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Walking the Tightrope of Appropriate Pain Management A fine line: practical advice for coping with the dilemma of delivering optimal pain management while minimizing risk of investigation
Raylene M. Rospond
Posted: May 2008  
Practical Pain Management: June 2007; Vol.7


On Sunday, July 26, 1998, Doonesbury captured the essence of the pain management tightrope when, in response to the statement "You know, Doctor, I think Mrs. Davenport is still in a lot of pain ... canít you just increase her morphine dose?" The doctor replied "Nope. Your dear friend has the misfortune of dying after 1914, which was the last time physicians had full discretion in prescribing narcotics." In 2007, this cartoon might be a statement of the impact of the insurance industry on the practice of medicine, however, it can also be a statement of the affect of regulatory oversight on the practice of pain management.

The Problem:  Pain is one of the most common problems experienced by patients in the United States and affects 50 million Americans. Chronic or recurrent pain affects 57% of adults in the United States creating the need for these individuals to implement lifestyle changes in order to accommodate the pain. The burden of chronic pain affects society as well as the individual, and costing over $100 billion annually in lost workdays, medical expenses and other related costs. In 2004, a study found that of persons employed and living with chronic pain, 41% reported that their chronic pain adversely affected their ability to put in a full dayís work, while 27% had difficulty in getting to work. In a recent study of 805 chronic pain sufferers, over 50% had to change physicians to achieve relief, either because their original physician was unwilling to treat pain aggressively, did not take the patientís pain seriously, or had inadequate knowledge about pain treatment.

Why Is Pain Under-Treated?  Many factors contribute to the under treatment of pain. The ability to achieve optimal pain management can be influenced by the patient, the health care provider, and the healthcare system. Healthcare professionals must be aware of these various barriers and prepared to address and overcome them when they occur.

Barriers to Adequate Pain Management: Patient and Family Members:
          Reluctance to report pain
          Reluctance to take pain medication
Health Care Professionals:
          Inadequate knowledge and training
Health Care System:
          Low priority given to pain management
          Inadequate reimbursement
          Restrictive regulation of controlled substances
Regulatory System:
          Anti-diversion policies
          Triplicate prescriptions
          Limits on the number of dosages that may be prescribed at one time

Fear of Over-Prescribing:  Although rare, high profile cases of physicians being prosecuted for prescribing opioids for pain management result in physicians remaining reluctant to prescribe pain medication for fear of potential penalties and the subsequent loss of professional standing and ability to earn a livelihood.

Legal Threat for Under-Prescribing:  Fear of regulatory scrutiny has been strongly tied to the under-treatment of pain. Until recently, there have been no incentives, other than professional and moral responsibility, for healthcare providers to adequately treat pain.

Striking a Balance:  So how does the provider strike a balance? Statements that there is nothing to fear from regulatory oversight will not remove this barrier to adequate pain management. An individualís fear is typically managed by developing coping mechanisms and minimizing risk. What can providers do to realize their professional obligations in providing optimal pain management while minimizing their risk of investigation or actions resulting from regulatory oversight? First, they must educate themselves and their staff on chronic pain. And prescribers should establish procedures that avoid perceived behaviors patterns that may be indicative of inappropriate prescribing.

Suspect Patient Behavior Related to Medication Use:
          Inability to take medications according to agreed upon schedule
          Taking multiple doses together
          Frequently runs out of medication early, despite dosage agreement
          Frequently reports lost or stolen prescriptions
          Forging prescriptions, stealing or borrowing drugs
          Solicits multiple prescribers
          Fails to refill others Rxs but always arrives for opioid prescriptions
          Reports no relief with other medications; reports allergies to all other drugs

Conclusion:  There are many factors that are keeping the United States from realizing our goal of optimal treatment for all pain patients. Fear of regulatory scrutiny on the part of healthcare providers plays a significant role but it can be addressed by following treatment guidelines and establishing procedures that: thoroughly assess pain patients; establish goals for treatment; clearly outline the healthcare providers expectations of the patient; documents the medications prescribed, efficacy achieved, side effects experiences, and documents and evaluates an aberrant drug taking behaviors on the part of the patient.

In establishing and following these procedures, healthcare providers can lower their risk of investigation and fulfill their professional obligations to provide appropriate patient care to pain patients.