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‘What Is Your Pain Level?’: The Wrong Question?
I had a fascinating Shabbos guest last week, who is both highly informed and well placed to address the ways in which the government may have caused (and can try to mitigate) the opioid crisis. He said some things that really surprised me.
For example, there were some 220 million prescriptions written last year for opiates/opioids. Almost all addicts start with legitimate prescriptions, and 95% of the drugs consumed are NOT smuggled illegal contraband, but instead started life as a prescription written by a doctor. In other words, the origin of the problem is not illegal drugs per sé. (Overdose cases are often addicts who are “fired” by their doctors and then go to the street in desperation.)
More than this: he claims that the system is rigged to incentivize prescriptions: doctors don’t get paid for calls, so they tend to oversubscribe drugs in the beginning (countless examples of 30-day scrips of Vicodin for wisdom teeth extraction which might really need four to five days). And a minimum of 5%+ of all people who are on an opioid/opiate prescription for 30 days will be addicted by the end of that period. So every prescription that lasts seven or more days is risky – and 30-day prescriptions, statistically, are guaranteed to create addicts.
How can it be fixed? Change the incentives. For starters, compensation formulas within the medical system can be changed so that overprescribing is less common.
Then he moved on to talk about how we have so few options available because we know these drugs work, so it has been hard to get other drug (and non-drug) alternatives developed.
But he also made a fascinating and salient point: people in the hospital are asked, “What is your pain level?” This question is asked as if different kinds of pain are equivalent, as if the drugs are the solution to all pain, and even as if eliminating pain is the primary goal. His argument was different: “We are asking the wrong question,” quoth he.
“Instead of asking ‘What is your pain level?’, we should be asking, ‘what do you need to do that pain makes it hard to do?’” After all, if we have knee pain that prevents the use of stairs, then the solution may well be cortisone or physical therapy – not opioids. The change in focus is on functionality, rather than obsessing on pain itself.
I found all this quite interesting. His numbers may be wrong, for all I know (and I may have misstated what he said, in some ways). But this is a person who is helping to shape the administration’s approach to these problems, and I thought it would be very informative to get the feedback from the Ricochet community.
Does this sound right?
Published in General
His numbers are wrong and his understanding of pain is wrong.
Unless he is a chronic pain patient, he has only cursory knowledge of the problem.
The correct levels of pain are:
I’m okay (Advil will work just fine. Yeah, I hurt. It’s Tuesday but no big deal).
Ain’t nobody got time for this (Opioids to get me through my tasks. I have no illusion I will ever be pain free, I’m just looking for a way to have a life, see friends, do tasks).
Make me unconscious (whatever it takes to put me asleep for a while so I can resume life tomorrow.)
The vast majority of chronic pain patients are not addicted. We don’t take anything 28 out of 30 days. But those 2 days? No emotional high, no pain free moments, just taking the edge off the sword stuck in our back, knee, or shoulder.
For a while, the notion that addicts were unconnected to people and community made lots of sense. I still think it’s part of the problem but it is not the entire problem. Nor am I a whiner. I just suck it up for the most part. The only thing that drives me crazy is when people who don’t hurt want to solve a problem they cannot understand.
The Federal bureaucracy is definitely part of this also. I suffer from a number of autoimmune diseases, some of which bring a lot of pain. Years ago, I was given a prescription for a machine that treats pain. The machine I have is rather high end and does much more than your average TENS unit or even other TENS stimulators. It is FDA approved for two of many functions it has. Maybe six months ago, the company had a notice out to all machine customers because the FDA decided they had not approved all of the attachments that have been used on the machine from day one in the approval process. The company had to send out a notice to all users to either destroy the attachments and report back or to send those particular attachments in. Now, they are finally replacing (for a price) the attachments with a new version of the same attachments made from slightly different materials that the FDA is happy with. The only thing done here, is that for six months, people in pain had to use less convenient and more time consuming methods to use their machines and they have to spend money to replace something they already had.
Although you have to be a doctor or have a prescription to buy these machines, they have a distributor sales network where basically anyone can sign up to sell them. I am still in contact with the person who sold me mine, and was over at her home a few months ago. (I have had this machine and its predecessor for well over a decade, so it has gone through changes.) I saw that she had a demo machine on a table, and it had glowing LEDs that should have indicated it was on, but the screen was not on. I asked if the screen were burned out.
