This month, the great minds of emergency medicine are debating the issue of pain management. I have never done a fellowship in pain management, but I have been taking care of people with pain for almost 40 years. There are things you learn over that period of time which are obvious. As Bob Dylan said, “You don’t need a weatherman to know which way the wind blows.” And after almost 40 years of dealing with patients in pain, you do pick up some generalities that guide the practice. First and foremost, pain is not a simple issue. Injuries which should be of minimal pain in the eyes of the physician may be of maximal pain to a patient. Is there any easy way to know? Not really. When I ask a patient if they have pain, I am basically asking them to reflect on how a disease condition or traumatic process is affecting them. There is no simple way to look at the pulse rate, the respiratory rate, the blood pressure, etc… and know the degree of pain that exists.
The first area that I’d like to comment on is the pain score. This seems to be a holy grail for administrative types and those running institutions like the Joint Commission. If there’s ever been less science in medicine, I’d like to see it pointed out. A scale from 0 to 10 is asked of people who have absolutely no scientific training. They have no way to stratify pain. Emergency physicians and nurses always poke fun at the patient with “10 out of 10” pain. Actually, the “12 out of 10” pain evokes even more humorous comments. In truth, I think it’s difficult for the patient to know how to utilize the scale. What I’ve learned is that the only thing that’s of use is the amount that their pain has changed. If a patient says that they start out with “10” – and most of them do – if it’s now at “5” I’m probably making some progress. But to say that it’s any more useful than a very general guide is to give it considerably more scientific validity than has ever been proven.
Secondly, there is no hot button in emergency medicine like the evil term “drug seeker.” It absolutely clouds our thinking about the patient and their problems. As soon as the label of “drug seeker” has been applied by the staff, all intelligent inquiry stops. We start to put up a wall, really for no good reason. It is always interesting to talk to physicians about whether they had a “good shift” or a “bad shift.” It almost never has anything to do with the actual disease entities that were presented. Often, it’s directly related to the number of patients they thought “really didn’t need pain medication.” I think that we put far too much stress upon ourselves when we start to feel that we are the gatekeeper to pain medications. It is interesting to note that when a patient comes back to the emergency department with recurrent pain, we refer to them as a drug seeker. We don’t refer to a patient with asthma who has come back for more treatment as an “oxygen seeker.” Exactly why is this a problem? I think to a great degree the personalities involved. Physicians and nurses are, by definition, type A personalities who do all, bear all, go through all, without whining or complaint. We long for the era of wooden ships and iron men when patients were grateful for care and kept their mouths shut. Anyone who has significant pain not relieved on the first attempt probably doesn’t deserve our care. This mentality becomes cyclical and frightening.
There are extenuating circumstances, however. As soon as we use “pain” in the same sentence as the word “cancer,” any therapy becomes acceptable. It doesn’t have to be a cancer from which a patient is dying. Somehow, adequate pain therapy for a cancer patient is OK. Why don’t we think that adequate pain therapy for a sickle-cell anemia patient is OK? Is this because they tend to be a more ethnic population? Is this because they tend to challenge our own sense of who deserves pain relief? There are considerable studies that show that the giving of pain medication in emergency departments is related to ethnic types. This is a black mark on the profession.
Another aspect of pain management is the fact that drug addiction is a ubiquitous problem in this country. No matter where I go and no matter where I teach, everyone starts out the drug-seeker conversation the same way. That is, “You don’t have all the drug seeking patients that we do.” News flash: It’s exactly the same everywhere. Rural, urban, north, south, east, west, black, white or Hispanic. It doesn’t make much difference. There’s going to be a certain percentage of patients at each ED who are going to be considered “frequent flyers” on pain. Is this a problem? Yes. Is it always appropriate to confront them? No. Having done this for a number of years, I view addiction as a complex problem involving both the psyche of the patient and whatever they’re addicted to. Addiction is a form of obsession and no obsession is amenable to instant therapy. Whenever I wonder whether I should or shouldn’t be giving a dose of pain medication, I always remember this: I’ve never created an addict by giving one shot of pain meds, and I’ve never cured an addict by withholding it. These are complex issues and I can’t always sort them out in the emergency department. There’s no question that there’s heavy pressure from the nursing staff to deny certain patients medication. The snide comment that “you’re not going to give them pain medicine, are you, Doctor?” has, more than once, intimidated and dissuaded otherwise compassionate physicians from acting. My philosophy on this is simple. I’d rather treat ten patients who don’t really need the pain medicine than deny the one patient who really does. The complexities that go along with making these decisions are much more than the number of visits and their underlying disease entities. It is a reflection not only of the patient, but of the doctors and nurses involved. Are there too many medications given in this country? Without question. But it’s not because of the emergency departments. Prescription drug abuse is a national phenomena and we should not be beating ourselves into thinking that we are the cause of the misuse of pain medications in this country.
Lastly, pain management is totally individualized. The dose that works for one patient does not necessarily work for another. I have long gotten over the idea that 6 mg or 8 mg of morphine is enough. You know what’s enough? The amount that works. I have no problem, if I’m going to use a narcotic, with using an adequate amount of that narcotic to solve the problem at hand. We need to ask this question: What’s the goal? What’s the end point? I’ve found that if I’m ultimately trying to give adequate pain medication and assuage a patient’s fear, there’s nothing better than to look them in the eye and say, “I have more pain medicine than you have pain. I can take care of the problem.” And I always assure each patient that there are no points given in my emergency department for suffering. If we’re not adequately treating your pain, let us know. We are not mind readers. But at the end of my career, I’d rather have over-medicated a couple patients than denied the many the adequate treatment for their suffering.
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