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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
I’m retired now so can say this without fear of getting fired: Not everyone has testicles. So I don’t think that calibration protocol would work.
Why are there “steps” on both of those lines in about the same places on the X axis? (Although the one on the 3-year line seems to be at slightly lower values of X.) Is it an artifact of the sampling method?
I fled to Saudi Arabia and JCAHO followed me.
Yeah, but they’re still here, too.
@kozak @vicrylcontessa
I was curious if something like the Penthrox inhaler would be useful in emergency rooms as an alternative to narcotics. It is approved in Australia, and seems ideal for the severe trauma.
I’m also curious what the calibration of the pain scale is. Probably the most severe pain I’ve had is a charleyhorse. Holy cow, that’s intense. It’s an immediate stop and wait for the muscle to un-cramp. If someone is having a constant charleyhorse, Lord have mercy, give them the good stuff.
I’ve also had someone pour hot water on my frostbitten hands, and had a chemical burn on my finger rinse with saline. That was some intense burning.
Umm. Probably. Admittedly, my perspective (IT manager) isn’t a clinical one, but I can certainly speak to the redundancy, the overhead, the aggravation, the re-invention of the wheel, the repetitious nonsense, and the exorbitant costs that are in place only because an organization that can’t achieve Joint Commission accreditation can’t stay in business. It’s the medical equivalent of the Middle States in academia. In healthcare, though, you also have the state and the feds interfering, both of whom have equally cumbersome, sometimes (but not quite) overlapping, and frequently even more expensive requirements. Sometimes I think it’s a miracle that there are any resources left to actually care for patients. I’m not sure I can even enumerate the number of agencies, departments, authorities and entities to which we had to report (for example) information which might be indicative of an outbreak of an infectious disease in the area. All of them used a different format, a different protocol, a different (expensive) mechanism. None of them were compatible. But they always reported essentially the same information in duplicate, triplicate, or quadruplicate. Such was my life for decades.
If people who complain about the $10 per aspirin charge actually knew what all the overhead was applied to (at least in decent, caring, non-networked, small-ish community hospitals such as the one I worked at for most of my working life), there’d be a healthcare revolution.
That’s the lens through which I have seen it also.
Indeed.
Reason has the best continuing articles about the opioid crisis. Jacob Sullam is the author. I have had friends commit suicide because they couldn’t get pain relief. They weren’t on opioids. Unless you live with relentless pain every day, it’s hard to know. Those of us who live with it are great at hiding our illnesses. Many of these illnesses and conditions are invisible, but they are there.
Another reason why the pain scale doesn’t work. I have red, yellow, and green days, like stoplights. Today has been a red day. Red: Can’t get out of bed. Yellow: Move with caution. Green: Lower pain day.
I don’t expect the pain to disappear. I just need it to be tolerable.
Do you remember how stellar a parent you were before you had children?
Certainly there are many stellar male OBGYNs. I choose not to go to one. I have used only women for years because I don’t have to explain what is going on.
Don’t most mechanics take on the profession because they love cars?
Maybe these were just poor examples. There are incredible cancer docs who have never suffered themselves, fertility specialists with several offspring, and great special ed teachers with no learning disabilities. That is not the question.
Pain is subjective. I happen to have an extremely high tolerance pain. How do I know? Because doctors, nurses, and other medical professionals have asked me how do I stand the pain. It’s because I do. I’m pretty stoic about the whole deal. So when someone who doesn’t have chronic pain on a daily basis starts in on how I should deal with it, I get more than a wee bit annoyed.
Yes!
Exactly. I have a high tolerance for pain as well. My best and most effective doctors come from places where either they, or someone they love, suffers.
Yep.
Rather a misleading statement. What is the reason for that first day?
And are we to believe that 6% of patients given six tylenol #3’s for a dental extraction will be so hooked after 24 hours as to seek out opioids for a year?
C’mon. I’ve used opioids, I’ve prescribed opioids, this is getting silly.
But, dude!, I need something to fill the void where that tooth used to be. It was my favorite tooth.
It’s how we write pain Rx’s. For a week, or ten days, or two weeks, or three weeks, or a month. It’s completely arbitrary, just how people think.
As someone who would not have survived the 2 and 1/2 years of living with an undiagnosed ailment without a very healthy sized prescription of vicodin, I would say this: I am not willing to set myself on fire so some other person’s family member can survive their addictive tendencies.
The day I found out that my problem was gluten in my diet and that once gluten was eliminated, then the weasel eating away at my belly would leave was the second to the last day of my life I needed that prescription.
No one with broken ribs, or a recently amputated leg should be trying to tough it out without opioids. Nor should cancer patients who need opioids be in that situation.
And believe me, doctors themselves are prescribing themselves these things. Their med cabinets are usually full of the stuff.
We need to stop being a repressive society in the throes of the logical fallacy of “appeal to authority.” And for anyone who thinks this is just about pain meds, this may be coming soon: “Authorities state that there should only be one pregnancy allowed per married couple.”
Oh, yeah.
Edited to add: In celiac disease, the small intestine is torn up by gluten, which if undiagnosed can lead to many other problems since the small intestine is not absorbing vitamins and minerals, including osteoporosis (caused because the body needs calcium and will leach it from the bones if it is not absorbing fresh to use in muscle and nerve reactions), thyroid problems (caused by not absorbing iodine), and many other problems, often showing up in weird places and ways, such as blisters on the skin. And this is how a 45-year-old man gets such brittle bones that he breaks his back by fainting.
Been done elsewhere.
Yes, revenue stream. Funny how the glorious modern day doctors and scientists avoid that word.
