Manage Pain, Not Regulations

Six weeks. That’s how long I laid in agony. I waited for six weeks as my doctor tried one thing after another, before finally prescribing adequate pain medication for my previously diagnosed juvenile arthritis. He was following protocol, of course, but lying in bed for six weeks as I was denied the pain relief I desperately craved, makes protocol a poor excuse for waiting. Had he prescribed them sooner, I would not have spent those many weeks in pain. However, that was not the “appropriate” way to handle the situation. Regulations mandated that he prescribe exercise and the weakest type of pain medications before slowly progressing to stronger ones. Because of this, I spent two weeks in an intensive exercise program, followed by four weeks of taking weak pain relievers such as acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID) commonly found in Tylenol and Midol, and naproxene, a different NSAID found in Aleve. Then, my doctor prescribed diclofenac, another NSAID specified towards arthritis. It was not until these methods had failed did I progress up the medicinal totem pole. Finally, I was prescribed prednisone, a corticosteroid hormone, which was at least more successful than the other pain medications. This, however, took weeks to achieve. This is only one example of the many people who anxiously await adequate pain relief, while doctors prescribe one useless thing after another, under the pretense of protocol.

Protocol is one of the main issues discussed in the larger debate surrounding pain management. At the root of the problem is the inconsistency among doctors. Some doctors adhere to protocol like it is stitched to their sides, while others merely consider it a guideline. Knowing when it’s appropriate to follow protocol and when it is better to think out of the box would contribute to the establishment of consistent care.

Although consistency is important, the bigger issue at hand concerns the regulations that determine protocol, though this is linked to consistency as well. Because there has been both the problem of doctors who over-prescribe pain medications and those who under-prescribe them, regulations appear to be necessary. While everyone can agree that they are necessary, it is difficult to come to a conclusion as to how far they should go. There will always be those who believe they do not go far enough and those who believe they go too far. Therefore the current question remains whether regulations are too strict or not strict enough in regard to prescription pain medications, especially opioid analgesics.

Patients, as well as some doctors, believe that the regulations go too far, and that patient care is suffering because of it. They think a patient’s pain should be prioritized above following regulations, and protocols that sometimes make acquiring adequate medication and relief more challenging. It is their belief that doctors are not taking their patients seriously enough, and also that the availability of stronger pain medicine should be increased rather than decreased due to the concerns of doctors and government officials.

On the other hand, government officials, as well as other doctors, believe that regulations do not go far enough, and that public safety is compromised due this. They are concerned about the potential addictive qualities of opioid analgesics, in addition to their side effects, and believe that a patient’s safety should be a matter of the highest priority. They are also concerned about the illegal recreational use of these drugs, and the possible consequences of making them more available.

Over the course of this paper I will show you why the pain management system is flawed and demonstrate the cruelty of under-treating or not treating a person’s pain. I will explain the causes of the problems with pain management, and refute the arguments concerning addiction and abuse. Finally, I will guide the conclusion that the way we view and treat pain is ineffective and inappropriate and should therefore be changed to better serve the needs of the patients.

It was easy to see the problems with pain management from the patient’s point of view-- from where I was sitting when I was anxiously awaiting some pain relief. Withholding treatment seemed an obvious issue, but for people who are not directly suffering from this, the concept might be more difficult to grasp. Chronic pain alone disables one in ten Americans, and over ninety billion dollars are lost by the United States economy in the form of disability, medical costs, and paid absences (“Chronic.org”). These numbers do not factor in pain due to other causes such as cancer or arthritis, or the number of people affected by pain in other parts of the world. Of the people in the world suffering from pain, eighty percent of them are either undertreated or not treated at all (Chen). These numbers are unacceptable, and represent the poor situation in which the pain management system currently resides.

A continuous problem for the pain management system is the understanding of the mechanisms that produce pain. With chronic pain, the central nervous system becomes sensitized, or continues to send pain signals despite what is happening at the origin of the pain (Schneider 17). This makes finding the source of the pain and treating it extremely difficult because even though the source may be healed, as long as the signals are firing, the person is still in pain. This lack of knowledge is a complication in diagnosing pain, which is its own challenge facing pain management.

Because pain is something that is felt by an individual, it ranges from difficult to impossible to diagnose. Although there are qualitative tests to run through to determine a person’s pain level, there are no definitive, quantitative ones like there are for other medical problems. Also, patients who have been in pain for a while, adjust their lives and their autonomic nervous system, so he or she does not exhibit traditional “pain behavior” such as crying, wincing, or hyperventilating. A lack of these actions does not mean he or she is not in pain, but that he or she has become accustomed to the pain so that it no longer warrants these intense behaviors. The ability to diagnose is a doctor’s most useful tool, yet pain evades that concrete knowledge. This makes many doctors cautious about prescribing opioids like Percocet and Vicodin, despite the fact that they relieve pain (Schneider 17). This is damaging to the patients because it causes the patients to suffer unnecessarily. It is also harmful to the pain management system because it leads to a poor patient-doctor dynamic, in which the doctor does not trust the patient and the patient exaggerates his or her pain to convince the doctor to prescribe the medication he or she should have prescribed in the first place (Parris). This becomes a vicious cycle with no end and no winner.

Another reason doctors are hesitant to prescribe pain medications is the rumors surrounding them. According to Dr. Winston Parris, a Professor of Anesthesia and Chief of Pain Programs at Duke University Medical Center, many doctors have a misunderstanding as to the effects, both positive and negative, of opioid analgesics. Once again, the primary issue seems to be a lack of knowledge on the doctors’ part. However, it is not necessarily their fault, but the lack of research and knowledge of the field in general. For example, there are no conclusive results on the long-term effects of opioids, as shown by the equal number of studies concluding that they have dangerous long-term effects and no long-term effects at all (Meier). Therefore, the debate over whether continued use leads to addiction, tolerance, and abuse is circular without a definitive answer. This ambiguity has many doctors reluctant to prescribe medicine that could potentially be harmful to the patients, no matter how effective it is in the short-run. Even without conclusive results, it can be observed that people who use it in the short-term and with monitored dosages feel effective pain relief that is sometimes denied due to miscomprehension.

