This piece, “Pain”, appeared on page 24 of the Fall 2023 issue of Chicago Life Magazine.
There is plenty of blame to go around for the horrible narcotic epidemic afflicting America today. Dr. Ringel discusses how, as a frontline doctor, he came to contribute to the problem.
It can be viewed using this link: Chicago Life Magazine - Pain
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In my forties I received out of the blue a letter from a guy who had lived around the corner when we were kids. It began, “There is no way this isn’t going to sound weird….” He went on to explain that he was on step 9 of the Alcoholics Anonymous 12-step program, which required making amends with anybody he might have harmed. As my old neighborhood pal saw it, he hadn’t been that nice to me. For me it was water long under the bridge.
I’ve been thinking lately about whom I’d be sending letters to if I were to take step 9 today. One category of recipients is some of the patients from my past who suffered with chronic pain.
Three incontrovertible and often conflicting facts about pain explain much of what follows.
1. Pain is personal and subjective. One person can never experience directly another’s pain.
2. There is nearly always a dose of opiate--morphine, codeine, hydrocodone, oxycodone, methadone, heroin, fentanyl, and a host of other substances, legal and illegal--that will temporarily take away most any pain.
3. Opiates have an enormous downside: multiple side-effects including drowsiness, confusion, constipation, nausea and, worst of all, addiction.
Now put yourself for a moment in my shoes, as a frontline doctor in a clinic, hospital, or emergency room. You are confronted with a patient who has excruciating acute pain or else suffers nagging chronic pain that interferes with their family life, work and sleep. You look for signs of discomfort like rapid heart rate, fidgeting, and wrinkled brow. But you mostly have to take their word for how much they hurt and how much the pain messes up their life. You know you have the power to make the pain go away, at least for a while. It’s as easy as ordering a narcotic. You also understand the risk that you could be starting that person down the slippery slope into drug dependency or, if they are already there, to perpetuating it.
None of this happens in a vacuum. It used to be that doctors were trained to be very, very stingy with narcotics. As a result I have seen many a patient suffer terribly, immediately after major surgery for example, because their doctor had prescribed inadequate opiate doses to be administered at too-long intervals by an inappropriate route. Then along came the Joint Commission on Accreditation of Healthcare Organizations (“Jayco” for short, now simply the Joint Commission). Healthcare organizations live in fear of the Commission, devoting inordinate resources to getting their houses, especially their policy and procedural manuals, in order for the inevitable white glove inspection.
The Joint Commission correctly identified pain management as an aspect of hospital care in dire need of improvement and therefore monitoring by them. In the late 1990s the Commission came up with the “fifth vital sign,” pain. As everybody knows, patients get their traditional four vital signs--temperature, pulse, blood pressure and respiratory rate--checked like clockwork. Staff was instructed by Jayco to collect a “fifth vital sign,” asking patients to rate their pain on a scale of 1-10 and then set in motion interventions that would move the pain number (or the circled cartoon face, ranging from smiley to frowny) down to an acceptable level.
Meanwhile, Medicare mandated adding an item about adequacy of pain control to the satisfaction questionnaire that they required be distributed to every patient post hospital discharge. Patient satisfaction scores were tied to hospital reimbursement. Happy faces on patients’ pain scales became linked pretty directly to happy faces on financial officers. It should be clear where this was leading. Medical culture around narcotics changed in a heartbeat from stingy to generous.
Not coincidentally, the pharmaceutical industry was simultaneously heavily marketing opiates. Drug companies severely downplayed the drawbacks of this class of drugs, especially of newly patented products like the notoriously over-prescribed multi-billion dollar Oxycontin. “Education” (lobbying), most notably by Purdue Pharma, the makers of Oxycontin, to the JCAHO and to physicians falsely declared that there was little addiction potential when narcotics were prescribed for severe pain that had a clear physical cause. This helped to set the stage for ever more aggressive attention to the fifth vital sign.
Medical practice is embedded in a culture and the new culture favored liberal use of narcotics for pain. Like many of my colleagues, I lost some of my fear of these drugs and over-prescribed.
The narcotic floodgates opened wide, not just in hospitals but everywhere. Too many people developed a taste for opiates. The world was soon awash in prescription narcotics, bought and sold on ubiquitous illicit drug markets.
How responsible do I feel for the wave of drug abuse set off by over-prescription of opiates? Not too much. Here’s how I look at it. I tended to err on the side of reducing suffering. I tried to be careful about sniffing out drug seekers. (I heard stories about prescriptions accidentally flushed down the toilet at least a half dozen times, for example.) If someone with chronic pain who was already opiate dependent consulted me in my office, I’d usually continue prescribing a narcotic. The patient first had to sign a contract that made me their only source and was very specific about quantities and timing of refills. This worked pretty well, even better once we had a statewide narcotics prescription database that I could consult in order to assure I was a patient’s sole source.
I wish I’d been better schooled at using non-narcotic interventions to help manage pain. There are some pain patients to whom I feel I owe an apology. Here’s what my step 9 letter would say. “There is no way this isn’t going to sound weird.” Then I would go on to apologize for how easily I refilled your narcotics prescriptions. I sincerely hope that, just as it was for me with my childhood friend, their pain is now water long under the bridge.
