From the countless adages and anecdotes to the fatalistic and sensationalist media coverage, Americans are constantly inundated with warnings, admonishments and doomsday lectures about the harms of pain medications. Sayings such as “what doesn’t kill you makes you stronger” adorn bumper stickers and T-shirt designs or are heard in pop songs. The idea that only the weak – or worse yet, drug-addicted – seek pain control is at the very least misleading and at worst dangerous.
Of course, the adverse outcomes related to pain medications cannot be ignored. In fact, the Centers for Disease Control notes that more people die from prescription pain medication overdose than cocaine and heroin combined.1-2 These gloomy statistics color our perception of the issue and encourage media representation of prescribing physicians as overeducated drug dealers. Understandably, after being exposed to such a negative image of chronic pain and pain medications, the members of the general public and physicians themselves are often wary of aggressive pain management. We have come to fear dependency, addiction, overdose and death. This may explain, at least in part, the mismanagement of pain in our society.
However, as is usually the case, the value of statistics is in their interpretation, and certainly in this case there is more to be understood than might be immediately apparent. First of all, the drugs responsible for many of these adverse outcomes are more likely than not being used without a legitimate prescription. That is to say that while these drugs were obtained by one person at one point in time in a legitimate way for legitimate pain, these prescriptions and pills were, somewhere along the line, passed on to people without legitimate needs and without medical counseling.1 Furthermore, these drugs were most likely not prescribed by pain specialists.1
While some recent data have likely contributed to the misconceptions about pain and pain management, it would seem that many of these myths are more deeply rooted. Perhaps one of the reasons pain management is too often regarded as a soft science – a luxury for which people might “doctor shop,” as with buying a new pair of shoes – is due to the intrinsically subjective nature of the disease process. As physicians, we are taught to be culturally competent practitioners. We are made aware, especially with the uniquely diverse patient population in America, that people express pain differently depending on cultural context.3-4 After much reflection, we are left without a definitive solution, only with the acknowledgement that we do not and cannot understand pain on a uniform scale.3-4 Instead, pain must be assessed on an individual basis with a full armamentarium of cultural awareness.3-4 Herein lies the real challenge. How can something be simultaneously open to interpretation and concretely defined? How can we objectively treat something that is, after all, so inherently subjective?4-5
Consider a patient who presents for a check-up and has blood work done. When asked if he has any concerns or complaints, the patient responds in the negative, although based on the results of his lab tests, he is diagnosed with hyperlipidemia and prescribed an adequate dose of a statin. In this scenario, the patient is told he has a problem. He does not have to exercise judgment or inform the physician of his ailment. He leaves the critical decision-making to the physician. He is told he has a problem and prescribed a medication. Perhaps it is easier for this patient to acknowledge and “indulge” in his illness because the burden of its diagnosis and assessment is on someone else. The patient does not second-guess or doubt. He does not think to himself “maybe it’s not that bad” and “I need to just deal with this.” The patient surrenders control and releases himself to the care of the physician.
When a patient experiences pain, on the other hand, the physician has limited objective information at his or her disposal when assessing the complaint. Aside from some possible physiological clues, it is entirely up to the patient to apprise the physician of his ailment. The roles are nearly completely reversed. Because of this, patients may doubt their symptoms. They may think, “I can get through this if I am strong” or “I don’t want to complain.” Naturally, cultural and other factors can strongly play into this internal dialogue as well.
Given this atypical paradigm of diagnosis and evaluation, it is rather easy to view pain management and medication as a choice. It is not offered by the physician but requested by the patient. If it is a choice, then it is something that can, and perhaps should, be avoided, particularly given the risks of overdose and death so frequently advertised. From this reference point, the public is easily led into its gross misunderstanding of the importance of pain management.
By appreciating the etiology and extent of the problem, we are better equipped to address and remedy it. An obvious starting point for the implementation of change is during the training of young physicians. Anesthesiology residents are privileged to have a mandated experience and exposure with pain management. However, every physician takes care of a patient in pain at one point or another, and as previously mentioned, many of the prescribing physicians managing pain are not specifically trained as pain specialists. Accordingly, it makes sense to require residents in every specialty to rotate with a pain management service at some point during their training. This would encourage a sensitivity, awareness and confidence when prescribing pain medications that seems to be lacking in our present system. This possible change in attitude among physicians might then be reflected in the perceptions of the general public, creating a much healthier mindset toward the treatment of pain in this country.
1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Policy impact: prescription painkiller overdoses. National Center for Injury Prevention and Control website. http://www.cdc.gov/HomeandRecreationalSafety/rxbrief/. Updated July 2, 2013. Accessed December 10, 2013.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers – United States, 1999--2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm. Published November 04, 2011. Accessed December 10, 2013.
3. Callister LC. Cultural influences on pain perceptions and behaviors. Home Health Care Manag Pract. 2003;15(3):207-211.
4. Free MM. Cross-cultural conceptions of pain and pain control. Proc (Bayl Univ Med Cent). 2002;15(2):143-145.
5. Cowan P. The myths of pain control. Chronicle. 2006(Fall):1, 7. http://www.theacpa.org/uploads/documents/chronicle_fall06_82806.pdf. Accessed December 10, 2013.