Kiran Gupta writes about her experiences as a resident in the Department of Medicine at Brigham and Women's Hospital. She has done research on domestic health policy issues, including health care costs, medical errors, and end-of-life care, and is a former columnist for the Financial Times Weekend Magazine. Kiran received her A.B. in Government with a certificate in Health Policy from Harvard College and earned her M.D. from Harvard Medical School.
I looked down at my pager. The emergency room needed me to urgently evaluate a patient. “Patient in pain, please assess.’’
By the time I reached his bedside, however, the young man had already received numerous doses of powerful intravenous narcotics and could barely keep his eyes open, making it impossible to take a proper medical history or perform an adequate physical exam. When I pressed on his belly, the patient hardly seemed to notice. The nurse told me he had arrived at the emergency room claiming to be in terrible pain. At this point, all I could tell was that he appeared to have been over-medicated.
An hour later, my patient briefly awoke and began asking for more pain meds. I went to see him, concerned that escalating his narcotic dose could cause respiratory depression – and potentially endanger his life. Looking over his chart, I saw that he had been admitted multiple times over the past two years seeking pain treatment; he also had a history of drug abuse. I decided to hold off on further narcotics. But a few hours later, my pager went off again. I returned to the patient’s bedside and once more found him in a deep stupor. At the sound of my voice, his eyes fluttered open briefly. He raised his hand in an attempt to gesture at the intravenous drip, as if asking for more, but it quickly fell limp at his side.
I was torn: Where did treating pain end and furthering addiction begin?
Pain is often called the fifth vital sign, after temperature, heart rate, blood pressure and oxygen saturation. Early on in medical school, we learn to ask patients, “What’s your pain on a scale of 1 to 10, with 10 being the worst pain you have ever experienced?’’ All around the hospital, posters depict pain charts with faces corresponding to different levels of discomfort. Patients often use these to provide caregivers with some sense of what they are experiencing. Yet pain is ultimately subjective. One person’s level eight is a mere four to another. Some patients may over-report pain out of fear that they will otherwise go undertreated. Others, perhaps for cultural reasons or out of sheer habit, remain stoic and must be pressed before admitting they feel discomfort.
Treatment of pain is complicated – the complex pathways that lead to its sensation are still not well understood. As physicians, we constantly confront patients suffering from all types of pain; it’s often what brings them to the hospital or our office in the first place. But we must constantly walk a fine line. Failure to treat pain appropriately can cause unnecessary suffering and erode a patient’s trust. Yet overtreatment, particularly with powerful and addictive medications, can worsen quality of life, prolong hospital stays, and even cause life-threatening complications.
The New England Journal of Medicine recently reported that between 1997 and 2007, the number of prescriptions for narcotic medications in the United States increased seven-fold. Opiate analgesics like Percocet, oxycodone, and OxyContin are today among the most widely prescribed drugs in the country. Though they are sometimes necessary, these medications come with serious risks. Prescription narcotics contribute to over 15,000 deaths from overdose and more than 25,000 admissions to health care facilities each year, while causing many more cases of sleep apnea, altered mental status, accidents, and addiction. As prescription rates continue to increase, these numbers are rising steadily. For this reason, a number of health policymakers have begun urging legislators to limit the use of narcotics, highlighting a deepening controversy within the medical community.
In many cases, prescribing narcotics to alleviate physical suffering is undoubtedly appropriate. Cancer, for example, is known for causing severe pain. Similarly, patients who suffer acute trauma or are recovering from major surgery face intense pain that can require powerful narcotics to manage. Patients who are terminally ill may also benefit from these drugs, though the choice can be difficult when minimization of pain means sedation and the inability to communicate with a loved one.
But the proper use of narcotics is less clear when managing those with chronic pain syndromes who often have a long history of prescription pain medication use. The young patient whom I admitted to the hospital was afflicted with a lifelong condition that causes serious discomfort when it flares up. He came in initially complaining of severe pain, but after receiving several doses of potent opiates, he no longer displayed any of its objective physical signs. When I examined him, his heart rate was not rapid, his blood pressure was normal, he was not sweaty, and he seemed to have no difficulty sleeping. In fact, I could barely rouse him. But each time he was asked, he would describe his pain as “10 out of 10.’’ Had I continued to treat his self-reported pain – or perhaps his desire for pain medication – with additional narcotics, I could easily have stopped his breathing.
Growing evidence suggests that chronic pain conditions are often best addressed through multi-disciplinary efforts. These typically involve pain specialists, social workers, mental health experts, physical therapists, and an exercise program. Patients who suffer from ongoing discomfort are frequently anxious, depressed, or impaired by other psychiatric illnesses that, if not adequately addressed, exacerbate their underlying sensation of pain. When these patients are instead treated with heavy doses of narcotic medications, they can develop addictions that make subsequent treatment far more complicated – like the young man in my care.
Treating pain is an essential part of a physician’s work. But perhaps we ought to more readily admit to our patients that doing so can be extremely challenging and may at times require trial-and-error before achieving an effective approach. Prescribing a pill might get a patient out of the office faster or silence the incessantly beeping pager, but it is not always the answer. While doctors have an ethical obligation to treat pain, in doing so we must remember to balance this duty with that which is paramount: to do no harm.