Over the past 15-20 years, it is estimated that the chronic pain incidence has doubled. In 2012, it was reported that chronic pain affects more than 100 million Americans or approximately 1 in 4 Americans1. Recently the book, Dreamland, written by Sam Quinones was discussed in Tim Flynn’s post, Oxy Death- It Requires Action by Each of Us. Dreamland is a fascinating read about Mexican black tar heroine and the American opioid epidemic. One aspect of this book I found particularly interesting (and somewhat nauseating) is the role medicine and Pharma played in the opioid epidemic and dare I say the pain epidemic.
Asking about your patient’s pain is likely something you do countless times each day, almost in a hypnotic state, likely without ever considering the effect this may have on your patient or your outcomes. There are many different scales used in medicine, but most commonly, patients are asked to rate their pain from 0 to 10 using the numeric pain rating scale (NPRS). Unfortunately, despite decades of research on pain, there are few tools for clinicians to measure pain objectively, yet pain is known as the “5th vital sign”.
To bring a little clinical scenario to this discussion, last week, I evaluated a 45-year-old female with chronic low back pain for the past 5 years. She is taking heavy doses of narcotic pain killers with a steadily increasing dose over the past 10 months. When I asked her how much pain she was having she reported a 9/10 (but she has a high pain tolerance). I then asked her what her goals are. She bluntly replied “to be pain free”, as if the absence of pain is a god given right. I felt deep compassion for this patient and felt so inclined to apologize to her on behalf of medicine. How did we arrive at the notion that “pain free” is the normal expected state?
In 1996, the president of the American Pain Society, Dr. James Campbell, said in a speech that “if pain were assessed with the same zeal as other signs (vital) are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign”. From this, the idea took hold that America was undertreating pain. This was viewed as an unnecessary epidemic, for medicine now had the tools to treat it…new formulas of opioids.
The following is a timeline of events that may have contributed to this medically induced epidemic:
In the wise words of Patrick Wall, “If we are so good [at treating pain], then why are our patients so bad?”.
I cannot help but draw the anecdotal conclusion that placing an over emphasis on pain has led to more pain, more medical spending and more accidental deaths as a result. In a 2006 study in the Journal of General Internal Medicine, it was concluded that routinely measuring pain by the 5th vital sign did not increase the quality of pain management. So, why do we continue to place such an emphasis on asking the patient about their pain rating? Why not focus on function? I have been working to change my practice and de-emphasize pain ratings. In stead of asking my patients about pain ratings I now ask them, “If I had a magic switch and could take away all of your pain, what would you go and do?” Taking this approach allows for an honest discussion about the patient’s deepest desires and goals in life. I then use this to focus my plan of care around what is most important to the patient…their function.
So I ask, will you be part of the revolution to change the stigma of pain? I welcome your comments and feedback on this topic.
- Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The Prevalence of Chronic Pain in United States Adults: Results of an Internet-Based Survey. The Journal of Pain. 2010;11(11):1230-1239. doi:10.1016/j.jpain.2010.07.002.
- Beck M. Doctor’s challenge: How real is that pain? Wall St J. 2011.
- Catan T, Perez E. A pain-drug champion has second thoughts. The Wall Street Journal. 2012.
- Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J GEN INTERN MED. 2006;21(6):607-612. doi:10.1111/j.1525-1497.2006.00415.x.