Pain Crisis

What is it like living in pain everyday? I know something of pain myself from a bad injury followed by multiple surgeries. It is enveloping and all consuming to be constantly in pain. I am fortunate because my pain finally got better after several bad years- what if your pain never got better?

That is a horrible reality many people are living in right now. The chronic pain population in this country is astronomical. Our offices, urgent cares, ERs, and hospitals are being overrun with patients whose pain is out of control.  They want a solution to this pain, and end to it.  But we cannot offer that.  In so many cases we do not have a fix, we cannot make the pain go away. So we talk about managing the pain, and coping with it. But the problem is many are not coping- they are turning to pain management for higher and higher doses of opiates. When they can’t afford them they are buying pills off the street. When they realize how much pills cost they start buying heroin to replace them. They lose their jobs, they lose their houses, they lose their families, and many lose their lives.

Does this happen to every patient with chronic pain? No, but we are seeing it more and more.  The heroin epidemic is real and soaring.  People of all ages, races and backgrounds are affected, and they are dying. Of overdoses, yes- but also of infections and severe medical complications of drug use. Lining the halls of our hospitals, they return again and again until the last time, when it is too late.  How many young people in their twenties and teens will we see die of florid heart failure from endocarditis? The numbers keep climbing and what used to be rare is now common.

How do we reverse this trend? How do we make the expectation that we very likely cannot rid you of pain, but slowly try and manage and reduce it? And do it all without any opiates?  Well, it will take a seismic shift in culture. We are so wired to the mentality of “take a pill and make it better” or “we can operate and fix that” that patients expect this when they come to us. To have to tell patients that we don’t have any quick fix is frustrating not just for them but for us as providers.  Getting a patient to accept as treatment physical therapy, exercise, cognitive behavioral therapy, medication for depression, tens units, injections, spinal stimulators, etc. when they really want something that will help right now in that moment- that is next to impossible. But it possible, and if we don’t change our culture this opioid addiction plague is going to become increasingly more wide-spread.  Many pain clinic incorporate all those previously mentioned strategies, but most patients complain that they have to “get through” the counseling, therapy, and other treatments in order to get their pain pills. If those opiate pain pills were taken off the option list, since they have been proven again and again to have little to no efficacy in treating the vast majority of chronic pain problems, then all that effort could be shifted to optimizing the modalities that have been shown to have a positive effect.

The demand for chronic pain management clinics and physicians is so high that we need more clinics where there multidisciplinary treatments can be given to patients. It takes months to get into pain clinics here in Ohio, and in the meantime most patients are getting by going to urgent cares and the ER to get short term pain pill prescriptions when they really need to be getting a jump start on PT, behavioral therapy, starting nutrition and exercise plans. Asking a primary care doc to deal with chronic pain is also a very difficult task- a patient will come in for a 15 minute visit with 5 chronic medical conditions that need addressed urgently but want to focus the whole visit each time on his chronic recurrent back pain. How can you keep a patient with morbid obesity, diabetes, and heart disease alive and going if you only get to treat their chronic pain issues every visit? In many cases, treating and improving chronic medical conditions (diabetes, obesity, depression) will also help improve and treat chronic pain, but again this is taking the long view and doesn’t offer any quick fixes for patients.  Many primary care doctors will not prescribe any opiates at all, which is a good strategy, however these patients then come to the ER and many ultimately end up admitted due to “intractable pain.” On the inpatient side of treatment we are then in a daily struggle with patients who want IV pain medications, which are not the recommended treatment for chronic pain conditions, and who don’t want to be discharged from the hospital because their pain is no better than when they came in.

Since I started medical school I have seen the problems and issues with chronic pain and opioids worsen ever year. It is creating a system in which more patients at more ages are on more long term pain medications. The consequences have been devastating to see and are continuing to accumulate. Reform is ongoing with more and more regulations over who can prescribe what narcotics. These regulations will help, but we have to keep working everyday stop the cycle of long term opiate prescribing.  The more rigid we are, the more boundaries we set, and the harder we make it to access opiates the less prevalent they will be in our everyday society and medical practices.

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