Pew: Steak and Pain

Thursday, April 14, 2016 | 0

A doctor, two pharmacists and a blogger walk into a bar ...

That's not a joke but how dinner started Tuesday in San Diego's Gaslamp District after a second excellent day at the Risk Insurance Management Society conference. As happens so often when I get together with friends and colleagues, at least half of the conversation became focused on the treatment of pain. Three excellent points were made in those wide-ranging discussions (well, actually there were more, but you probably don't want to hear all of them).

The longer someone uses opioids, the more likely they are to keep using them. This sounds like an obvious statement, but the doctor had a very interesting way of stating it. His preference is to not prescribe opioids but recognizes they are appropriate in some circumstances (and evidence-based Medicine agrees).

Whenever he prescribes them, he has "the talk" — a realistic and honest explanation of the risks and benefits (something every doctor should do). Not to scare them but to ensure they fully know the journey on which they're about to embark. And here's where it got interesting: If a patient came directly to him for care during the acute stage (i.e., the first prescription is his), after "the talk" about 60% of patients would decide to forego opioids. If a patient came to him after having been prescribed opioids elsewhere (i.e., his would be the second prescription), after "the talk" only 25% of the patients would decide to forego continued opioid therapy. It doesn't take much speculation as to why.

Takeaway: It may only take one pill, so "the talk" by an informed prescriber is important on Day 1.

Mark Pew

Treatment of pain is not a black and white issue, It's gray and nuanced. We all agreed that opioids have a place in the treatment of pain. But it's very narrow and very focused on results. In other words, only if the patient has pain relief and a return to function. Period.

So knowing what treatment — any treatment, by the way, not just pharmacotherapy‎ — should be prescribed and/or continued is based on the patient's response to the treatment. Not how they feel about the treatment, but how they feel.

Because every individual's circumstance is unique and changes as their injury and body age, it's very important that neither the treating clinician nor patient put it on auto-pilot but constantly reassess the care and be open to change.

Takeaway: Treatment should be individualized and constantly reassessed.

Total relief of pain may not be achievable. There are some injuries that will have lasting effects that create lingering (aka "chronic") pain. All of the best medical treatment, applied appropriately and timely, may not be sufficient to completely eradicate the pain.

Yet patients can have the unrealistic expectation, which may not be challenged by the physician or pharmacist, that their pain will go away. Like to zero on the one-to-10 subjective scale. But who, after all, is ever a zero? Many people start their day at a one or two — from past injuries or getting older — and yet they still function. They don't take analgesics; they don't lie on the bed; they live their life in spite of the pain.

Learning to overcome pain is either instinctual or taught, but it's not impossible. Real discussions need to occur, which may include a reset of expectations, to ensure the patient is ready to deal with what may be their "new normal."

Takeaway: Honesty about pain is not a nice-to-have, but a must-have.

Mark Pew is a senior vice president for Prium, a medical cost-containment provider that serves the workers' compensation industry.