Keeping Pain A Priority

Before pain was introduced as the “fifth vital sign” and the Joint Commission issued its standards, more than a decade’s worth of international research indicated that pain was largely ignored, untreated, or undertreated. The best tools available to treat pain (opioids) were reserved for patients on their deathbed. The horrific results of the SUPPORT study at the nation’s leading hospitals revealed that most patients had severe, uncontrolled pain up until their final days of life.¹ Unfortunately, research suggests we are still reserving opioids for the last days or weeks of life.²

In 1992 and 1994, the Department of Health and Human Services issued clinical practice guidelines highlighting the huge gap between the availability of evidence-based pain control methods and the lack of pain assessment and treatment in practice.³ When these guidelines failed to change practice, the Joint Commission added “attending to pain” to its standards—the first effort to require that evidence-based practices be utilized. Twenty years later, the National Academy of Science issued a report stating that, despite transient improvements, the current state is inadequate since pain is the leading reason people seek health care. Patients with pain report an inability to get help, which is “viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.”⁴ Since I started working as an NP in 1983, I have never seen as many patients with pain stigmatized, ignored, labeled, and denied access to treatment as I have in the past year.

Pain afflicts more than 100 million Americans and is the leading cause of disability worldwide.⁵ Acute pain that is not effectively treated progresses to chronic pain in 51% of cases.⁶ An estimated 23 million Americans report frequent intense pain, 25 million endure daily chronic pain, and 40 million adults have high-impact, disabling, chronic pain that degrades health and requires health care intervention.^6,7 The most notable damage is to the structure and function of the central nervous system.⁸ Brain remodeling and loss of gray matter occurs, producing changes in the brain similar to those observed with 10 to 20 years of aging; this explains why some of the learning, memory, and emotional difficulties endured by many with ongoing pain can be partially reversed with effective treatment.⁹ Left untreated, pain can result in significant biopsychosocial problems, frailty, financial ruin, and premature death.^10-14

Prescription drug misuse and addiction also affect millions and have been a largely ignored public health problem for decades. Trying to fix the pain problem without attending equally to the problems of nonmedical drug use, addiction, and overdose deaths has contributed to the escalation of health problems to “epidemic” and “crisis” proportions. Although most patients who are prescribed medically indicated opioids for pain do not misuse their medications or become addicted, the failure to subsequently identify and properly treat an emergent substance use disorder is a problem in our current system.¹⁵ Unfortunately, making prescription opioids inaccessible to patients forces some to abuse alcohol or seek drugs from illicit sources, which only exacerbates the situation.¹⁶ A national study performed over a five-year period revealed that only 10% of patients admitted for prescription opioid treatment were referred from their health care providers.¹⁷ So, health care providers may have been part of the problem but have not been fully engaged in the solution.

Although opioids are neither the firstline, nor only, treatment option in our current evidence-based treatment toolbox, their prudent use does not cause addiction. Only 1% of patients who receive postoperative opioids go on to develop chronic opioid use, and adolescents treated with medically necessary opioids have no greater risk for future addiction than unexposed children. It is the nonmedical use of opioids, rather than proper medical use, that predisposes people to addiction.^18,19 Discharging or not treating patients suspected of “drug-seeking” exacerbates the problem. Rates of opioid prescription have declined, while overdoses of illicitly manufactured fentanyl increased by 79% in 27 states from 2013 to 2014.²⁰ In Massachusetts, only 8% of people who fatally overdosed had a prescription, while illicit fentanyl accounted for 54% of overdose deaths in 2015 and more than 74% in the third quarter of 2016.²¹ We need to screen for nonmedical use, drug misuse, and addiction before, during, and after we treat with this particular tool.

Unfortunately, the prevalence of pain and addiction are both increasing, especially for women and minorities—but there are safe, effective medications and non-drug approaches available to combat this.^22-24 These problems will not go away on their own, and every health care professional must choose to be part of the solution rather than perpetuate the problem. A good place to start is to become familiar with the Surgeon General’s Report and the National Pain Strategy. Educate your patients, colleagues, and policy makers about the true nature of these problems. Take a public health approach to primary, secondary, and tertiary prevention by recognizing and treating these conditions in an expedient and effective matter. When problems persist, expand the treatment team to include specialists who can develop a patient-centered, multimodal treatment plan that treats co-occurring conditions. If we continue to ignore these problems, or focus on one at the expense of the other, both problems will worsen and our patients will suffer serious consequences.

