The Increasing Politics of Pain Control
Pain distracts us from work, from enjoyment, and from life. It takes an immeasurably high toll on the quality of our lives along with the lives of others who love and care for us. It costs corporations, as well as ourselves, billions each year in lost time and productivity, not to mention medical bills.
Yet, increasingly, pain is a political entity all its own. Lawmakers want to decide how pain is controlled. The government at both the state and federal level want to watch who gets what drugs and how much they use.
Even some religious leaders have spoken out strongly against the use of drugs used in pain control, often citing that such drugs interfere with natural state of being. For example, there was much criticism leveled in early 2005 when it was announced, apparently in error, that a brain damaged young woman whose feeding tube was removed in a celebrated case that caught the attention of politicians was being given morphine continuously. While she only received light pain medication, the fact remains that such drugs often play a part in relieving any unnecessary suffering at the end of life.
When politicians and bureaucrats get involved, their measures often interfere with a physician’s ability to treat their patients as may be most effective. In the state where I live – Vermont – a rule on the books with the state medical board basically cites that unless a patient has cancer, extreme care should be taken before a decision is made to use painkillers with any patient.
Unfortunately, however, not every person in severe, life-altering pain is also suffering from cancer. Taken strictly, this could mean that if you have a severe toothache, your dentist will not be able to write you a prescription for Tylenol #3, which adds codeine. Or, suppose you break your leg and experience horrific agony and even after you receive the prescribed aspirin and a pat on the head, you’re still screaming and writhing.
Doctors who want to keep their ability to both prescribe any type of medication as well as their capability to practice medicine at all have to walk a narrow line these days. They are under increasing scrutiny for each and every medication they recommend to their patients.
But doctors face special watch for every controlled drug they prescribe; most drugs that relieve moderate to severe pain even temporarily fall into the controlled categories, called drug schedules by the Federal Drug Administration (FDA). A pharmacist, a drug store clerk – and just about anyone else – can call in an anonymous complaint to various agencies at all levels of government that a doctor is abusing his or her DEA (Drug Enforcement Agency) prescription writing privileges. Whether or not an individual or an isolated report triggers a full-scale investigation is usually at an agency’s discretion.
Under the greatest scrutiny of all appears to be doctors who specialize in the treatment of patients with chronic pain. Such doctors are far more frequently apt to prescribe controlled medications because they obviously deal with those who suffer pain over a long period of time. Some have spoken up to say that this type of intense monitoring interferes with their ability to treat their patients to the measure of the Hippocratic oath that requires them to relieve pain.
On the flip side, of course, is concern that some patients “shop” for doctors willing to write them prescriptions not only for heavy-duty painkillers like OxyContin and morphine but also for a myriad range of other frequently abused drugs like sleeping pills and anti-anxiety medications such as Xanax (alprazolam) and Ativan (Lorazepam). Also, we hear stories cited of doctors who “sell” prescriptions at a price. Usually such sensational stories imply that a physician or dentist does not actually treat or examine a person but merely accepts money to write a ‘script. Yet studies, even those by those whose business is law enforcement, suggest the number of doctors who commit such fraud is fairly rare.
What occurs far more frequently than doctors abusing their privilege to prescribe or perhaps even patients “shopping” for a compassionate doctor willing to provide them with a drug they want is the under-treatment of severe pain. Although technology in medicine is not perfect, skillful doctors can usually find ways to alleviate the worst effects of pain without sending patients into a drug-induced fog. For instance, patch-provided pain relief may take care of the majority of discomfort with a lesser drug taken orally, as needed, by a person for breakthrough pain.
But the scrutiny doctors now face seems to have the effect of making it far tougher for doctors to feel comfortable in prescribing sufficient levels of medication. When I was researching the book, “Buying Rx Drugs Online: Avoiding a Prescription for Disaster” (Course Technology, January 2005), I talked with several physicians and patients.
Many of the doctors said that it can be very difficult for them to weigh the desire to relieve suffering against the risks they face if some non-physician decides they have over-prescribed. Likewise, many chronic pain patients I interviewed stated flatly that they suffer far more than they should because they feel they must justify every single pill they take.
Studies bear out my findings. In a few recent ones, as many as 50 to 70% of pain sufferers complained that they experience too much discomfort because their physicians are reticent to prescribe “as needed” medications. As one elderly woman, the victim of a number of bone fractures from osteoporosis, explained to me, “How dare anyone stand in the way of my doctor’s ability to treat me in a way that lets me live life rather than sit in a chair, afraid to move? I never took a pain pill in my life until I was 81! But after my third fracture, my own doctor said he couldn’t give me pain pills anymore because it might give him problems. At 85, I had to go find a doctor who wasn’t as scared. Imagine that.”
If you think the number of people affected by chronic pain is a relatively small percentage of the whole, think again. Some studies suggest that at least 50% of people will, at one time, suffer chronic pain so severe that it disrupts at least some aspects of their lives. Chronic pain may be no less severe than acute pain rather; the only difference usually lies in the length of time that same level of pain is experienced rather than in terms of severity. Such pain can come from a huge host of possible culprits, including cancer, the nerve damage, crushing bone injuries, scar tissue left behind in organs after surgery or infection, and any number of other causes.
