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The Doctor as Pain Management Scapegoat

Leap, Edwin MD

Second Opinion

Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. Past columns are available on his web site, www.edwinleap.com.

I see a lot of patients with slurred speech. Not the kind of slurred speech that makes me contemplate thrombolytics. Not the kind of slurred speech that makes me wonder if they have botulism. Their slurred speech comes from the use of pain medications.

In our rural county, there have been several overdose deaths in the past few years. They weren't people who left a note, distraught, intending to end their misery. They were people who probably said to their families, with slurred tongues, “This pain is killing me. I'm going to take something.” And they did. They took their pain medicine, over and over, and the other pain medicine they received from various doctors. And in the morning, their family looked at them sound asleep, breathing quietly on the couch, and went to work. And when they came home, they were dead.

I'm tired of this pain dance that we all have to learn. I'm tired of the pain scale, which is almost always reported as a 10/10. I'm sick of hearing physicians accused of ignorance and cruelty in the management of pain. I'm shocked that so many organizations, whose representatives frequently aren't evaluating pain on a daily basis, feel free to evaluate emergency physicians in this arena. The joint commission, CMS (via EMTALA), nursing associations, and various pain management and pain advocacy groups all consider us inept in managing pain, both acute and chronic. These groups are counterbalanced by federal and state controlled substances policies, state medical boards, and investigators for both, who are eager to find patterns of overprescribing. And, of course, there are always lawyers anxious for a hint of liability in either direction.

I admit, some doctors are bad at pain management. Some doctors I see consulting in the ED don't know the doses of common narcotics, especially for children. Some surgeons I have known simply think that large wounds and fractures just aren't that bad. Some internists fail to appreciate the horrible pain of metastatic cancer. But these are exceptions. On the other hand, I believe that emergency physicians as a group believe in giving comfort to the suffering and that we do it well.

Some think we are abysmal failures, however. The thing is, pain is not objectively quantifiable yet. There isn't a painometer that we can attach to someone's scalp. All we have is the pain scale, our objective, scientific assessment of the problem before us, and our interpretation of the patient's appearance and vital signs. But most pain advocates feel that our objective interpretations are relatively worthless, that pain may be severe without an obvious physical abnormality, and so the pain scale is all that remains. And because much of the pain that we see is terribly subjective, the management of pain is difficult at best, and at worst is a daily battle to decide who is lying and who isn't.

We find ourselves left with slurred speech in the young and old, who have frequently come to define complete pain relief as complete unconsciousness. Left with 21-year-old patients with chronic back pain who spend their lives passed out before the television waiting for their disability check while their families hope for something, anything, to change their lives. Left with 85-year-old patients whose spouses think they have had strokes, despite the fact that they take five different narcotics. Almost all of these patients are being treated by one or more physicians, anxious to be compassionate, even as they continue to feel that we in the emergency department are to blame if they continue to report, “My pain ith about a t-t-ten.”

How about a solution? Here is a possible answer to taking the blame away from physicians in general and emergency physicians in particular. Let's legalize the over-the-counter purchase of narcotic analgesics. Now I've never really been a legalization advocate before, but it makes some sense. After all, if I can't accurately interpret a patient's pain and only he can, why shouldn't they get the drugs and get me out of the middle? We're always told by pain specialists that only a fixed number of patients will become addicted no matter what. And most of those are getting their prescriptions from doctors anyway. So let patients be in charge, in a sort of outpatient, oral PCA arrangement.

There are advantages. It will save patients the cost of frequent ED visits. It will save the system the cost of uncompensated care among those who can't pay. It will help patients avoid the struggle of finding pain specialists.

It can be controlled, if we like, with national tracking. If you want to buy your own narcotics, you need a narcotic purchasing card that evaluates your background and links all pharmacies. That way you can't just buy endlessly for the purpose of suicide or social occasions. If you need more than a threshold amount, you must certify that you are under the care of a pain specialist.

The involvement of the pain experts is very important. I know they understand the science of pain better than I do. So let's ask the pain guys to put up or shut up. If pain is a national epidemic with untold millions of patients suffering needlessly, then do something about it. Let there be more residency slots in anesthesia or neurology. Let there be pain management fellowships for primary care doctors. Let there be more free-standing pain management facilities to guide patients who need extra help beyond their over-the-counter purchase of narcotics. Let's have an EPTA, or Emergency Pain Treatment Act, that involves nonemergency department facilities so we can stem the tide of this national crisis. We're talking about helping our fellow men and women who are unjustly neglected by hard-hearted ED types! It makes sense.

But it won't happen for a couple of reasons. It isn't that the finances are a problem in terms of buying narcotics. Without the cost of doctor's visits, patients who already buy narcotic prescriptions or narcotics on the street could afford medicine more easily. There will be those who need pain specialists, however. And they don't, or won't, come cheap. Anesthesiologists would be very unhappy with anything like the arrangement we work under, where everyone gets care without cash up front. I'm afraid pain care is a lot like dental care. It's generally a nine-to-five, weekday national crisis, which is best handled by the less than capable in the emergency department during off hours.

But the main reason it won't happen is that it would shift responsibility from physicians to patients. It would require that a patient be the one making the decision to use the drug, the one deciding how to use it. (This is what we're approaching already, as we assume that the patient always knows best in some twisted business philosophy gone awry.) It would mean that if adverse outcomes happened, no physician or hospital could be blamed. It would take most of us out of the middle, and drop an enormous weight of accountability into the laps of the patients whose pain we are accused of neglecting.

It won't happen because despite our alleged ignorance, sloth, and willful cruelty, the system needs doctors in the middle, if for no other reason than to accept the blame for problems that other people create. And it's never more true than in the management of pain and the use of narcotics.

© 2004 Lippincott Williams & Wilkins, Inc.