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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
Agreed.
Learned something from my mother. I’ve used it and passed it on to my daughter and all her peers.
Don’t ever, ever tell your doctor what’s wrong with you. He will reflexively diagnose you with something else. (I won’t bore you to tears about a years long struggle with a parasite that I made the mistake of googling myself and diagnosing. I literally had to change docs to get the treatment I needed)
And when you’re the mother of a newborn and your doc is advising : breastfeeding, not breastfeeding, waking the baby up to get him on a “schedule”, supplementing with bottles, blah blah blah, smile and nod and thank the good doctor for his advice
Then go home and call your mom or your auntie.
Doctors are a blessing and we should be grateful But like good husbands … they need to be managed
I once had a doctor, a woman with an “MD” after her name, tell me that putting Vick’s vapo rub on the bottom of my child’s feet was a cure for the cold or some such malady. I didn’t go back to her. I think I was probably a bit blunt in my response to her as well.
And then there was the woman teaching the birthing classes (a complete waste of time, as was most of the advice anyone ever gave concerning child birth) that kept trying to push “recipes” for the placenta. Doctors and medical people are usually very good, but as in every field, there are odd balls too.
I have very fond memories of the woman who taught our birthing classes (32 years ago ) but I swear I was only one listening. Three births drug free and many happy post partum months thanks to her giod advice
I was once telling my doctor what was wrong with me when he interrupted me and quietly asked, “Would you like me to confirm your diagnosis?” He was a good ‘un, but discontinued his private practice during the Great Obamacare Consolidations, with the result that I went a couple of years without a primary physician.
I didn’t say people don’t have a high pain tolerance. I’ve seen lots of them. It’s just that they don’t make a point of announcing it.
The oddest example of self-diagnosis I’ve ever experienced came when I woke up with excruciating pain on my back. It didn’t matter if I moved or lay still, it was agonizing, and I had no idea what it was. I’d been dreaming about being up a ladder and nailing a new roof on the house.
Mr. She bundled me (gently) into the car, and drove me to the Emergency Room. On the way there, I put two and two together, and realized that my dream about “shingling” the roof was somehow related to “shingles” on my back.
There are some benefits to working for decades at the small local hospital where you’re being treated–one of them is that you’ve known many of the doctors since they were still wet behind the ears–when I arrived in the exam room and announced, “I have shingles,” the doctor took me at my word, took one look at my back and concurred with my diagnosis.
That was in 1994. Twenty-five years later, I still get periodic bouts of postherpetic neuralgia across the nerve path involved. It feels as if there are hundreds of little ants crawling along it, underneath my skin. Shingles is/are nasty.
That is very interesting.
People react to pain in a variety of ways. Some people mask their pain very well and others cry out in pain because its expected.
I’ve had back problems that had me crawling on my knees to get in the car to go see a doctor (I used percocet to stretch these out) and I’ve calmly and quietly, with out tears, informed my mother my arm was broken and I needed to see a doctor.
I actually kept pegging lower on the pain scale while I was in labor. Because that’s not how labor works, they gave me drugs to increase my pain.
I understand the need for the pain scale.
Actually he may fall right down the “confirmation” bias hole. This is where we lock into a diagnosis early on and just look for things to confirm it. “This is my migraine headache”. So we focus on that and don’t get the history or skip something on the exam that would have tipped us to the fact this time it’s a subarachnoid hemorrhage.
For a good doctor it’s not being obstinate or contrary, it’s trying to actually get to a correct diagnosis.
I understand the need for, and the value of, talking about pain as it relates to one’s condition. I don’t think anyone is suggesting there isn’t one.
But having three hundred million individuals using a scale which objectifies pain on a scale of 1-10, with no common point of reference, or any sort of definable baseline, strikes me as not terribly helpful for reasons given by several folks above. Further objectifying pain as the “fifth vital sign” (see JCAHO) isn’t helpful either, as it’s quite different from the other four (temperature, pulse, respiration, blood pressure), all of which can be measured in discrete and consistent units, whereas the reporting of pain levels, as you point out, may be underreported, exaggerated, masked or delivered according to expectation.
It might be better to allow a patient’s experience of pain to emerge from his narrative of his symptoms and condition, or via the evidence that presents itself in the clinical encounter, rather than requiring a single-digit data point which is, IMHO, essentially meaningless. That’s my point.
Just a heads up, y’all: Never, ever, EVER put @ejhill in charge of “pain standardization testing.”
That has been my experience too. I’ve had to teach myself not to even make jokes with doctors about what I think the problem is, either for me or someone I’m accompanying.
You have all sent my mind wandering back to some great doctors I’ve known. One of my favorite guys was the ER doctor at Cape Cod Hospital who used to wear a Red Sox hat and shirt. There was no child so scared who did not smile and feel better at the sight of this doctor. It was really cute. :-)
Except for the Yankee fan on vacation in Cape Cod…
I disagree to some extent. I came close to dying having my first child. The second child was just about pain free. A couple of bear down contractions, maybe on the scale of 3 or 4, and she was here. 7 hrs of labor scale of 2? then boom, here she was.
I think at times it depend on the doctor. I had no prenatal care for the 1st child or they would have discovered there would be complications.
2nd child I had a doctor who believed having a baby should be pain free or at least not really uncomfortable. I followed his suggestions like a religion, and indeed had no problems and very little pain.
Right. Can’t emphasize this enough. The trend is to increasingly base reimbursement, pay, etc. on patient satisfaction. This is a big hole in the effort to get the opiate crisis under control.
Agree. And, as a healthcare consumer in my own right, I want to be treated well, and be “delighted” with the provision of healthcare services which I always hope will “exceed my expectations.”