Quite a while ago, I did something to my back. I thought the doctor would give me a refill on my vicodin prescription, which had not been used in two years. But instead I was given a prescription for a new drug: Fentanyl.
First big difference was that while vicodin is one of the cheapest drugs out there, with 20 pills available for as little as 10 bucks, these new pain pills actually cost me over $ 400. So I took half the prescription, setting me back $ 200.
Then I went home and the new pills incapacitated me to the point where I could not work. So sitting home watching the TV, the Mucinex monsters on a commercial came through the TV screen and walked around my living room. I was not a boozer or a doper: this was my reaction to Fentanyl.
These days people are given Ativan as a pain med. Read the side effects of vicodin: for those who tolerate the pills, the only problem is constipation and perhaps sleepiness. With the caution that if you have addiction tendencies, vicodin can be addictive. The side effects for Ativan go on for over a page and a half. Chris Cornell, a much loved rock and roller, committed suicide while on Ativan.
But I would have them calibrated. When I smash their nailbed and see them sweat, get tachycardia and their BP shoot up I know their “20” is pure BS.
Protip.
Never ever ever tell a physician your pain is greater than a 10. We tend not to believe anything you say after that.
Ditto telling us you have a “high pain tolerance” Making that statement tells us you have no pain tolerance.
Pretty insulting. I’m sure you have reasons.
I’m also happy that my docs, who actually see me and my MRIs, pay attention to the patient in front of them.
Well, it would seem that you could then help people out a lot by writing six day, 13 day, or 29 day prescriptions. It wouldn’t solve the problem, but it would significantly improve their odds of avoiding addiction.
By the way, thanks for pointing out the meaning of those break points. I hadn’t caught that at all.
Like many people, I am generally not going to go to the doctor unless something is wrong. I get quite annoyed on the rare occasion when a doctor thinks I’m wasting his time.
I once had, as I later learned, laryngeal spasms. Suddenly my throat would close (usually after a laugh or some other such event) and I’d be on my knees gasping for a breath. I learned to not panic and wait and my throat would open up again, but that took awhile. It was pretty scary. The first doctor I went to thought I was a nut and pretty much told me to just go away. We were just starting two weeks in the field and I suspect he thought I was gold bricking. He didn’t know me very well. Later I went to an ENT who correctly diagnosed it and it went away in short order. But I was quite annoyed to be treated like a fool by the first doctor.
If a doctor told me that my pain wasn’t bad enough for him to give me drugs, and I thought differently, I’d be going to find another doctor pronto. I’m sure that would put me on some government watch list. I frankly don’t like pain pills and avoid them as much as possible. But I’m no idiot, and if I’m in pain, I take them. If I can’t trust my doctor, then he’s getting the heave ho.
Yeah. Been there, sort of. I was having sinus troubles and went in to the doc. He gave me three prescriptions. He would have been better off with just the one. It was Claritin, since my real problem was allergies, and then Guaifenesin, and an antibiotic in case I had a real sinus infection. (This was more than twenty years ago.) I reacted badly to the antibiotic. On Thursday, it had built up enough in my system to have side effects. It was what the pharmacy label referred to as “May cause anxiety.” In my case, it was more like causing postal worker syndrome. I caught the weirdness of my thoughts, and remembered reading something on one of the labels. So, I went home from work and read the labels. Decided the antibiotic was the likely culprit and didn’t take the next few doses. Went into work normally on Friday. On Saturday, as an experiment, I tried the antibiotic again. Same reaction.
Some weeks or months later, having another issue, I made another appointment with the doctor, but wound up with his business partner in the clinic. He said he was going to put me on an antibiotic, and I suggested the last one I was prescribed was a bad idea. When I described the problem, the doctor said, “That can’t happen.” I then explained that the reaction had happened, I had confirmed which medication it was through the label, and then reconfirmed the next weekend by trying to restart the medication because I know the scientific method and believe in repeatable results in experimentation. “Oh, they put all sorts of things on those labels, but that can’t happen.”
Giving me a line like that, insulting my honesty and intelligence, he was lucky to get out of the examining room alive.
Good thing you weren’t on that antibiotic at the time!
Indeed. And good thing I grew up watching what trouble a hot temper can cause. I had long tamed my natural instincts before then.
What’s the problem?
if the problem is opioid addiction, we outlaw all opioids and stop writing prescriptions. Done. At least any opioid related deaths can’t be blamed on the med profession
oh wait. Do we have a problem with people who suffer from chronic pain and need help to get through the day? Opioids for all.
Anyone like me who has lived a blessedly pain free life whose mind was changed by Dennis Prager? He wrote about his step children’s father who committed suicide thanks to doctors who wouldn’t prescribe the drugs the poor man needed to get through the day.
We don’t have one problem. We don’t have two. We have as many problems as there are people who are suffering and each and every one of them deserves to be treated by an individual as an individual – not a statistic.
On a personal note, I recently met with a business contact I hadn’t seen in a year – and I didn’t recognize him (weird for me) Turns out he spent weeks in the hospital after a burst appendix. While he was in the hospital he got everything he needed to get through the day.
Then they sent him home. He spent a few weeks begging his girlfriend to get him something – anything. Lucky for him his gf and mom and dad took care of him and got him off the ledge.
Granted I’m a cynic. But it appears obvious to me that it’s a lot easier for docs and nurses to have a hospital patient who’s whacked out and no trouble
Send him home and make him someone else’s problem. Not everyone else has a someone else.
There are plenty of people who were given large doses of morphine in wartime for extended periods who simply stopped using it when no longer needed.
There is no automatic dependency. We are all individuals and should be treated that way.