The following manuscript was submitted to the October 2018 Complications theme issue.
In order for the country to make meaningful progress in tackling the opioid epidemic, we need a cultural shift in the way patients and providers think about pain.
Pharmaceutical companies and physicians are being demonized for their manufacturing and dispensing of opioid analgesics. Money-hungry executives from Big Pharma caused the crisis by brainwashing doctors to prescribe these medications left and right. Greedy doctors want patients dependent upon them for years, ensuring a steady stream of paying patients in their waiting room. Drugs drive the market. Drugs lead to big profits for everyone involved. The more drugs, the better.
Wrong. I firmly believe physicians want what’s best for their patients. We train for years before becoming independent health care providers. We spend hours with patients and their families, asking questions, ordering diagnostic tests, establishing diagnoses, and counseling patients on treatment options. We not only care for, but also care about, each patient. We have a vested interest in their outcome, both on a clinical and personal level.
If doctors were so greedy, wouldn’t Wall Street have been a better destination than our clinic exam rooms? And to think we’re mindless drug pushers, being driven by pharmaceutical companies and their incentives is downright insulting. Physicians take pride in their education, their evidence-based approach to patient care, and their relative independence from the market-driven industry.
But why now? Where did this opioid epidemic come from?
We may never completely understand the “perfect storm” that precipitated the crisis, but one obvious culprit is the emphasis on providers and health care organizations to optimize pain control. The movement began in 2001 when the Joint Commission, an independent US-based organization that accredits and certifies over 21,000 health care organizations and programs, instituted its Pain Management Standards. Following recommendations put forth by the American Pain Society, the Joint Commission emphasized pain needs to be regularly assessed in all patients, serving as a “fifth vital sign.” Pain was now considered next in line to: heart rate, blood pressure, respiration rate and blood oxygen level. With each patient encounter, health care providers were required to ask and record the patient’s pain level, typically on a 0-10 scale, alongside clinical measurements indicating the state of the patient’s essential bodily functions.
Fast-forward a few years. The traditional fee-for-service payment models were falling by the wayside and physicians were now being reimbursed via pay-for-performance models. And what goes into the ‘performance’ calculations? Patient satisfaction.
The writing was on the wall. Pain control and patient satisfaction go together like fine wine and stinky cheese. Physicians were now being encouraged to optimize pain control for every patient, in every setting.
And why did we turn to opioids? Because they work. Every patient will achieve some degree of pain relief from opioids. The flavor and dose may vary from patient to patient, but they’re all effective. They may not be the “best” drug for the job, but they provide patients with pain relief, are widely available and relatively cheap, and carry relatively tolerable side effects.
Patients had improved pain control, doctors had higher patient satisfaction scores, and the hospital administrators were happy. But wait … what is Newton’s Third Law of Physics? “For every action, there is an equal and opposite reaction.” And that opposite reaction has grown into the opioid epidemic we have today. No one wanted or asked for this, but some could argue it was the logical next step to overtreatment and over-prescription.
So, what are we ignoring when it comes to tackling the epidemic? Two things: the public’s perception of pain control, and physicians’ willingness to discuss pain management expectations with patients. We need a cultural shift in pain management.
As a surgeon, I’ve had patients look at me in complete dismay when I tell them pain is to be expected after their surgery. I may tell them “Sir, you’ll have some pain after your tonsillectomy and it will last for up to two weeks. We’ll provide you with pain medications, and these will ease but not eliminate your pain.” Most patients seem understanding, but it’s not uncommon for patients to say, “I don’t want any pain. Is there something you can give me for that?”
You’re undergoing surgery. We’ll be cutting into your flesh, inducing tissue damage, and sewing you together. What part of that makes you think you’ll have no pain afterwards? Or, more importantly, what makes you think I can take away every ounce of pain with a single miracle drug?
As an ENT, I perform primarily elective surgeries (sinus surgery and ear tubes). The goal of most of these procedures is to improve the patient’s quality of life. Do you have chronic sinus infections? Let’s “open things up” and reduce the frequency of those infections. Do you have sleep apnea? Let’s “widen the throat” to allow for more comfortable sleep. I point this out to make the comparison to life-saving procedures. The risk-benefit ratio is different when considering elective versus lifesaving surgeries.
When a surgeon discusses a surgical procedure with a patient preoperatively, the emphasis should be placed on risks versus benefits. A thorough discussion of the goals of the procedure, available alternatives, and expected postoperative outcomes is critical to obtaining informed consent. “Let’s make a shared decision on what’s best for you.”
In this discussion, surgeons should be talking to patients about post-surgical pain. The real question physicians and patients should be discussing is, “What’s your acceptable level of pain?” Sure, there’ll be discomfort and most patients understand this going into the surgery. But patient’s need to know what postoperative pain control options they have, what their side effects include, and the risks associated with each option. In addition to prescription and over-the-counter pain medications, nonpharmacologic techniques should also be discussed (e.g., ice, heat, massage).
The goal in pain management should not be a “0” on the standard 0-10 scale, but rather a score closer to the patient’s acceptable pain level. This goes for acute, chronic, inpatient, and outpatient pain management. The system’s design is flawed.
This culture shift is essential. Pain is here to stay. So are opioids. Let’s learn to use them wiser and educate patients on their intended uses, side effects, and relative risks. Let’s highlight the importance in the patient-doctor relationship in the national opioid conversation, not simply restrict supply and criminalize illicit use.
It starts one patient and one physician at a time. We need to redefine what it means to achieve “optimal pain control” by reeducating patients on acceptable pain levels, rather than nonexistent ones. Patients need to find a doctor they trust, develop a relationship with them, and establish realistic treatment expectations. This is a fundamental component to addressing the opioid epidemic.
Image source: Another Needle by Eric Molina licensed under CC BY 2.0.