As an employee of the genre, though, I’ve think I’ve lived through every damn “process improvement,” “quality management,” quality improvement,” “management process” that’s ever been devised. And as an IT person, I’ve too often found myself in the middle, circling the drain, trying to send this, or that, entity the same information in a different format, for different time periods, in order to achieve some sort of compliance. So. Much. Money. Wasted. You. Can’t. Even.
I’ve mentioned Dr. Large many times before on this site. When we moved into the sticks, almost 35 years ago, our closest little town was bounded by “Marshall Little, DDS” on the one end, and about three short blocks later, “Fred Large, MD” on the other. About ten years after we moved here, and as Dr. Large was retiring, the hospital I worked for acquired his practice, and in a move that (I believe) it never repeated, it also bought his accounts receivable.
We had a marvelous time trying to balance the accounts, which were largely (pun intended, I guess) made up of honey, chickens, bacon, eggs, and various other agricultural motifs.
You see, Fred Large charged what his patients, and the local market could bear. And I’m guessing that Gallup, or Press Gainy, or whoever the hell might have bothered to ask (except nobody did), would have found that his patients were all “very satisfied” with his treatment of them. He’s still a legend around here.
I’m surprised no enterprising lawyers haven’t seized on this and gone after the employers/ insurers for this.
“Doctor X over prescribed narcotics because he had a financial incentive to do so in getting increased reimbursement from his employer/the insurance company.”
I wonder if you get ‘extra credit” and a chance of getting pain meds if this happens to you:
https://www.cbsnews.com/news/hospital-errors-lead-to-dead-patient-opening-eyes-during-organ-harvesting/?fbclid=IwAR2arcIzJBASENvivXhHHpdMgwdHbQ7UOBljzwQbTGfbh0eSOGj0E1QFL7I
wow. That is truly horrifying.
Oh, like you need all your lungs.
I like this guy. Large and in charge.
I have a tremendous respect for doctors, nurses, and so on. The problem is that patients lie to their doctors. I do too; I’m always forgetting a relevant detail, or I’m embarrassed to admit to something (even though I’m well aware that that’s a stupid attitude to take). As such I’m inclined to be charitable when doctors assume I’m lying to them in everything, even when it’s condescending.
I do wish doctors had a little more humility. And occasionally that water wasn’t so wet.
@iwe
BTW one of the reason there are so many prescriptions for opioids is that due to the stringent regulations, especially here in Calif, and other places, a patient no longer gets 100 pills to stretch out for six months.
Now you only get ten pills, so if you really need to have more than that, you need to re-visit the doctor and then get 10 more. So what used to be one prescription could now become ten prescriptions! Then the experts on this crisis can point to the increasing prescription rate and say, “We need to be even more stringent!”
With any luck, should the Dems get in, or this new breed of Republican that likes having the government weigh in on decisions that only doctors should weigh in, we can surely expand the DEA to include an entire department that makes sure no one is ever getting more than half a pill at a time.
You mean kind of like having to show your driver’s license and beg for pseudoephedrine at the drugstore? And somehow the meth just keeps getting made.
I guess it is just very very hard for the cops to figure out where the meth labs are hidden. While my county, circa 2012 to 2016, undertook police raids that indicated total vigilance on their part, so medicinal cannabis users who planted five plants too many came home from a day’s outing to find their dogs shot or run off, their crop confiscated, and their fences torn down, not a single meth lab was uncovered during the same time.
Given that the police had the ability to plea bargain down any speed freak who was arrested, and get from them the names of who sold what to whom, this is rather surprising.
But hey, in the end those people whose rights had been violated received very large court settlements, that took about 1.5 mil bucks out of the budget of this tiny impoverished county. So why should any of us complain?
I say this in all seriousness. There are many small counties where the meth lab owners and distributors have great influence over the police and judicial entities of that county. It’s easy to control a small county. Larger counties are a bit harder to control; Not for lack of willingness by the counties, but from the number of people that need to be involved.
I have chronic migraines and a rare bone disease. I had a 23 lb. ovarian tumor two years ago that I basically ignored because I just thought I was getting fat. (My mother was dying and I was in “ain’t got time for that” mode.) I asked my oncologist if I still hold the hospital record for the biggest mass and he said I am still champion – yay!
I have no idea what those pain numbers mean anymore. I try to explain it this way: I put the pain in a mental box in my head, and try to proceed as best I can until I need to lay down.
I have a physical therapist who specializes in vestibular issues, and she asks me about my pain at each visit.
“How are you today, Lucy?”
“Pain wise? Maybe a 3-4 for baseline.”
“So that’s a 7-8 for everyone else.”
“Really? Who knows anymore?”
Drugs don’t help my pain much, either. The migraines have turned my brain into one that has been concussed. Words escape me a lot and I get confused and frustrated.
All of this is to say I completely understand how people get addicted BUT there are lots of folks with chronic pain who regulate their meds and are suffering more because of the restrictions on opiods. I have a friend who saves her annual dose of 14-day steriods so she can go on vacation with her family and for emergencies. THAT SUCKS. I needed muscle relaxers because I broke my leg and post op I had awful leg cramps. One refill. I resorted to foregoing pain meds so I could have booze to get to sleep.
Complex issue, no simple fixes. Then throw in mental health issues and it’s a real mess to clean up. Sigh. Anyway, thanks for listening.
Lucy
Most of the meth in the US now is smuggled in from Mexico and is not the home brew stuff of past decades. Lot of it comes over on the backs of illegals paid to be drug mules.
You have my sympathy. I love the pain chart! It’s very accurate. I don’t drink so that’s not an option for me.