“Pain is inevitable, suffering is optional.” A large number of the prescriptions that I fill every day are for the treatment of some type of pain, chronic or acute, localized or general. Pain helps keep my profession in business.
Pain does not come cheaply. The Institute of Medicine puts the direct health care cost at close to $300 billion and the indirect costs of diminished work capacity at just over $300 billion. This $600 billion amounts to $2,000 per person per year for each and every citizen in the U.S. That’s a hidden pain tax!
Twice as many Americans are being treated for chronic pain as those with diabetes and cancer combined. Of course there is overlap. Many patients with diabetes, cancer and other morbidities also have pain. Coincidental to chronic pain are issues with sleep, depression, anxiety, obesity, cognition deficits, and a significant disruption of general well-being. Anhedonia, a term I learned early in pharmacy courses, the inability to experience joy, is a common symptom for chronic pain sufferers. Chronic pain ruins lives.
It’s hard to find a pain study not funded by a pharmaceutical company, but I came across this survey from the American Pain Foundation that had some staggering results:
Almost two-thirds (59%) reported an impact on their overall enjoyment of life.
More than three quarters of patients (77%) reported feeling depressed.
70% said they have trouble concentrating.
74% said their energy level is impacted by their pain.
86% reported an inability to sleep well.
Looking at that study, funded by Endo (makers of Percocet!), led me to even more incredible discoveries.
The American Pain Foundation (APF) closed down of May 3, 2012. The web site still exists and the cover letter explains a lack of financing and other resources, hopes to transfer content to other organizations, and asks for a public outcry against the government that is blocking access to these wonderful drugs. What a crock of crap!
The APF got 90% of its funding from Big Pharma and Big Medical. When a US Senate committee started to investigate the distribution and marketing of narcotic analgesics one avenue of investigation led to APF. Seems that materials distributed to patients and providers were essentially commercials for their sponsors drugs, explaining and exaggerating the wonderful therapeutic effects of these narcotics while minimizing the risks.
As a practicing pharmacist, I have seen the good, the bad, and the ugly sides of pain management. What has happened, is happening, is once again, the corruption of health care by the forces of greed. We see it in so many aspects of the new American capitalism that I do not need to point out the disparities in big business that are destroying the middle class and wrecking the idealistic principles that are the foundation of our democracy. Pain meds are marketed commodities and their manufacturers are doing everything they can to maximize profits. The APF was just another puppet organization that scurried into the shadows when exposed to light.
This whole process has made pharmacists take a bigger role in law enforcement to help prevent diversion of prescription narcotics. I recently attended a DEA Diversion Conference where the discussion focused on the pharmacist as the primary gatekeeper for the distribution of legal narcotics. Yes, we saw undercover footage of bad doctors prescribing oxycodone, alprazolam, and carisoprodol as thought they were candy. Mostly, these docs hardly looked at the patient, let alone doing any kind of assessment. There is much cash to be made and unscrupulous prescribers and pharmacists tend to reach into the honey pot with both hands. Until they are caught. The problem is how to separate the good from the bad. What is best for the legitimate patient is balanced against drug abuse and profiteering. Its not all on the manufacturers, of course, certain people will abuse drugs. Mankind has been experimenting with altered mental states for as long as humans have been thinking and there is no reason to imagine we will suddenly give up that quest for blissful nirvana.
In our pharmacy, we have strict guidelines for filling controlled substance prescriptions. We try our best, but I often wonder if we are enabling some abusers while sometimes denying medication to legitimate patients. We are not perfect and each order is a judgement call. We make use of our state controlled substance monitoring database, which helps identify some bad apples, but is only an effective tool some of the time. I believe in science and expect that as we learn more about pain and addiction we will become better at pain management. In the meantime, however, we have a huge problem with prescription drug abuse and it is up to all of us, not just pharmacists, to do what we can to improve the situation. This might mean taking the time to listen to a patient in pain, dealing with pain in novel ways, funding stronger enforcement, re-educating prescribers, and providing good guidelines for health care providers as well as alternative resources for patients.
Most folks are often left on their own to self treat pain, choosing from the assortment of pain relievers seen on most supermarket and drugstore shelves. Although there appear to be a multitude of choices, only four non prescription pain meds are offered. These three medications, aspirin, ibuprofen, naproxen, and acetaminophen. Acetaminophen acts as an analgesic and antipyretic, helping with pain and fever. The other three are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and also help with pain and fever and also reduce inflammation. Those are your choices. They may be combined with caffeine, diphenhydramine, or even one another, delivered in tablets, capsules, caplets, liquids, and more, but these are really all there is to choose from. Other modalities exist on drug store shelves, such as TENS (Trans-dermal Electrical Nerve Stimulation) devices, topical preparations, and heating and cooling appliances. Each has advantages and drawbacks and as always, I encourage everyone to read the labels and talk to your pharmacist.
Others have taken the lesson of the opening quote and applied it to their own situation, focusing on the manipulation of suffering rather than the pain itself. Yoga, mediation, prayer, acupuncture, mind-fullness, hypnosis, massage, music therapy, and other spiritual or metaphysical strategies have all been attempted and recommended as ways of limiting suffering. Most accept the pain and choose to limit the suffering as a matter of perspective. Many emotional factors can affect physical pain and a support system is essential to managing chronic pain. Having others around that care for and about you will lessen suffering. Love and comfort ease the pain, loneliness makes any pain more painful. State of mind determines your reaction to pain.
Pain is complicated. I’ve experienced a variety of pain from the minor sting of a flu shot or a minor burn, to sweet pain during sex, to sudden, violent trauma that brought me to my knees. Guys are told to “suck it up.” I have had extensive dental work, even once coming awake during dental implant surgery, but I am fortunate not to have significant chronic pain. I’m on my feet at work all day so I have an aching back quite often and the older I get the longer it takes to recover from muscle pain from unusual physical exertion. No pain, no gain isn’t as appealing as it used to be. Having somebody to love and to care for helps to let the pain go away.
Pain is inevitable, suffering is optional.
Maybe we need fewer pain killers and more hurt blockers.