What's Your Pain Care Philosophy?

Because I read WhiteCoat's Call Room blog, I do what I do at most blogs -- inadvertently click on the wrong thing.

This time, though, I was happy where I landed: a column entitled "What's Your Pain Care Philosophy?" by Greg Henry, MD, part of the many interesting offerings in the Emergency Physicians Monthly.

Don't worry. I make sure to only understand what the average layperson "ought"! (Medicos are invested in everyone else being uninformed... Distribution of knowledge might set off a nasty case of Socialism!)

First that problem that I think everyone, from the person in pain to the healthcare professionals to the local pharmacist, recognizes as a problem: the pain scale.

"The first area that I’d like to comment on is the pain score. This seems to be a holy grail for administrative types and those running institutions like the Joint Commission. If there’s ever been less science in medicine, I’d like to see it pointed out," writes Henry.

He concludes, as other medical bloggers have, that what may be useful is to consider the patient's degree of change from the pain's "norm." Last July, Scalpel or Sword wrote a piece proposing "the Delta P," a consideration of change in pain from baseline. This makes enormous sense, and we patients would appreciate the clarity, too.

Next, Henry turns to the issue of drug-seeking, certainly the most cited bête noire of ER/ED workers. It is a heavy onus we place on ER/ED workers, doctors and nurses, alike. We want prompt and perfect care, delivered with compassion and sincerity. We want it all. Now.

It truly is an impossible burden and I understand the rancor that frequently inhabits the blogs of these healthcare professionals. I think Dr. Henry explains things well, even if he can barely scratch the surface in such a short piece. He is starting an interesting conversation:

"[T]here is no hot button in emergency medicine like the evil term 'drug seeker.' It absolutely clouds our thinking about the patient and their problems. As soon as the label of 'drug seeker' has been applied by the staff, all intelligent inquiry stops. We start to put up a wall, really for no good reason. It is always interesting to talk to physicians about whether they had a 'good shift' or a 'bad shift.' It almost never has anything to do with the actual disease entities that were presented. Often, it’s directly related to the number of patients they thought 'really didn’t need pain medication.' I think that we put far too much stress upon ourselves when we start to feel that we are the gatekeeper to pain medications. It is interesting to note that when a patient comes back to the emergency department with recurrent pain, we refer to them as a drug seeker. We don’t refer to a patient with asthma who has come back for more treatment as an 'oxygen seeker.' Exactly why is this a problem? I think to a great degree the personalities involved. Physicians and nurses are, by definition, type A personalities who do all, bear all, go through all, without whining or complaint. We long for the era of wooden ships and iron men when patients were grateful for care and kept their mouths shut. Anyone who has significant pain not relieved on the first attempt probably doesn’t deserve our care. This mentality becomes cyclical and frightening."

He raises the spector of racial bias, noting that studies show that pain relief is less likely to be afforded certain ethnic types and not others, calling this a "black mark on the profession."

The complicated issue of drug addiction, which Henry recognizes as an "ubiquitous problem in this country," cannot be addressed in the emergency department. Some of the more morally imperious will accuse him of being part of the problem, and complacent.

"Whenever I wonder whether I should or shouldn’t be giving a dose of pain medication, I always remember this: I’ve never created an addict by giving one shot of pain meds, and I’ve never cured an addict by withholding it. These are complex issues and I can’t always sort them out in the emergency department. There’s no question that there’s heavy pressure from the nursing staff to deny certain patients medication. The snide comment that 'you’re not going to give them pain medicine, are you, Doctor?' has, more than once, intimidated and dissuaded otherwise compassionate physicians from acting. My philosophy on this is simple. I’d rather treat ten patients who don’t really need the pain medicine than deny the one patient who really does."

I hope others will join in the conversation.