What is it like living in pain? Those of us who have ever experienced unremitting pain for months or years know that it is enveloping and all consuming. I struggled with intractable pain for several difficult years, and I am fortunate because my pain finally got better — what if your pain never did?
That is a horrible reality millions of people are living in right now. The chronic pain population in this country is astronomical. Our offices, urgent cares, ERs and hospitals are being overrun with patients whose pain is out of control. These patients want a solution to their pain — an end to it. But in many cases, we do not have a cure. We cannot make the pain go away. So, we shift the discussion to managing the pain and coping with it.
The problem is, many are not coping — they are turning to pain management and chronic narcotic therapy or illegal drugs for the pain numbing effects of opiates. When legal pain management options have failed them, some patients turn to illegally buying pills or using intravenous drugs. In the process, many will lose their jobs, their houses, their families and even their lives. Does this happen to every patient with chronic pain? No, but we see this pattern more and more.
How do we reverse the climate in America which presumes physicians can provide instant or complete pain relief? How do we as providers set the expectation that we very likely cannot rid our patients of pain, but slowly try and manage and reduce it? And do it all without using opiates?
Well, it will take a seismic shift in culture. We as a society are so wired to the mentality of “take a pill and make it better” or “we can operate and fix that” that patients demand this when they come to us. To explain to our patients that we don’t have a quick fix is frustrating not just for them but for us as well.
When a patient is in pain, it can seem impossible to convince them to accept as treatment any of the many proven pain management techniques that aren’t a narcotic pill (including physical therapy, exercise, cognitive behavioral therapy, medication for psychiatric comorbidities, tens units, injections, spinal stimulators, acupuncture and massage etc). Historically, writing a prescription is easier and takes less time than having that kind of difficult discussion with a patient.
With the right approach and buy-in from members of the medical community, we can change this country’s outlook on treating chronic pain. It will take a concerted effort from each of us prescribers to stop utilizing opiates. If we don’t, the opiate addiction plague is going to become even more widespread, and thousands more will die. One of the barriers to this culture change is that many patients have no faith in non-narcotic pain management. This despite study after study showing that opiate treatment for chronic pain has no benefits long term with regards to morbidity or mortality. It does have significant risk of harm. That fact is now well known to physicians but not well known or understood by the public.
We need to alter the conversation with our patients, and take opiates off the table as a routine treatment option. We can then redirect our efforts to optimizing the modalities that have been shown to have a positive effect on chronic pain. To that end, we need to open more clinics where multidisciplinary non-narcotic treatments can be offered to patients. Here in Ohio, it takes months to get into a pain management specialist, and in the meantime, most patients will survive by going to urgent cares and the ER to get short term pain pill prescriptions. What these patients really need is to start PT, behavioral therapy, nutrition and exercise plans. So how can we make that the new expectation?
Since I started medical school, I have seen the battle with chronic pain and opioids worsen every year. We have created a health care system in which many patients have been treated for pain with long-term narcotic pain medications, and it is extremely difficult to walk back from this mindset. The consequences have been devastating to see and are continuing to accumulate. Reform is ongoing with more and more regulations over who can prescribe what narcotics and for how long. These regulations will definitely help to decrease use, but we as a medical community have to keep working every day to stop the cycle of opiate prescribing. The more boundaries we set, and the harder we make it to access opiates the less prevalent they will be in our society and our medical practices.
Jenny Hartsock is a hospitalist.
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