Paul Arnstein, PhD, NP-C, FAAN, FNP-C

Boston, MA

Before pain was introduced as the “fifth vital sign” and the Joint Commission issued its standards, more than a decade’s worth of international research indicated that pain was largely ignored, untreated, or undertreated. The best tools available to treat pain (opioids) were reserved for patients on their deathbed. The horrific results of the SUPPORT study at the nation’s leading hospitals revealed that most patients had severe, uncontrolled pain up until their final days of life.¹ Unfortunately, research suggests we are still reserving opioids for the last days or weeks of life.²

In 1992 and 1994, the Department of Health and Human Services issued clinical practice guidelines highlighting the huge gap between the availability of evidence-based pain control methods and the lack of pain assessment and treatment in practice.³ When these guidelines failed to change practice, the Joint Commission added “attending to pain” to its standards—the first effort to require that evidence-based practices be utilized. Twenty years later, the National Academy of Science issued a report stating that, despite transient improvements, the current state is inadequate since pain is the leading reason people seek health care. Patients with pain report an inability to get help, which is “viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.”⁴ Since I started working as an NP in 1983, I have never seen as many patients with pain stigmatized, ignored, labeled, and denied access to treatment as I have in the past year.

Pain afflicts more than 100 million Americans and is the leading cause of disability worldwide.⁵ Acute pain that is not effectively treated progresses to chronic pain in 51% of cases.⁶ An estimated 23 million Americans report frequent intense pain, 25 million endure daily chronic pain, and 40 million adults have high-impact, disabling, chronic pain that degrades health and requires health care intervention.^6,7 The most notable damage is to the structure and function of the central nervous system.⁸ Brain remodeling and loss of gray matter occurs, producing changes in the brain similar to those observed with 10 to 20 years of aging; this explains why some of the learning, memory, and emotional difficulties endured by many with ongoing pain can be partially reversed with effective treatment.⁹ Left untreated, pain can result in significant biopsychosocial problems, frailty, financial ruin, and premature death.^10-14

Prescription drug misuse and addiction also affect millions and have been a largely ignored public health problem for decades. Trying to fix the pain problem without attending equally to the problems of nonmedical drug use, addiction, and overdose deaths has contributed to the escalation of health problems to “epidemic” and “crisis” proportions. Although most patients who are prescribed medically indicated opioids for pain do not misuse their medications or become addicted, the failure to subsequently identify and properly treat an emergent substance use disorder is a problem in our current system.¹⁵ Unfortunately, making prescription opioids inaccessible to patients forces some to abuse alcohol or seek drugs from illicit sources, which only exacerbates the situation.¹⁶ A national study performed over a five-year period revealed that only 10% of patients admitted for prescription opioid treatment were referred from their health care providers.¹⁷ So, health care providers may have been part of the problem but have not been fully engaged in the solution.

Although opioids are neither the firstline, nor only, treatment option in our current evidence-based treatment toolbox, their prudent use does not cause addiction. Only 1% of patients who receive postoperative opioids go on to develop chronic opioid use, and adolescents treated with medically necessary opioids have no greater risk for future addiction than unexposed children. It is the nonmedical use of opioids, rather than proper medical use, that predisposes people to addiction.^18,19 Discharging or not treating patients suspected of “drug-seeking” exacerbates the problem. Rates of opioid prescription have declined, while overdoses of illicitly manufactured fentanyl increased by 79% in 27 states from 2013 to 2014.²⁰ In Massachusetts, only 8% of people who fatally overdosed had a prescription, while illicit fentanyl accounted for 54% of overdose deaths in 2015 and more than 74% in the third quarter of 2016.²¹ We need to screen for nonmedical use, drug misuse, and addiction before, during, and after we treat with this particular tool.

Unfortunately, the prevalence of pain and addiction are both increasing, especially for women and minorities—but there are safe, effective medications and non-drug approaches available to combat this.^22-24 These problems will not go away on their own, and every health care professional must choose to be part of the solution rather than perpetuate the problem. A good place to start is to become familiar with the Surgeon General’s Report and the National Pain Strategy. Educate your patients, colleagues, and policy makers about the true nature of these problems. Take a public health approach to primary, secondary, and tertiary prevention by recognizing and treating these conditions in an expedient and effective matter. When problems persist, expand the treatment team to include specialists who can develop a patient-centered, multimodal treatment plan that treats co-occurring conditions. If we continue to ignore these problems, or focus on one at the expense of the other, both problems will worsen and our patients will suffer serious consequences.

