What a Pain to Manage Pain
I have spent the last 72 hours thinking about pain. My own post-surgical pain, the way to manage whatever pain I have been experiencing, and why, in 2013, we have such problems involving the use or misuse of pain medication. The medical community needs to rethink and revise its management of pain.
As a result of my very own combination of genes, some recklessness, and compulsive activity, I am a serial orthopedic surgery patient. I generally know how to manage the pain in the hours and days immediately following the operation. This surgery, however, included an anesthetic nerve block behind my knee, which I do not recall from prior visits. I did not receive any warning that the pain would be so severe once the nerve block wore off, that I would need to take some prescribed narcotics before that happened. Despite filling the same prescription for OxyContin that I have had following other operations, I did not take any before the block wore off and I woke in agony. Because I was “behind the pain,” even taking a couple of pills didn’t allow me to “catch up” to it, resulting in several hours of severe discomfort. During that time, I would have snorted glue or chugged cough syrup if they were available.
The reason that this happened to me, and probably to scores of other patients, is a reaction on the part of health care providers to the highly addictive nature of painkillers. For decades, doctors doled out narcotics prescription with abandon, but they now approach pain treatment with great caution. One illustration of overprescribing is the ubiquitous presence of half-filled pill bottles of narcotics on medicine cabinet shelves across the country. The CDC estimates that as many as 15,000 people per year die in the United States from accidental or intentional use of opiods. With estimates as high as 2 million Americans being addicted to prescription painkillers, it is no wonder that hospitals and service providers are worried about contributing to this epidemic, or of being sued for enabling that dependency should something awful happen. They must balance that fear with the task of relieving acute pain caused by almost every invasive medical procedure.
Ironically, we have entered the era in which “patient-centered care” has moved to center stage in the mission statements of most hospitals. Considerable resources are now applied to interview and surveys of recently discharged patients, analysis of the data, and oversight board-level committees, including patient advocates, that are dedicated to improving patient care. I happen to be on the patient care committee and board of trustees of an academic medical center. It turns out that absence of pain and comfort are two key ingredients to a positive patient experience. Therefore the dilemma facing health care administrators is how to marry the competing objectives of optimizing the entire patient experience and eradicating post-surgically-initiated drug addiction.
The real problem may be the tendency to prescribe in a “one size fits all” manner. At the most simplistic level, the doses to handle similar pain for a 56-year-old, 115-pound woman and a 225-pound, 23-year-old male are unlikely to be identical. How then do we tailor the treatment to the individual? Patients have not only a great variability in age, weight, existing health status, and to some extent, tolerance for pain, but there are probably huge differences in the pain caused by specific surgeries. Also, there are clearly — as the numbers would suggest — a tendency for some patients to abuse painkillers. Hospitals, doctors, and pharmacies have records of which patients have requested refills of opiate prescriptions. This obviously does not suggest that these individuals would be at high risk for addiction, but such information is valuable in planning the best course of pain relief for these patients.
Since the current prescribing practice is imprecise, there should be more dialogue between patient and doctor about post-surgical pain management. If the goal to develop practices to tailor the treatment to the patient results in lesser volume of narcotics prescribed, what is the incentive for the drug companies to undertake clinical studies to fine-tune dosing, intervals between doses, and longevity of prescription? There are current examples of diseases, such as breast cancer, where tests that now determine the specific genetic causation lead to the creation and ultimate approval of highly targeted products that eliminate the need for some other drugs. Customized chemotherapy has lowered sales of some agents, but opened up a new platform in research and discovery for genetically-based cancer treatments, which have taken their place. The drug companies, which have embraced the concept of developing molecules that provide superior efficacy to a range of narrower patient populations within what was once a very broad indication, have benefitted from that choice.
Manufacturers of opiates and narcotics to address pain, should move in the same direction. The handwriting is already on the wall; governments are already restricting allocation of pain medication. New York City recently passed a law limiting emergency room opioid prescriptions to three days. Since the “one size fits all,” two- to three-week allotment is bound to disappear, the best business practice is to get ahead of the inevitable. This means moving aggressively to follow the lead of cancer drug innovators who crafted therapies which customized treatments, improved outcomes, reduced spending on unnecessary medicine, but also raised overall revenues because the novel drugs command higher prices.
One positive innovation in the narcotics market is the approval of tamper-resistant formulations that prevent crushing tablets, thereby curbing abuse. The FDA will require generic versions of narcotics to also contain this property. This ensures that the companies that developed the technology profit from its premium qualities, and that low-cost generic versions of the same drug, but without the tamper-resistant feature, cannot flood the market with low-cost, highly abuse-enabled product.
The medical profession faces the dueling challenges of addressing the acute pain that accompanies almost all medical procedures and also reducing any unintentional drug addiction. Since the medical community is already rationing narcotics, it must also learn how to best connect the available therapies with those individual patients undergoing different surgeries or suffering from a variety of ailments. Clinical studies, research and coordination among the medical community, policy makers, and the biopharmaceutical industry need to start now to solve our current pain dilemma.