Struggling to manage pain

Many patients suffer needlessly because health care is focusing elsewhere.

Posted: April 20, 2011

Many medical stories recently have discussed the issue of pain management. A Consumer Reports survey reported a particularly compelling finding: 97 percent of doctors polled thought they were at least somewhat effective at minimizing pain and discomfort. Within that group, 37 percent said they were "very effective."

Unfortunately, the difference between "very" and "somewhat" is anything but minor. Individual patients suffer needlessly, and that suffering has an effect on a larger scale.

A recent case illustrates the point: A 27-year-old father was dying from widespread abdominal cancer. All he wanted was to spend his last days pain-free with his two young children, who just wanted to be with their father.

Doctors want to treat disease, but in this case what the patient wanted was quality time. Indeed, sometimes alleviating pain is all caregivers can offer people at the end of life.

But this is getting harder to do. Many hospitals are cutting pain services. This comes at a time when national patient-satisfaction surveys gathered by the federal government show that about 8 percent of hospital patients feel their pain was never well-controlled during their stay.

Insurers also are using their clout to discourage the use of expensive but much needed treatments, particularly in end-of-life care. With revisions coming to U.S. health care, hospitals and physicians may be reluctant to prescribe certain pain-relieving therapies if they are not being reimbursed.

Yet the lack of pain care is not the only problem. The prevalence of abuse of painkillers and addiction to them muddies the issue.

Philadelphia abortion doctor Kermit Gosnell was shut down not by state health inspectors but by drug agents investigating the large numbers of pain meds he was prescribing, independent of his abortion practice.

The state of Florida has seen police swarm down on pain clinics, dubbed "pill mills," for the large number of pain drugs they prescribe.

Bad publicity like this helps drive pain services underground, making it harder for doctors to help their patients. The burden of chronic pain remains staggering. It reduces overall quality of life, social functioning, and psychological well-being. A 1998 National Institutes of Health report estimated that pain costs the U.S. public $100 billion a year in associated health care, lost wages, and legal costs. The report estimates that the direct health-care costs associated with back pain alone were $90.7 billion.

These numbers may be dated, yet the treatment of pain has not dramatically improved. People still live in agony. And with an increasing population of individuals living longer lives, the problem is likely to get worse. Studies show time and again the number of people suffering from chronic pain is growing rapidly.

The good news is that doctors know the first steps to turn this around.

First, caregivers must recognize that pain management is a wildly neglected part of medical education and training in the United States. The average amount of time that a doctor receives education in pain management is 90 hours. It is critical for physicians to have the knowledge and skills to effectively manage chronic pain, and 90 hours is nowhere near enough time to learn this.

Second, all members of the medical team must work together to provide the best possible treatments. Evidence suggests, that when someone's pain management is handled by all of his doctors, from psychologists to specialists, a patient suffers less and his care actually saves money.

This is not something that can be changed in a day, but I have seen it work in my hospital and know that the big challenge is simply talking to one another more. Every doctor should feel they can manage pain "very" well, but doctors must be encouraged to work together across teams.

Third, health care must collect and disseminate better information on pain treatment. Right now, patients are asked few details on how their pain was handled. If more information was gathered, doctors would have concrete data on how effectively they're treating pain. No longer would a patient's comfort be the focus of a guessing game.

Patients like the dying 27-year-old father of two deserve to spend their last days without excruciating pain. And chronic pain sufferers should not face days filled with anguish. It is a reasonable goal for a health system undergoing reform.


 


Anita Gupta, an assistant professor of anesthesiology

and critical care at the Hospital of the University of Pennsylvania, specializes in pain medicine. Contact her at anita.gupta@uphs.upenn.edu.

 

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