“Oh, no, it’s just not turned on.”
“Then why are the LEDs on?” I asked. Mine only has the LEDs on when it is on.
“To show it’s plugged in. It’s a change the FDA demanded on newer machines.”
To keep their FDA approval, the company is constantly having to jump through hoops. It is a machine. It is not a drug. It is not a food. Yet, the Food and Drug Administration gets to jerk their chains all the time. It costs ridiculous amounts of money to get and keep FDA approval. And this is why so few alternatives to opiates are out there.
Now, since I have this machine, and since certain pain meds actually exacerbate some of those autoimmune diseases, I tend not to be into taking pills. It also helps that I have had so many adverse reactions to medications in the past. Also, many drugs do not work right on me for whatever reasons. Alcohol does nothing for me. Caffeine is a relaxant. I could go on, but the short version is that I don’t trust drugs.
About ten or eleven years ago, due to a side effect of one of the autoimmune diseases, I broke my back through fainting and falling to the floor. I was in the hospital from Saturday through Thursday, and although they were dosing me up with Cod only knows what, I also had and was using my machine in the hospital. It’s an approved medical device, after all. When I left the hospital, the doctor gave three prescriptions. One was for a massive vitamin D pill to help strengthen the bones. One was an opioid pain reliever, a 30-day, 60-pill prescription. The last was for something to treat a side effect of the opioid. Had I known about these prescriptions, I only would have filled the vitamin D prescription, but my wife went ahead and filled them without consulting me.
I used the pain reliever that next day, Friday. I decided I didn’t need it, didn’t want it, and it was causing too many side effects and too much trouble, so I stopped taking it. I had my machine to help the pain, I didn’t need the pills. Next doctor visit, I took the bottle with:
“I’m not using these. How do I get rid of them?”
The doctor said, “Keep them. You’ll have bad days.”
“No, doctor, I won’t. How do I dispose of them?”
He had no answers for me. I brought them again at our last appointment. Still with 58 pills. He still suggested I keep them.
I finally had to contact my brother who was a policeman and former narcotics detective to find out how to get rid of them. What a waste of money.
‘Pain management’ is a primary goal (we were explicitly told this for years), which is why every doctor’s office sick visit includes a question in which one is forced to identify, on a scale of 1-10, or by circling an emoji-face veering from smiley to screamy (for those who can’t read yet), what the pain is right now, as one sits in the exam room explaining one’s symptoms.
I’m pretty determined in those situations, and rarely give a straightforward answer. If the doctor can’t see I’m writhing in pain (as I was at Thanksgiving, when something in my back pinged, and it gave out), or that I’m perfectly coherent and complaining of a dull, low-level muscular ache that won’t go away, and he or she isn’t willing to treat me accordingly, without the little circle round the face, or the “X” in the box, then perhaps he or she shouldn’t be practicing medicine. I don’t think so much that it’s the ‘wrong’ question, because we should be talking about pain, but I think the determination to objectify it to a number, as if all sorts of “3” pain, or “6” pain are the same, is wrong. (There’s also an incentive (at least I think there is), to ramp up the answer, which is always “what is your pain level right now?” Actually, at Thanksgiving, once the nice lady had picked the whimpering me up off the floor in the building lobby, put me in a wheelchair and propelled me upstairs, wasn’t all that bad. Standing up and walking, though, was excruciatingly, impossibly, off-the-charts, painful. So, rather than saying “right now, sitting down, it’s a four or a five, but I can’t stand up or even try to walk” I said, “watch this,” and stood up. (My pain tolerance is rather high, which is another thing the current system doesn’t account for.) In that instance, I did end up with a (short) course of Percoset which did wonders. (So I think I am agreeing with @iwe’s friend that “functionality” should be discussed, rather than just pain level.)
Of course, what they want to do is reduce the pain level on a quantifiable scale for patient satisfaction reasons. Pain, like long waits in the emergency room, is a key indicator of patient misery. They want to reduce or ameliorate both of them as quickly as possible, and send one home and feeling better. Alleviating pain is one of the fastest route to that end.
