There is a kind of comfort in an objective finding.
When I’m taking care of a patient, something abnormal on the exam will often be the one helpful piece of information that leads me toward the correct diagnosis and plan. A knee that wiggles when it shouldn’t or an angry-looking sore on the back of a child’s throat can serve to guide me toward the appropriate treatment.
Complaints of pain are among the most common reasons people come to see me. Something hurts, and they want to feel better. As a pediatrician, most of the patients I see have an acute issue that, if properly addressed, will resolve and take the pain with it. But even I have my share of patients with chronic pain of some kind, be it in the abdomen or head or back. Knowing how to treat the pain appropriately can be exceedingly difficult, particularly when I can’t find any underlying condition to account for it.
An earache in a child with a perfectly normal exam is more difficult to figure out than one with a bulging and inflamed eardrum. Often I can still come up with a reasonable idea of what the problem could be, but sometimes I can’t. Of course, the lack of anything I can find on my exam doesn’t mean the pain isn’t there.
In recent years, there has been increased attention to the importance of evaluating and treating patients’ pain adequately. Various pain management initiatives have sprung up around the country, whether related to cancer or other causes. In 1999, the Veterans Health Administration started one such initiative in its facilities, requiring that a patient’s pain rating be a documented “fifth vital sign” (after temperature, heart rate, respiratory rate, and blood pressure). Unfortunately, it demonstrated limited benefit to patients.
The subjective and unverifiable nature of pain is one of the most challenging aspects of managing it. A 10-point rating scale like the one used in the VA’s initiative—with 1 being minimal pain and 10 being the worst pain a patient can imagine—is meant to be a helpful assessment tool, but its usefulness can be iffy. I’ve had patients tell me their pain was “10 out of 10” while chatting with me amiably and showing no visible signs of distress. Others in obvious discomfort have rated their pain as much lower on the scale. One patient’s “4” is another patient’s “9,” with no way of pinning either number to an objective measure.
Another major difficulty in pain management is the potential for abuse and addiction of many medications that are used to control it. Abuse of opioid medications like codeine and oxycodone, found in brand-name medications like OxyContin and Percocet, is rampant nationwide, with deaths from accidental overdose of these drugs tripling since 1990
In an effort to stem this growing problem, last week the Drug Enforcement Administration announced new restrictions on hydrocodone, the ingredient in such medications as Vicodin, the most commonly prescribed medication in the United States. The DEA categorizes controlled substances by “schedule,” and the new rules will put hydrocodone in Schedule II alongside others like Adderall and methadone on the list of medications with an accepted medical use but high potential for abuse, as well. (Stand-alone hydrocodone has always had this designation, but medications that combined it with acetaminophen were in the less-restricted Schedule III.) This change will mean that Vicodin will no longer be refillable from a single prescription, all prescriptions must be signed by hand instead of being called in, and no more than a 90-day supply can be prescribed at any one time.
According to Dr. Adam J. Carinci, director of the Center for Pain Medicine at Massachusetts General Hospital in Boston, this is a welcome change.
“I think it’s absolutely appropriate,” Dr. Carinci told The Daily Beast. “In general, not giving refills will go a long way. It’s been very easy to write a prescription for three months, and then not see your patients again for a long time. Closer follow-up will be better for patients, and really will be a long-term benefit [of the schedule change].”
In a policy statement last year, the American Academy of Pain Medicine took a neutral position on the potential change in schedule, but did cite the need for more medical appointments as a barrier to care for patients who have legitimate need for pain medication [PDF]. Dr. Carinci does acknowledge the lack of convenience for both patients and providers as a possible downside, but thinks the increased time spent checking up on patients will ultimately be for the best.
Though I prescribe hardly any narcotic pain medications, most ADHD medications are also Schedule II. Every so often a patient runs low and has trouble making a follow-up appointment before they run out. While it would certainly be easier just to call in more Ritalin, having them come back in helps assure that the medication is being appropriately monitored. Given the widespread over-prescription of hydrocodone-containing pain medications, with the attendant problems of addiction and overdose deaths, putting similar requirements in place is a step in the right direction.
“Doctors generally don’t get great training either in medical school or residency about the use of narcotic medications,” Dr. Carinci said. “Education on the part of physicians is important, to be aware of the downstream effects [of prescriptions]. These are very helpful medications, but also potentially dangerous.”
Other methods he suggests to lower the risk of opioid prescriptions being abused or diverted to other people include random urine tests at follow-up visits to assure patients are complying with treatment and not using other illicit substances, and contracting with providers to avoid such things as “doctor-shopping” for narcotics. For those patients with chronic pain that seems to require long-term use of potentially harmful medications, referral to a pain specialist may be in order.
Nobody disputes that pain is a problem to be taken seriously, even in the absence of a clear underlying cause. Narcotic pain medications, used judiciously, can be an important tool in treating patients in legitimate need. But they have also proven a significant public health problem on their own, and medical providers should not dole them out cavalierly. The hydrocodone schedule change serves to remind us of our duty not to contribute to the growing problem of drug abuse in our country.