Pain relief is also denied due to government agencies’ regulations, such as those of the Food and Drug Administration, or FDA. These regulations restrict access to pain medications on the basis of side effects, potential addiction, and recreational abuse, though none of these reasons treat the actual patients fairly. As a pain sufferer, I understand there are risks and side effects associated with opioid analgesics such as drowsiness, weight gain, and in extreme cases cardiovascular complications (Payne 60). In fact, even Bextra, an NSAID, was taken off the market in 2005 by the FDA because it was shown that they had too great of risk of severe cardiovascular problems and deadly skin disease, especially in the older patients it was being prescribed too (O’Connor). However, there are just as many side effects associated with sleep medicine, baby aspirin, and cancer treatments such as dependency, ulcers, nausea, and severe bone pain respectively (“ACS”, “Baby”, & “Side”). The argument for the latter is that cancer is a more serious issue because it leads to death, and in fact doctors are more willing to prescribe opioids to cancer patients because their life span is already shortened (Schneider 17). Nevertheless, pain affects more people and results in less overall productivity than cancer, yet pain patients are subjected to more strict regulations and testing (“Chronic.org”). This is cruel to the patients who are affected by a serious medical problem that is not being taken seriously. These patients have a basic human right to treatment, which is being denied by unnecessarily strict regulations.

Additionally, the FDA is concerned about the potential for addiction and the recreational abuse of prescription medications (Woodcock 2105). Since the discovery of Oxycontin, there has been an increase in the prescription drug abuse. In response to this, they implemented stricter regulations regarding pain prescriptions (Schmidt 554). In 2001, the Drug Enforcement Agency (DEA) began investigating doctors, both physicians and pharmacists to ward off accusations from Glen Fine, the inspector general of the Department of Justice, that their organization was not effectively preventing illegal prescription drug use. With the DEA and FDA targeting them, doctors became more hesitant to prescribe opioids, even to those who needed them.  Though, in general doctors want to help patients, they are not willing to sacrifice their medical license to do so. This is not beneficial to anyone. The patients do not receive the relief they require; the doctors neither fulfill their potential nor abide by their oath to do no harm; and the government agencies lose the public’s trust and support.

Although there is a problem with drug abuse, as noted by the 5.2 million people who used prescription painkillers in a nonmedical way in 2007, it is wrong to punish innocent patients in need of relief for their bad behavior (Clemmitt). This is clear because despite the DEA’s attempt to tighten regulations on the prescription medication market in 2001, as of 2007, prescription medicine is still used for recreation by more than double the number of people who use cocaine (McBride). If the tighter restrictions are not preventing people from using prescription medicine recreationally as it was predicted they would, then they should be revoked based on the inefficiency alone. This is not to mention the negative effects these regulations have had on patients. As of December 2009, thirty two million Americans have experienced pain for over a year, and as of March 2010, at least ten thousand pain patients are not being adequately treated because of regulations (“Drugs” & Payne 60). This huge medical issue is not being treated properly. If this affects this many people in our society, then the government whose job is to help our society, should indeed help by loosening the restrictions on pain medications.

Now that the issue has been defined, and the causes have been made clear, I hope it can be agreed that the current system of pain management is not working. There are too many doctors under-treating or refusing to treat pain, and too many patients suffering because of it. This is not a humane way to handle this. Although I agree that addiction and abuse can be an issue, the pain of the innocent people is the bigger issue at hand, and everyone should be viewed as innocent until proven guilty. Pain is not something that shows up on a test or that a doctor can experience for the patient. Pain is one of the most debilitating medical issues in the United States, so it is not a matter to be taken lightly (McBride). Therefore, it is necessary for doctors to listen to their patients and trust that they are telling them the truth. This would prevent patients from exaggerating to receive the treatment they need.

Along with the doctors’ trust, government agencies such as the FDA need to trust that the doctors are not going to prescribe the pain medication to anyone who walks through their doors. Instead of establishing regulations preventing patients from feeling relief, theses agencies should be instating regulations mandating everyone’s pain be treated equally and taken seriously. Although the FDA should be far from promoting overuse of the prescription pain, they should be advocating for the best quality of care possible.

When it involves the issue of pain management, the general pain-feeling community and the pain management government agencies are rarely on the same side. Consequently, the debate over where to draw the line for regulations goes back and forth much like an intense game of tug-of-war, with each team pulling with all its might to get the flag on its side of the line. Ultimately, the flag belongs in the middle, or more towards the patient care side, though currently it resides too far towards the regulations one. There are many reasons as to why the flag belongs towards the patients.  A person’s pain is of the utmost importance because it interferes with daily functioning and activity, so to ignore a person’s pain is cruel and unjust. Why would doctors be so cruel? Though the potential dangers could be one reason, more likely is that they fear the very regulations drug control organizations want to implement. While the government may be worried about addiction and abuse, if good judgment is used and the patient is monitored, then that should not be an issue. Lastly, although there is a prescription drug abuse problem in the recreational field, there are too many people whose pain goes untreated or undertreated for abuse to take the main priority. The pain community needs to come together for further education about opioids and the mechanisms involved with pain management. It needs to increase the number of patients who feel relief by decreasing regulations and lightening the investigations on the prescribing physicians, or everyone will suffer the pain of the suffering.