So, yes, I think the question is asked the wrong way, and that too much reliance is placed on an objective number and taking the patient’s word, rather than actual evidence. I think many people think that any pain is too much pain, and that one person’s “10” is another persons “2” or “3.” That makes the scale meaningless. If the doctor doesn’t know one well, I’m not sure how he’s supposed to know the difference without basing his treatment on actual evidence (which is what he should be doing anyway).
I also think a lot of people won’t challenge their doctors, or argue, or keep making the case, whatever it is, as much as I do. 25 years of working in hospitals probably has something to do with a willingness to do that.
I’m not surprised that a significant number of addiction problems start with legal prescriptions. (I suppose one could say that a significant number of alcohol addictions start with legal purchases, too.) My doctors are chary of more than 2-3 days of opiate prescriptions. My endodontist prescribes the stuff like candy (I’m a frequent flyer (but not in the drug sense) on the root-canal and gum surgery front).
@she, you have it 100% right. This pain question is all part of our satisfaction scores and if we don’t get great scores our compensation can suffer. It’s convoluted. It’s government. Go figure. I hardly ever ask this question. I’ve been nursing for 30 years. If I can’t figure out your pain level in the first 30 minutes I have you as my patient (I get folks ready for surgery), then I need to retire. I love hearing my coworkers ask this question. The patients never know how to answer. Some people will tell you they are an “8” and be laughing with their family like they are at a party. I’m sorry, that’s not an 8. What’s even better is the reassessment that must take place if someone is given meds. Now this will really get us docked if it isn’t done and if the patient doesn’t get relief down to a 3 or 4 (I believe). I could go on, but you get the idea.
The fight against “pain” has certainly become a major pillar of US medical practice, and I think this is in no small part because dealing with pain is certainly something we can actually do easily through opioids. But, also relieving people’s pain is maybe the most basic of human instincts when it comes to medicine. We don’t like to see people suffer especially when you know that there are effective ways to stop it (at least in the short term). Of course pain itself shouldn’t be underestimated as a medical problem, chronic pain increases stress and can greatly impact a persons life and well being. All things being equal it is better to not be in pain than to be in pain. Ultimately I think you can only nibble around the edges of this problem, because ultimate responsibility to avoid abusing drugs lies with the patient. They should have the greatest incentive not to become a junkie, and you can’t just have doctors holding their hand all the time monitoring their drug intakes.
This letter to the editor to JAMA in Jan 1980 was the start of the problem…
TO THE EDITOR
Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients1 who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients,2Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.
Jane Porter
Hershel Jick, M.D.
Boston Collaborative Drug Surveillance Program Boston University Medical Center, Waltham, MA 02154
This article in the Atlantic
The One-Paragraph Letter From 1980 That Fueled the Opioid Crisis
explains how we got from there to here.
Those of us on the front lines, in the ER’s knew this was going to lead to trouble. When CMS and JCAHO started putting the screws to us to “adequately treat pain”, and forced us to use that idiotic “what is your pain on a scale from 1-10”. Ignore the fact that the patient has no physiologic response to his 10/10 pain. Ignore the fact the patient is smiling, joking, texting etc. It’s like the idiocy of the “believe every woman”. Right. No one is manipulative, deceptive, pathologic has ulterior motives or secondary gain. Combine that with a marketing campaign by the drug companies to ensure us that prescribing their new extended release opiates was safe. Add the “customer service” model of medicine. I no longer have patients, I have “customers”. You know the basic difference between a patient and a customer?
Patients are supposed to get what they need. Customers get what they want.
JCAHO tracks us and woe be to the doctor and hospital that doesn’t get his patients pain scores down. Press Ganey tracks us for “patient satisfaction”, and it affects getting and keeping a job as well as pay and bonuses. Don’t give that patient a narcotic and guess what happens to your satisfaction score. Get a patient complaint and you are in the same situation. The complaints are never “the doctor didn’t give me the oxy 80’s I wanted”. It’s the doctor was rude, or unfeeling, or racist, or sexist etc etc. Doesn’t matter if the complaint letter is written in crayon and is clearly the product of a disturbed individual.
One day I got 3 letters from the State Medical board telling me I had 3 separate complaints. In my 30 year career I have never had a complaint to a state board. The letter said I must respond, might be called to appear before the board and could lose my license. To be continued.
