Yes, We Can Control Your Pain

As a practicing cardiovascular surgeon, I fully understand that our profession (healthcare/medicine) has to do a better job of policing itself. And perhaps even more government regulation/policy oversight is necessary.   I would also argue that perhaps too much government intervention has a role in our current narcotic addiction crisis.

It is equally important for the public to understand, at least in part, how we got here.

Here are a few facts that I am sure you are aware of but perhaps your friends and colleagues are not.

1. In the 1970s the JCAHO (Joint Commission on Accreditation of Hospital Organizations) began a significant policy review and regulatory oversight of physician practices related to inadequate pain control, particularly in the inpatient setting.

 2.  In the 1990s after realizing the inadequacy of pain control, JCAHO made sweeping changes to its policies and advocacy for pain control in hospitals. Not only did physicians respond by increasing prescribing habits, so too did the pharmaceutical industry respond by developing more potent narcotic drugs for pain control.

 3.  Additional forces were shaping the landscape of medical practice in the late 90s and early 2000s.

Toward the end of President Clinton's time in office, we recall the Institute of Medicine's report on deaths attributed to medical errors-"To Err is Human." This report led to renewed focus on the quality of healthcare in the US. Thus, physicians were faced with new mandates not just for quality as defined by providers and provider systems but also those relevant to patients such as Healthcare Consumer Assessment of Providers and Hospital Systems (HCAPHS).  HCAPHS scores became publicly reported. A portion of which is weighted on the patient’s perception of pain control in acute care settings.

Simultaneously, the transformation of healthcare delivery systems saw a surge in mergers, acquisitions and integration of physician practices.  To increase the value of healthcare to consumers, and to achieve quality goals and strategic objectives, hospital systems implemented incentive programs based on quality metrics, guess what including HCAPHS and its pain control component. 

 The unintended consequence of pain control policy.

1. Over-prescribing of narcotics when alternative methods may perhaps be safer. See Table below. 
2. Increase in adverse drug reactions related to narcotic use
3. Increase in unintentional overdose
4. AND YES, increase in narcotic addiction.

Yes, we can control your pain!  And yes we can also contribute to your addiction!  In as much as the healthcare provider has a role to play in altering the course of addiction in our communities, so too does the “community”.   The responsibility also lies with policy-makers who must think beyond the sound bite when making decisions that will have irreparable, long-term consequences on our society. 

For further reading, please see references below. 

1.  Undertreatment of medical inpatients with narcotic analgesics.

Marks RM, Sachar EJ

Ann Intern Med. 1973 Feb; 78(2):173-81.

1. Pain management: the fifth vital sign.

Lanser P, Gesell S

Healthc Benchmarks. 2001 Jun; 8(6):68-70, 62

1. Quality improvement guidelines for the treatment of acute pain and cancer pain. American Pain Society Quality of Care Committee.

JAMA. 1995 Dec 20; 274(23):1874-80

1. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement.

Zacny J, Bigelow G, Compton P, Foley K, Iguchi M, Sannerud C

Drug Alcohol Depend. 2003 Apr 1; 69(3):215-32

1. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings?

Vila H Jr, Smith RA, Augustyniak MJ, Nagi PA, Soto RG, Ross TW, Cantor AB, Strickland JM, Miguel RV

Anesth Analg. 2005 Aug; 101(2):474-80, table of contents