Recognizing the War on Pain Medication
There is a war on physicians—and therefore on patients. However, there is another attack on the medical profession—the war being waged against pain treatment. Pain medications in particular are under the scrutiny of both the US Congress and in state legislatures.
For the last several years, there has been a push in Jefferson City, the state capital of Missouri, for the establishment of a Prescription Drug Monitoring Program, one that would track prescriptions for controlled substances in the state. One of the biggest arguments for this program is that Missouri remains the last holdout in the Union to not have one of these programs. But apparently, these programs are not sufficient: just look at the long list of bills introduced in this US Congress alone regarding pain medications:
- 1392 https://www.govtrack.us/congress/bills/114/s1392/text
- 1431 https://www.govtrack.us/congress/bills/114/s1431/text
It is clear to see from this list that the United States Congress thinks it is the job of the federal legislature to “control” not only medications, but also who may write the prescriptions, mandate a protocol that must be utilized, create a master list of patients who take the prescriptions, enable access to a patient’s prescription record, and limit access to certain pain medications for Medicare beneficiaries.
I cringed to read the summary of HR 3719 that requires the department of Health and Human Services to coordinate with the DEA, the Department of Defense, the Department of Homeland Security and the US Attorney General to develop “best practices” guidelines. PLEASE NOTE THAT NONE OF THESE INVOLVE PHYSICIANS OR PHYSICIAN GROUPS.
HR 3677 would establish “peer review” process—this is equivalent to having physicians spy on other physicians regarding their prescription writing. From reading over the summaries of most of these proposed legislations, it is obvious that our congressmen and women feel it is their responsibility to “take on” the misuse of prescription pain medications. While that may seem a noble cause, you may rest assured that means more regulation, more loss of privacy, decreased access to these prescriptions and most likely decreased access even for physicians still willing to prescribe them.
When I was in medical school, there was a push to include a pain scale as another “vital sign.” That meant we should ask about EVERY patient’s pain, have the patient scale it one to ten, and record it in the beginning of all our notes along with other vital signs: blood pressure, heart rate, respiration rate and temperature. We were chastised if every single note in a patient’s chart did not provide this scale, even if pain was not one of the complaints. By residency, I had learned enough to make Tylenol and/or Ibuprofen an order for every hospital patient, because I knew the likelihood of being called for “something for pain”, and generally at 2:00 in the morning. We were instructed on which narcotic pain medications tended to work best for different kinds of pain, which were safe in pregnancy and breastfeeding, what “schedule” each one had (whether they required a paper prescription, could be faxed, called in or could have refills) based on the regulations of the DEA.
Pain is strange. It is a totally subjective problem, meaning: there is really no outward sign, no testing that can be done to scale it and it is totally dependent on the patient reporting it. We always ask a patient to “describe the pain”: location, intensity, what does it feel like (burning, stabbing, aching), does it come and go, what makes it worse, what makes it better? These questions help us understand from where the pain may be coming, what may be causing it and if there is something else going on that could be disastrous or fatal. It also helps us understand whether we as physicians need to treat it. Sometimes it is best to let the pain go untreated, as it can guide us. Some people do better with pain than others. Depression will make someone feel more pain, and pain can be depressing. Pain raises blood pressure. It causes the excretion of stress hormones, such as cortisol, which works against insulin; so, diabetics with pain will tend to have higher blood sugars. Pain can cause nausea and vomiting. It can alter a person’s thought processes and can cause anxiety. Pain is not necessarily a benign symptom.
However, because narcotic pain medication is easily misused, because people can claim to have pain when they do not, and because physicians have been trained to help alleviate pain and treat it as one of the main vital signs, there are a lot of prescriptions for pain medication. Pain relief is often one of the main reasons people seek help from physicians in the first place. Pain is the body’s way of telling us something is amiss, and it comes in various shapes, sizes and styles. People have different tolerances for pain. In spite of all these variances, because of a handful of people who use their medications incorrectly, because of the thieves, the addicts and the greedy, it has become nearly impossible for physicians to adequately treat pain in today’s medical atmosphere. Further regulations, as well as both state and federal drug enforcement agencies want to be able to reach into medical records, physician prescription habits and patient privacy and consider anyone who either prescribes, fills prescriptions or accepts prescriptions from the pharmacy as suspects.
I fully believe there will be a day that I can no longer prescribe any pain medications for patients. It may initially be patients on federal or state insurance programs; then it may extend to those privately insured. Eventually, it will hit the cash-paying uninsured patients. And at that time, I suspect that the only way to obtain pain medications will be on the black market. Because, as we are all well aware, what is made illegal does not simply go away—it just goes underground.