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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
With enough pain, drinking becomes an option. About every thing does.
Not if alcohol doesn’t affect you in normal ways.
If it stops or decreases the pain or your conscious recognition of it, then it is. If it can distract you from it, even for a small bit of time then it is.
I don’t drink for personal and religious reasons. I’m a member of the Church of Jesus Christ of Latter Day Saints (Mormon).
I quite disagree. As a Doc, I have learned that if a patient believes she has a problem, you must rule it out. If a patient says, “I had XYZ before, and I think I have it again”, believe her and rule it out.
As a senior medical student I consulted on the Infectious Disease service to the Emergency Room. A man there claimed to have malaria. He had had malaria before, and now he knew he had it again. Fevers and sweats every three days, pissing blood, the whole shebang. Three days earlier he went to another ER which dismissed him as having a virus, gave him Tylenol. We believe him, admitted him, found the Plasmodia in his blood smear, gave him chloroquine and made him better.
If you ask enough questions of almost any patient, she will tell you her diagnosis. You just have to be skillful in probing.
Now if I could just find a doctor like you in my local area, I would be in seventh heaven. (I had a wonderful doctor two years ago, but his clinic’s directors felt he spent too much time with each patient, and he was given his walking papers.)
I don’t doubt you for one minute, Doc. Let me just say this has not been my experience, nor the experience of anyone I know. What is this “probing” of which you speak?
Not only did I have trouble getting a diagnosis with my first bout with the parasite, when I exhibited the same symptoms two years later, my doctor said it was impossible and refused to give me the prescription I needed. I had to wait 7-10 days for the test results; by that time I had lost 15 lbs and looked like the walking dead.
How does one get these parasites?
Right? My brother had the same problem a few years later and we joked that we could bottle it and call it the “High Sierra Diet” and make a fortune.
Joking aside, it wasn’t worth it.
Well, I’m in western Massachusetts. But I practice reproductive endocrinology & gynecology, so unless your problem is in one of those realms, I’m sorry but I can’t help you.
Asking the right followup question, looking at the patient’s reaction, going to the next step. Belly/pelvic pain is a good example. This can have innumerable causes. As the patient gives you a description, one asks where it begins, what makes it happen, what you are doing when it happens, how it affects bowel and bladder, etc. “What does it feel like” is really important. Ask the patient to depict the pain with her hands. The cramping of a viscus versus the stretching of a ligament will often be clearly differentiated with this trick.
Eventually one gets the right organ system (gyn, urologic, vascular, intestinal, neurologic, musculoskeletal) and then can hone in on a diagnosis using physical exam and imaging. Imaging is of great importance but should take second place to questioning and exam.
This all takes time. One needs half hour appointments to give this kind of care. That’s why no one ever experiences a Doc doing this.
In a busy ER, someone with belly pain needs a diagnosis promptly to rule out lethal conditions, so the Docs there must limit this. They must resort to more testing and imaging and sooner. This is a feature, not a flaw. Patients with appendicitis or a bleeding ulcer don’t have time for my probing questions.
The best Doc visit I ever had was in December 2006 when I went to a big hospital in Boston for a second opinion on my first cancer therapy. The oncology fellow spent more than 40 minutes taking a detailed history and doing a very very thorough exam. Then he disappeared, presenting to his attending, and they re-entered and spent a half hour talking to me. The attending was Glenn Bubley, if you ever need cancer care in Boston, give him a call.
The worst Doc visit I ever had was the Wednesday after Labor Day 2016. I went to my PCP in an add-on appointment at 0800 with pneumonia. He spent 7 minutes with me, confirming the diagnosis with a chest Xray but declining to take the time to answer the three questions I had written down.