Pain Control and the Law of Unintended Consequences

While medicine can carry an aura of nearly miraculous treatments in the minds of many of our patients, we know that there is not much we can really do to alter the disease processes for many of our patients. Relieving patients from acute pain is one of the greatest gifts physicians and nurses can offer. 

Driving home, I’ll reflect that the relief in the eyes of a pain free renal colic patient or the smile of someone with a dental abscess after a nerve block was the most satisfying part of my day. These moments stand in stark contrast to the interactions I have with patients whose complaints center around chronic pain. We know them well by many names… seekers, frequent flyers, chronics. Admittedly, I do not enjoy picking up these charts because there is little chance that anyone will be leaving the ER with a smile afterwards.

Where does my angst come from? Why do I care? After all, these patients aren’t in real pain. They’re just trying to get high. They’re not really sick. Plus, the nurses will get on my case if I write for narcotics. Do I feel like bargaining, negotiating, or fighting today? But what if they’re not happy? What if my satisfaction numbers go down? What if they sue because I refused to treat their pain? This dichotomy creates internal conflict in deciding how to confront chronic pain patients. There is no doubt that we are seeing an increase in prescription opioid abuse. It is a true epidemic. One colleague stated that, “I have no doubt that we [emergency physicians] are the true cause for drug abuse in the United States.” Wow! That’s quite an indictment and one we should reflect upon.

The CDC recently reported that there were 27,000 deaths in 2007 from prescription drug overdoses, a five-fold since 1990¹. Deaths from opioid overdose now exceed those of cocaine and heroin. Drug overdoses, in general, are killing more people than suicide, homicide or firearms, and are close to killing as many people as motor vehicle crashes. I once had a recovering addict tell me to never prescribe opioids to young people because of their addictive potential. Is this realistic or fair? Should I not give morphine to a patient with acute appendicitis because they could get addicted? No, but this is a serious public health topic and it is relevant to emergency medicine because we see these patients. We see them when they attempt to gain access to their drugs of choice and we see them when they overdose.

Now the CDC is convening meetings and President Obama has placed prescription opioid abuse as one of his top priorities on his healthcare agenda. Yet, government policy may be partly to blame for our current situation. How did we get here? Why the increase in abuse of prescription opioids? The reasons are likely multi-faceted. The HIV epidemic pushed people away from intravenous drug use.

Development of potent opioids like fentanyl and oxycontin created a market. And the fact that these medications are “prescribed” at some point lends an heir of legitimacy. Finally, the number of prescriptions for opioids has skyrocketed in response to public demand for improved pain control by physicians. In 1999, the VA stated that pain measurement and treatment should be the fifth vital sign and that prompt pain management was a quality care standard. We are pressured daily by hospital administrators to treat pain effectively because pain management is viewed by physician groups, insurers and governmental regulatory agencies as important.

Soon physicians started treating pain aggressively, and patients realized that just by saying “eight” they could get that medicine “that begins with D”. Just like the four-hour rule for pneumonia, lead us to giving every cough a Z-pack, blanket statements from large regulatory agencies often lead to unintended consequences. Medicine can not be practiced wholesale and physicians inherently resist being told what to do. I think our collective reaction is often, “Fine. You want to tell me what to do. Then, I’ll just stop thinking and do what you say…right or wrong”. This is certainly an easier alternative to fighting or patients, bosses and Capitol Hill in order to do the right thing.

So what is the right thing? Well, as always, it is the hardest option. Treating pain first requires us to seek the cause and classifying pain as acute or chronic. Acute pain should be treated as we traditionally do. Most evidence points that acute pain in the ED can be effectively managed with 0.1mg/kg of morphine (or equivalent doses of other opioids) with frequent re-assessment and titration². Patients presenting with chronic pain, however, present a dilemma. First, we must overcome the stigma associated with these patients, and the barriers to communication that exist. Often, these patients moan, act out or become aggressive in regards to treatment for pain. These acts often result from fear of not being treated, so patients display those behaviors which they feel will result in treatment of their pain³. Often, clear communication to let the patient know that you believe them and will try to alleviate their pain can defuse a patient who is “acting out”.

Next, we have to determine if a patient with chronic pain is presenting out of dependence or addiction. I ask myself, “Will administering or prescribing opioids help this person improve their daily function or contribute to self-destructive behavior?”

This is tough. Many “red flags” we look for to identify misuse of opioids like presenting to multiple ED’s, inconsistent histories, and manipulative behavior can easily be due to under-treatment of chronic pain, or pseudo-addiction, coupled with poor access to primary care and chronic pain clinics. Chronic pain patients also develop tolerance and physical dependence to opioids that do not arise from addiction⁴.

Certainly, self-imposed increases in doses of opioids and demanding brand name opioids are also “red flags”; however, there is no behavior that absolutely distinguishes an addict from a patient suffering relief from chronic pain. Yet, kids are dying out there. They are getting sold drugs from people who got prescriptions from us or they are getting prescriptions directly from us. Now the total number of opioid prescriptions from EDs is dwarfed by those from primary care clinics or pain clinics (both legitimate and illegitimate) but we can not turn a blind eye to the epidemic occurring in front of us, and yet we should not ignore treating our patients appropriately whether their pain is acute or chronic.

No absolute rule or blanket statement will fix this problem. I am sure that another governmental taskforce is not the answer and may lead to more unintended consequences. The answer, as always, lies in finding balance. It takes a thoughtful clinician establishing a relationship with their patient and working with them to solve their problems. If you think a patient needs treatment for a chronic painful condition, then work with them to achieve manageable pain control…no matter what their grumbling nurse may mutter. If you think a patient is addicted to or diverting opioids, be honest with them, offer treatment, and withhold opioids…no matter they may say on your physician survey.

 _{¹ “Health, United States: 2010” U.S. department of Health & Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics ² Hein A. “Focus On: Effective Acute Pain Management” ACEP News. October 2005. ³ McCaffery M. “On the Meaning of “Drug Seeking”: Discussion” Pain Manage Nurs. 2005; 6(4): 122-136. ⁴ “A Balanced Approach to Chronic Pain Management: Distinguishing Addiction and Diversion From Ambiguous Behaviors” Medscape Neurology and Neurosurgery. 2006;8(1) 2006 Medscape}