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Lessons Learned in Measuring Pain and Prescribing

A roundtable discussion from the California-based Cooperative of American Physicians
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With T. John Hsieh, MD, Medhat Mikhael, MD, Charles P.  Steinmann, MD, and Jae Townsend, MD

The Cooperative of American Physicians (CAP) offers medical professional liability protection and risk management services to nearly 12,000 California physicians. Recently, the group held a clinicians' roundtable called “Pain Management in the Crosshairs” to anecdotally discuss their careers in pain management, from measuring pain across diverse populations, to safely prescribing in a culture of pill-popping, to challenges with insurance and in the differences between patient expectations and physician expectations. The following transcript is published with permission from CAP. Participants included:

Moderator: Carole A. Lambert, MPA, RN, vice president and program director of practice optimization, CAP

Discussants:

Charles P.  Steinmann, MD - an anesthesiology specialist in Costa Mesa, California. He earned his medical degree from the University of California, San Francisco, School of Medicine and has more than 47 years of medical practice experience. Dr. Steinmann is affiliated with several hospitals, including Hoag Memorial Hospital Presbyterian in Newport Beach, CA.

T. John Hsieh, MD - a board-certified anesthesiologist and interventional pain management physician based in Irvine, CA. Dr. Hsieh is affiliated with Newport Harbor Anesthesia Consultants and earned his medical degree from the University of Kansas Medical School. 

Jae Townsend, MD - a board-certified anesthesiologist affiliated with Huntington Hospital in Pasadena, CA. She received her medical degree from University of Tennessee College of Medicine.

Medhat Mikhael, MD - a double-board certified anesthesiologist and pain medicine practitioner. Dr. Mikhael is director of the Pain Medicine Division, Department of Anesthesiology, at Hoag Memorial Presbyterian Hospital in Newport Beach, CA. He is also an active member of the cancer committee of Hoag Memorial as well as the Long Beach and Orange Coast Medical Centers.

 

Ms. Lambert: Dr. Steinmann, [can you get] the ball rolling by sharing a brief historical perspective on the challenges of pain management while you have been in practice?

Dr. Steinmann: The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain protects us from injury and disease. Fact is, we always will have to deal with pain. The trick is once the injury or disease is recognized, how do we shut off that response?

In one of the earliest recorded pain treatments, the ancient Egyptians used beer for surgical procedures. For the last few centuries, the gold standard for controlling pain has been morphine. By the time of the Civil War, general anesthesia – ether or chloroform – was used in over 85% of all amputations on the battlefield. During the mid-20th century, multiple other mechanisms began to be used such as local anesthesia, pain blocks, acupuncture, antidepressants, pain pathway inhibitors like gabapentin, and anti-inflammatories.

By the late 1990s, it was still easier for prescriptions for pain medications – such as Vicodin or codeine – to be written that way. At the same time, multiple pressures were put on the physician to prescribe more. Because of the problem of addiction, now we are under pressure to prescribe less. 

Dr. HsiehI’ve watched the pendulum swing throughout my career. In 1980, a letter to the editor was sent to the New England Journal of Medicine, stating that treating pain patients with narcotics would not cause them to become addicted to narcotics. This was a revolutionary statement, and that letter - with its observations and conclusions - became the most cited publication for the treatment of pain and influenced how physicians prescribed opioids for the following 25 to 30 years.

But, pinpointing where and when the use and abuse of addictive substances really took off is difficult because our society has historically been a society of using pills. In the years I was going through high school and college, the use of cocaine and ready access to prescription drugs was obvious. It’s very hard to say that physicians promote pill popping when it is such a part of American society. And there is the economic reality that prescription medications are big business, which has to be part of any attempt to deal with substance use and abuse.

At the end of the day, pain is very difficult to measure. It is ultimately subjective and unlike any other vital sign in that there is no real measuring device you can use. When you're treating pain, it is based on the patient’s perspective and sometimes a lot more complicated than it first appears.

Dr. Townsend: My experience in collecting historical information for a patient going into anesthesia and then receiving post-op care just underscores the fact that every human being is wired differently. So the wiring of a female is different from a male. A person who has had past experience with pain throughout their whole life, or just even early in childhood, has different wiring than an adult who has no experience. As a society, as a culture, I encounter people daily who are about to undergo surgical procedures and have an unrealistic expectation that they're going to have zero out of 10 pain post-operatively. So as a society, we've set ourselves up to have an unrealistic societal expectation that you're never going to have any pain or suffering. We are a culture of pill poppers.

People have pills for every single thing from slight anxiety or slight depression to minor discomfort. Granted, there are plenty of times that this is warranted and appropriate, and I'm not undervaluing that at all. But we have to undergo nothing short of a cultural revolution in which we, as physicians, educate people that it's unrealistic to expect no pain. I typically tell my patients that we're going to have controlled or managed pain after surgery. 

Overprescribing originated due in large part to instances in which physicians were held accountable for patients with uncontrolled pain. Specifically, end of life, death, and dying. There was liability, there was accountability, there were physicians who were sued. In consequence, I think clinicians overreacted and began overprescribing because they were afraid of having patients complain about there being under-prescribers.

Let me just add to that opioid use in the United States has consistently been the same. We just had opioid use that was prescription opioid use. Whenever there wasn't a lot of prescription opioid, there was a lot of heroin. Now that there's less prescription opioid, there's more heroin. People in this culture, in this society, are addicted to opioids and we have to have a societal change.

Last updated on: July 27, 2018
Continue Reading:
CDC Issues Final Guidelines for Opioid Prescribing: PPM Editorial Board Responds
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