As deaths from prescription opioids grow more frequent than deaths from heroin, the epidemiology of victims has shifted. Intentional and unintentional harm from painkillers has made the population of victims more white, suburban, and affluent. For better or for worse, this has made our country more aware of the dangers of narcotics. It has also forced our profession to think more thoroughly about appropriate use of narcotics as well as how to reduce the harm caused by opioids when they are indicated.

Every physician going through training these days has heard at least one talk (if not more) about how to approach prescribing narcotic medications. Beyond these didactics, every physician-in-training has likely had at least one experience with an adverse outcome from prescription painkillers. For example, I recently admitted a patient after overdosing on prescription morphine tablets — this was the patient’s second admission for the same reason.

As we hear more and more stories like this, we become increasingly reluctant to provide patients with opioids. I find that this is a tension that we feel not only when negotiating with our patients, but it is a constant internal struggle as well. We see our patients suffering and in pain and we want to help, but we worry about the harm to our patient as well as the harm that might occur to the community if an individual diverts the medication into the black market.

In the midst of this internal struggle, I worry that we will swing the pendulum of pain management all the way to the other side. We will begin to undertreat pain with opioid analgesics, even when they are indicated. This is a difficult balancing act, one that we in medicine have traditionally not balanced well. One of the faculty members at my institution recently provided advice that really struck a chord for me: We prescribe painkillers to help patients with their suffering, and if the medication does not help with their suffering — which, unfortunately, is often the case — then we should think creatively about other ways to manage pain. Many of us went into medicine to help people. I hope that by staying focused on helping people and reducing suffering, we can find the appropriate balance between under and over-treating pain.

Narcotic medications are not inherently evil, but they clearly are not a panacea either. There are times when we should use them and times when we should not. As the opioid abuse epidemic becomes rampant, we should make sure to remember this.

Elaine Khoong is an internal medicine resident. This article originally appeared in The American Resident Project.


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