Pain was widely under-treated in the 1980s. Two decades ago, pain was recognized as an important problem that needed to be managed by healthcare providers. Today, the opioid crisis has led to under-treatment once again.
Professional recognition of pain as a symptom that needs managing was the eventual outcome of several decades of research. Again and again, studies showed that pain was inadequately treated. As usual, the problem was worse for women and people of color (meaning this was and is an issue pertinent to advancing health equity). Physicians often discounted reports of pain and were likely to brand the complainers as “bad patients.” All this led to a national outcry in the late 1990s/early 2000s. Admittedly, the pharmaceutical industry’s profit motives may have fed that outcry.
The role of the Joint Commission
The Joint Commission, an accrediting organization for healthcare providers, first published pain management standards in 2001. These standards included asking about pain and treating it appropriately. Today’s standards are quite nuanced and detailed, in part because the Joint Commission has had to defend them [PDF]. Critics complain that treating pain as a vital sign, along with temperature, pulse, respiration and blood pressure, is impossible because pain cannot be measured objectively, only subjectively reported. Critics also say that treating pain with opioids has led to overprescription, overtreatment, diversion, addiction, and deaths on a scale never seen before.
Instead of adopting newer and better non-opioid pain management strategies, physicians and nurses appear to be backing away from assessing or treating pain entirely. In 2016, the Pain News Network reported:
The AMA’s new president said physicians played a key role in starting the … opioid epidemic by overprescribing pain medication, and now must do their part to end it.
“Just as we now know earth is not flat, we know that pain is not a vital sign. Let’s remove that from the lexicon,” James Milam, MD, an AMA delegate said in MedPage Today. “Whatever it’s going to take to no longer include pain as a vital sign … Let’s just get rid of the whole concept and try to move on.”
If we ignore it, it doesn’t exist?
During the Trump administration, the care experience survey for home health patients was redesigned, and a pain-related question was removed (whether the home health staff talked with the person receiving home health care about pain). Other surveys administered by government agencies also had pain-related questions removed or modified. It appears that some have decided that if we don’t ask patients about pain, we can ignore the whole problem.
The most severe repercussions of the new national paranoia about assessing and treating pain are seen in people with cancer. Cancer-related pain is legitimate, and can be both excruciating and disabling. And yet, multiple studies have found that, even at the end of life, few people with cancer are provided with effective pain management.
Palliative care does not mean hospice care; it is designed to relief suffering. The American Cancer Society has said that palliative care “should be offered and be available from the time of diagnosis until it’s no longer needed – at any stage and in any care setting.” In our research, only a third of people with cancer had any palliative care encounter during the 5 years after their diagnosis.
Needless suffering
In practice, this means that people with legitimate cancer-related pain are suffering. In my own family, two relatives with cancer diagnoses in the last few years were not treated for their considerable pain, including post-surgical pain. One relative said that if they had known how bad the pain was going to be, they would have declined the surgery entirely. Another relative said their doctor told them, “Pain won’t kill you.” That doctor must not be familiar with the vast body of research on pain-related suicides.
How is it possible that pain could be so poorly managed today? How can clinicians justify patient suffering to this extent? Surely, in the tug-of-war between patient needs and the desire to avoid inappropriate opioid prescribing, patient needs must be respected and non-opioid pain management strategies adopted. No one should be forced to endure un-managed pain caused by cancer-related surgery, at the very least!
Informed opinions
I previously wrote in this blog about my family member with chronic pain, as well as thoughts on the difference between opioid use, misuse, and addiction. Having done extensive academic research plus had a front-row seat for the opioid crisis for more than 15 years, I know there are solutions that do not take us back three decades in terms of pain management. Non-opioid pain management strategies are available, but under-utilized.
As I’ve written before, one partner in treating pain should be natural remedies like cannabis and other beneficial plants. Other tools include meditation, yoga, and acupuncture. The imperative to ask about and treat pain does not imply that only opioids can help. Clinicians also need more and better training about reliable, validated pain measures and alternative approaches to helping people with legitimate, severe pain.
Lisa M. Lines