A few months ago, I was having lunch with a friend. He mentioned a recent outpatient surgery that he had and indicated that upon being discharged, he was given a prescription for 30 pain pills. Although the recovery was uncomfortable, the pain was not overwhelming. But, as a precaution, it was assumed that he needed this powerful pain relief to be available even after he told the provider that he was not going to take it. Years earlier, he had taken a similar drug in the hospital after dealing with the excruciating pain of kidney stones. As he noted, “The pain was intense, and the medication was both useful and necessary!” However, upon being discharged, he was given a further prescription for this same medication and told to take the drugs every four hours to “stay ahead of the pain.” After two doses, he decided to stop. He described feeling “loopy and out of it.” As he further elaborated, “I wasn’t clear-minded or sure on my feet. I had young kids in the house and didn’t like the idea of feeling that way if something were to happen and they needed me.”
In 1998, the Joint Commission designated pain as the “fifth vital sign,” and every hospital was required to ask their patients about it. This practice quickly spread throughout various outpatient clinics and practices. Yet gradually, many patients began finding out that opioids were being used, even against their wishes. Recently, an article was written by a former patient and someone who works in the insurance industry. She describes her personal experience in which repeatedly, her documented demands that opioids not be used were ignored, even so much as being shocked to find that a nurse was trying to administer Dilaudid through an IV while she was sleeping. As the article described, it was as is if most involved in her care assumed that she could not simply tolerate the pain involved in the procedure without this high-level pain relief. It also illuminated what is well known in the medical community and through associated research, which is that opioid prescribing has been profitable for hospitals. Because patient satisfaction scores are being increasingly linked to reimbursement rates, and because research has indicated that satisfaction rates are generally higher for those who are prescribed opioids, then hospitals and providers are increasingly tempted to use them inappropriately because of the incentives they provide. Unfortunately, what often is lost is a true understanding of what is best for each individual given their unique circumstances.
In May of 2018, the City of Evansville joined many other communities in filing a federal lawsuit against opioid manufacturers and distributors in their responsibility for the opioid epidemic. The lawsuit alleged that companies lied about the costs and benefits associated with the opioids and did not flag questionable prescriptions that could have reduced a growing drug trade associated with this prescribing. Like hundreds of other cities and counties filing a similar suit, the community of Evansville is struggling to financially and logistically manage many of the negative consequences that have resulted from this tragic situation.
One of the many ways in which the opioid epidemic is affecting communities relates to increased parental incapacity and subsequent foster care needs. In Florida, between 2012 and 2015, for every 6.7 additional opioid prescriptions written per 100 people, the number of children entering the foster care system due to parental neglect increased by 32 percent. An increase of 129 percent in foster care needs occurred in Florida during this time frame. Nationwide, communities are increasingly struggling with what to do when parents are no longer able to care for their children due to opioid drug addiction.
All of this brings us back to that 1998 decision by the Joint Commission to designate pain as the fifth vital sign. Prior to this, vital signs typically included the following: body temperature, pulse rate, respiration rate and blood pressure (in addition to height and weight). Where pain differs from all of these is that there is no objective measure of pathology. Having worked with a number of individuals who report varying levels of acute and chronic pain, it is clear that what for one person is reported as unbearable is for another quite manageable. Yet as hospitals have increasingly sought to remove pain from even the simplest of procedures (e.g., numbing cream designed to help children not feel injections) and treat it as a symptom to be removed, not a sign to be understood, physicians and hospitals have fallen prey to the notion that they should be ones who take all the pain away.
To be clear, no one (myself included) likes pain, and for some, it is downright brutal and seemingly unfair. The purpose of this article is not to suggest that we shouldn’t provide responsible options for pain relief. But rather, it suggests that we as a culture and medical community are doing almost nothing to help teach people the value of pain and how to best bear and reduce it (naturally) when it does occur.
Years ago, in working at a children’s center in a hospital, I noticed that there was a significant focus on removing all pain for youth as part of a “children’s bill of rights.” Although born out of good intent, I was uncomfortable with the idea that children were being taught that pain was not important to understand and should be eliminated. As the past decade has taught us, these two messages have unfortunately brought about an exponentially greater level of pain and heartache than any initial pain and suffering that might have incurred. Recently, the Southwest Indiana Chamber of Commerce voted on the most important business issue of the year. In an unprecedented move, the normally business-minded membership stepped outside into the “medical domain,” indicating that the opioid crisis was the most important issue facing the business community today. Whether it is parents struggling to care for their kids, or business people struggling to fulfill their work roles, everyone is suffering when we fail to consider how to, well, best handle suffering that will occur.
There have been many good ideas on how to best manage the epidemic. But as parents, it may turn out to be that our role in this is the most important. Early in life, when our children first encounter the inevitability of pain, they will look to us in considering just how they are to manage its discomfort. Do we talk about possible causes, and talk about non-pharmacological means to manage and reduce it best when it occurs? Do we help them understand its usefulness even while acknowledging it is no fun? Do we support them and strengthen them when, unfortunately, it remains? Or do we repeatedly just teach them to treat it immediately and try and make it go away? Obviously, each person and situation deserves an empathetic consideration, and likely a balance of the previous approaches. But when they become adults, maybe instead of asking each person how bad their pain is, maybe we should inquire about how they are doing, and let them decide whether the pain is part of their concern. For people who existed in this world prior to the last 100 years, options for pain relief were limited at best or not present at worst. I can’t imagine incurring an amputation without even a simple local anesthetic to offer or dealing with kidney stones with no pain relief in sight. Today, though, opportunities abound for immediate aid, but potentially carry a long-term price. More than ever, it demands that we all take a broader look at just how we deal, and help others deal, with all types of pain and the motives that underlie it. Fortunately for my friend, his upbringing and approach to life helped him recognize when he was approaching a danger zone. But for many, these roadblocks are not in place, and what started as pain relief may end up leading them down an avenue of broken dreams.
Jim Schroeder is a pediatric psychologist.
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