Be suspicious. Be very suspicious. But not overly suspicious.
That's the advice given to emergency physicians, who are told they don't manage their patients' pain well, and to beware the epidemic of prescription drug abuse.
When the World Health Organization weighed in with this message four years ago — a published policy on opioid administration that appeared to suggest it was time to reduce skepticism about pain treatment — the Joint Commission on Accreditation of Healthcare Organizations followed suit.
Since that time, a virtual chorus of medical groups has called for more pain relief, with guidelines aimed at rectifying inadequate pain control. The American Medical Association, for example, recently alleged in one of its published articles that only one in four patients who needs pain relief is likely to be getting it in adequate doses.
Yet in some states, such as Utah and New Mexico, palliative care for terminally ill patients that has been found to exceed acceptable standards has resulted in court battles, even criminal prosecutions, despite the new guidelines and a flurry of pain relief legislation designed to protect health care providers from just this kind of threat. In Southern California, physicians have been the targets of litigation both for under- and over-prescribing (Southern California Physician, May 2002).
In addition, prescription drug abuse is up — way up, according to the National Institute on Drug Abuse (NIDA).
“I feel like I am caught in the middle on this.” - Dr. Edwin Leap
To Edwin Leap, MD, who has seen countless patients stream into the ED seeking pain medication for everything from an alleged back-spraining tumble to a supposedly stress-induced headache, the idea that he and his colleagues in emergency medicine can make a distinction between an addict and a hurt patient under such circumstances is almost amusingly unrealistic.
Late at night or on a weekend, without a reliable patient history record, and in the face of self-reported symptoms, “we are being told —you've got to watch that pain scale,'” said Dr. Leap, an emergency physician at Oconee Memorial Hospital in Seneca, SC. In contrast, some medical publications have begun promoting wariness, with cautionary tales of con artist patients. “I feel like I am caught in the middle on this,” he said.
Dr. Leap is not alone.
The “pendulum has really swung” in favor of patients who want medication, noted Bill McCarberg, MD, a president of the Western Pain Society. It has made the current climate a confusing time to be an emergency physician, he affirmed. While many medical groups are telling physicians about the problems of undertreatment, “in the ED, there is no question that they can be deceived,” he said.
For the past several years, growing complaints of inadequate pain medication have been documented. (J Med Licensure & Discipline 2001;87(4): 130.) And, in one recent California case, a verdict was returned for a dying patient who suffered what was said to constitute abuse at the hands of his physician, allegedly because he was denied “adequate pain management.” (West J Med 2002;176: 17.)
“In the ED, there is no question that they can be deceived.” - Dr. Bill McCarberg
But surveys show high abuse of these medicines, too. Five years ago, when NIDA began looking at the issue, nine million people 12 and older were estimated to be using drugs for nonmedical reasons. At the time the data were collected, many reported their first abuse of prescriptions had occurred only months earlier, indicating the survey may have coincided with the early stages of this trend. By 2004, the problem was believed to be so pervasive that NIDA no longer was issuing estimates.
Five years ago, NIDA found nine million people 12 and older using drugs for nonmedical reasons
Then, in October, New York magazine weighed in with the new teen prevalence for these drugs. In a cover story, “Generation Rx,” adolescents confessed to cunning ways of marshalling their medication-fed highs: learning to speak jargon from medical textbooks, finding safe ways to secure the prescriptions, and extracting information from online sources for pill-grinding and mixing to achieve the most mind-relaxing effects.
Meanwhile, newspapers have published ominous reports of inadequate pain treatment. Last January, the Los Angeles Times ran a first-person account under the heading “With Chronic Pain, Discrimination Hurts.”
“It is a difficult situation,” said Dr. McCarberg, also the founder of the Chronic Pain Management Program at Kaiser Permanente in Los Angeles. “I think the pendulum may be ready to swing back a little.”