Paul Arnstein, PhD, NP-C, FAAN, FNP-C

Boston, MA

Before pain was introduced as the “fifth vital sign” and the Joint Commission issued its standards, more than a decade’s worth of international research indicated that pain was largely ignored, untreated, or undertreated. The best tools available to treat pain (opioids) were reserved for patients on their deathbed. The horrific results of the SUPPORT study at the nation’s leading hospitals revealed that most patients had severe, uncontrolled pain up until their final days of life.¹ Unfortunately, research suggests we are still reserving opioids for the last days or weeks of life.²

In 1992 and 1994, the Department of Health and Human Services issued clinical practice guidelines highlighting the huge gap between the availability of evidence-based pain control methods and the lack of pain assessment and treatment in practice.³ When these guidelines failed to change practice, the Joint Commission added “attending to pain” to its standards—the first effort to require that evidence-based practices be utilized. Twenty years later, the National Academy of Science issued a report stating that, despite transient improvements, the current state is inadequate since pain is the leading reason people seek health care. Patients with pain report an inability to get help, which is “viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.”⁴ Since I started working as an NP in 1983, I have never seen as many patients with pain stigmatized, ignored, labeled, and denied access to treatment as I have in the past year.

Pain afflicts more than 100 million Americans and is the leading cause of disability worldwide.⁵ Acute pain that is not effectively treated progresses to chronic pain in 51% of cases.⁶ An estimated 23 million Americans report frequent intense pain, 25 million endure daily chronic pain, and 40 million adults have high-impact, disabling, chronic pain that degrades health and requires health care intervention.^6,7 The most notable damage is to the structure and function of the central nervous system.⁸ Brain remodeling and loss of gray matter occurs, producing changes in the brain similar to those observed with 10 to 20 years of aging; this explains why some of the learning, memory, and emotional difficulties endured by many with ongoing pain can be partially reversed with effective treatment.⁹ Left untreated, pain can result in significant biopsychosocial problems, frailty, financial ruin, and premature death.^10-14

Prescription drug misuse and addiction also affect millions and have been a largely ignored public health problem for decades. Trying to fix the pain problem without attending equally to the problems of nonmedical drug use, addiction, and overdose deaths has contributed to the escalation of health problems to “epidemic” and “crisis” proportions. Although most patients who are prescribed medically indicated opioids for pain do not misuse their medications or become addicted, the failure to subsequently identify and properly treat an emergent substance use disorder is a problem in our current system.¹⁵ Unfortunately, making prescription opioids inaccessible to patients forces some to abuse alcohol or seek drugs from illicit sources, which only exacerbates the situation.¹⁶ A national study performed over a five-year period revealed that only 10% of patients admitted for prescription opioid treatment were referred from their health care providers.¹⁷ So, health care providers may have been part of the problem but have not been fully engaged in the solution.

Although opioids are neither the firstline, nor only, treatment option in our current evidence-based treatment toolbox, their prudent use does not cause addiction. Only 1% of patients who receive postoperative opioids go on to develop chronic opioid use, and adolescents treated with medically necessary opioids have no greater risk for future addiction than unexposed children. It is the nonmedical use of opioids, rather than proper medical use, that predisposes people to addiction.^18,19 Discharging or not treating patients suspected of “drug-seeking” exacerbates the problem. Rates of opioid prescription have declined, while overdoses of illicitly manufactured fentanyl increased by 79% in 27 states from 2013 to 2014.²⁰ In Massachusetts, only 8% of people who fatally overdosed had a prescription, while illicit fentanyl accounted for 54% of overdose deaths in 2015 and more than 74% in the third quarter of 2016.²¹ We need to screen for nonmedical use, drug misuse, and addiction before, during, and after we treat with this particular tool.

Unfortunately, the prevalence of pain and addiction are both increasing, especially for women and minorities—but there are safe, effective medications and non-drug approaches available to combat this.^22-24 These problems will not go away on their own, and every health care professional must choose to be part of the solution rather than perpetuate the problem. A good place to start is to become familiar with the Surgeon General’s Report and the National Pain Strategy. Educate your patients, colleagues, and policy makers about the true nature of these problems. Take a public health approach to primary, secondary, and tertiary prevention by recognizing and treating these conditions in an expedient and effective matter. When problems persist, expand the treatment team to include specialists who can develop a patient-centered, multimodal treatment plan that treats co-occurring conditions. If we continue to ignore these problems, or focus on one at the expense of the other, both problems will worsen and our patients will suffer serious consequences.

Paul Arnstein, PhD, NP-C, FAAN, FNP-C

Boston, MA