Continued.
The letters were from a woman, her husband and a second woman who was their friend. All accused me of mistreating them. My mistreatment consisted of not giving them the narcotics they wanted although they never stated that so bluntly. My response to the medical board was to point out some interesting facts about the letters. That all three were in the same handwriting which i pointed out to the board. The husband did indeed sign his letter. The friends letter had a forged signature ( I used the patients signature from the hospital forms to prove this). The husband had chronic back pain. The wife had chronic foot pain. The friend had chest pain, and I did a complete ER workup for chest pain. I did nothing wrong or unprofessional. Yet my livelihood was threatened by these drug seekers, who knew exactly what button to push to cause me the maximum pain. I sent my response to the board and had the pleasure of receiving 3 “never mind letters” in the mail one day. Interestingly enough the husband and wife had the balls to come back to our ER. I had no choice but to treat them thanks to EMTALA. I made sure that a nurse was present for the entire patient interaction with both the husband and wife so I would have a witness.
So after a couple of decades of this kind of pressure, that amounted to a gun to our heads to prescribe narcotics, we have an epidemic of addiction. Surprise. And now the pendulum has swung to the other side, and we are being pressured to not prescribe narcotics at all. Fortunately, I never did write more than a handful of Oxycontin scripts and those for terminal cancer patients. I have always limited my prescribing to less than 20 Vicodin or Percocet, typically 12. I continue to do this for those I feel have legitimate acute pain issues.
One more thing. There is a lawsuit by several cities suing JCAHO for helping to create the addiction epidemic…
Four West Virginia Cities Sue The Joint Commission
The Pain Scale is of no use as there is no standard. What is an “8” for you may be a “5” for someone else. Maybe at age 16 we could lead everyone into the torture chamber and set baselines. “Here’s a jumper cable clamp to the testicles. That’s a seven. Do you think you can remember that?”
Writing script is part of the assembly line medicine we have today. We treat symptoms, we tackle illnesses, we don’t treat patients. They are just the vessel the diseases and the pain are carried in.
There’s another often overlooked issue with the problem of opiates in the community: early releases from hospitals after surgeries. And outpatient care generally.
Everyone got what they wanted when these practices came about years ago–getting people out of the hospital as quickly as possible. The savings were so dramatic that the change to treating people at home was equally dramatic. :-)
But it created many side effects. Hospitals and doctors didn’t want their surgical and acute care patients to wake up in the middle of the night in wracking pain with no painkillers. These patients were not able to get to the drug store, if there were even any that were open at odd hours such as holidays and through the night. For example, there’s only one drug store open all night in twenty-mile radius from my house on rural Cape Cod to this day.
A lot of people should be receiving more skilled-nursing care than is currently possible.
I think the opiates problem is very complicated. The government keeps trying to stab at it with a single solution when we need to look at the entire picture for everyone involved.
Do we really believe this? Is this like saying that only women can be OBGYNs or only car-owners can be mechanics?
Yeah. I used to joke we needed to “calibrate” the scale for patients. Take their thumbnail and apply 5 psi to it with a pair of pliers, “Thats a 5, now what is your pain again?”
Oh. That’s a five? In that case, about a twenty.
Bravo. Couldn’t happen to a nicer bunch.
Does everyone who has ever worked in healthcare feel that way?
I knew I had read this recently:
“For starters, among people who are prescribed opioids by doctors, the rate of addiction is low. According to a 2016 national survey conducted by the Substance Abuse and Mental Health Services Administration, 87.1 million U.S. adults used a prescription opioid—whether prescribed directly by a physician or obtained illegally—sometime during the previous year. Only 1.6 million of them, or about 2 percent, developed a “pain reliever use disorder,” which includes behaviors ranging from overuse to overt addiction. Among patients with intractable, noncancer pain—for example, neurological disorders or musculoskeletal or inflammatory conditions—a review of international medical research by the Cochrane Library, a highly regarded database of systemic clinical reviews, found that treatment with long-term, high-dose opioids produced addiction rates of less than 1 percent. Another team found that abuse and addiction rates within 18 months after the start of treatment ranged from 0.12 percent to 6.1 percent in a database of half a million patients. A 2016 report in the New England Journal of Medicineconcluded that in multiple published studies, rates of “carefully diagnosed” addiction to opioid medication averaged less than 8 percent. In a study several years ago, a research team purposely excluded chronic-pain patients with prior drug abuse and addiction from their data, and found that only 0.19 percent of the patients developed abuse and addiction to opioids.”
https://www.politico.com/magazine/story/2018/02/21/the-myth-of-the-roots-of-the-opioid-crisis-217034
I’m not disagreeing about the facts of individual’s own issues, but rather the statement you made that “Almost all addicts start with legitimate prescriptions”. I’m assuming that to have meant prescriptions properly assigned to the user.
I say I am allergic to opiates, but that may be wrong, what happens is the drug triggers a massive migraine headache that can last to a day or more. Usually the headache is worse than any pain I am having. A ten+ pain is having a double radical subcutaneous mastectomy, given an opioid, vomiting your guts out standing blind from the headache over a john. And you just got home from the hospital and are alone. I know of nothing that will counteract morphine.
Other 10+ pains I’ve had are a “strike” in the occipital nerve behind my ear but 10 minutes later it is gone. So I’ve given up pain medications altogether. Rare occasions one Motrin. Surface pains I use the salve from a compound pharmacy that Doc Jay suggested.
As a percentage of total usage or even total population of the US, this might seem like a small number, but think about 1,600,000 individuals overusing or abusing opioids.
I have been very calm about the opiate crisis in and of itself. I can’t help seeing it as a psychiatric issue rather than simply a drug issue. However, last week I saw an upsetting article in the local paper, the Cape Cod Times, which stated that there were 71 “opiate-related deaths” on Cape Cod in 2018:.
Over the thirty years I’ve lived here, I’ve always known we have had a serious drug and alcohol problem. The drugs are easily brought ashore from boats. That’s one problem. And we have a depression issue here during the quiet winter months.
But Cape Cod is also an almost idyllic place to live. It’s a little bit of heaven here. (I’ve always told my kids that the good Lord is going to keep me purgatory for a long time to make up for the perfection of my life here! :-) ) The weather is gorgeous most of the time, the people are nice, and according to the state of Massachusetts, there are a thousand nonprofits on this peninsula. It’s a place where people still care about their neighbors. And there are doctors and nurses and social workers and all kinds counselors and clinics for whatever problems people have. Hundreds of small functioning churches here. There’s abundant nonjudgmental help here for the asking.
Seventy-one deaths here in one year? When the economy is racing along? When there’s hope everywhere I look in new businesses and new homes?
I cannot fathom so many people dying from such a preventable cause. Not here. I can’t explain it. It makes me very sad.
Sure. But figuring out how to solve it means applying resources to the correct source of the problem. As the linked article said, the notion that the root of the problem nationwide is properly prescribed prescription painkillers is ubiquitous.
Agreed.
See here.
This suggests the initial prescriptions definitely play a role….
The odds of long-term opioid use increased most sharply in the first days of therapy, particularly after five days of taking the drugs. The rate of long-term opioid use increased to about 13 percent for patients who first took the drugs for eight days or more, according to the report.
“Awareness among prescribers, pharmacists and persons managing pharmacy benefits that authorization of a second opioid prescription doubles the risk for opioid use one year later might deter overprescribing of opioids,” said senior researcher Martin Bradley. He is from the division of pharmaceutical evaluation and policy at the University of Arkansas for Medical Sciences.
“The chances of long-term opioid use, use that lasts one year or more, start increasing with each additional day supplied, starting after the third day, and increase substantially after someone is prescribed five or more days, and especially after someone is prescribed one month of opioid therapy,” Bradley said.
link
I wonder if the FDA could handle these thing more expeditiously (in those cases where it’s the FDA’s business to handle them) if it had half the budget and half the number of employees.
I don’t have fancy graphs but I am extremely skeptical of the claims that you present here.
I don’t trust “scientists” much anymore, and if the claims seem outlandish, as these do here, I am inclined to suspect they are wrong.
Why would they want to? Most of the folks in the FDA have either come from or will go to drug companies. These machines are one-time sales, generally speaking. Drugs are a revenue stream. Connect the dots.