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The Conflict of Pain in America

There is a lot of pain in America. Over 400,000 prescriptions for opiate analgesics were filled annually during the 1980’s. Over 1.6 million prescriptions for opiate analgesics were filled in 1998, with that number growing above 2 million in 2000 (SAMHSA, 2001). There was a four fold increase in the production of hydrocodone from 1990 to 2000. Hyrocodone/APAP was the number one prescription retail drug sold in America in 2002, and again in 2003 (NDC, 2003). Data from DAWN, SAMHSA’s early warning system of emergency room contacts related to drug misuse, showed an 84% rise in hydrocodone ER visits from 1995 to 2000. It showed a 239% increase in the same five year period for oxycodone (SAMHSA, 2003). There is a lot of pain in America. These facts and figures are not dry, impersonal data. The facts are organic, breathing visceral representations of real lives, real people. They are also schematic blueprints of the daily experiences of nurses. The value of facts and figures is that they give us reason to pause and think, in ways we often cannot in the hectic moments of caring for the real patients behind the facts. The facts give us pause to think about how we should respond to all the pain, to all the prescriptions, all the patients. To think what they say about health, addiction, about health care in America. We struggle with pain and prescription medication and addiction in this society. It is estimated that over 50% of primary care visits are related to chronic pain. Often these patient’s concerns result in prescriptions for opiate pain relieving drugs. As nurses we feel an obligation to ease suffering, to comfort the pained. So we advocate for those whose pain is “real” and who need adequate pain management. But also as nurses we feel an obligation to do no harm, to prevent abuse of highly addicting medications. So we often resist management of patients whose pain seems rooted in addiction. We are faced daily with these two populations, both in pain, but with different health needs. The challenge for us is to effectively and efficiently separate out and respond to the two populations. To know who is who; who is the “legitimate” pain patient and who is the “addict?” It is one of the most stressful and difficult aspects of clinical nursing, a challenge of increasing legal and professional importance. Recent clinical guidelines and JCAHO regulations are forcing attention on best practices for pain management, at a time of increased media attention and growing concern over opiate drug abuse. And so we shift our feet, shift our position, our care, our policy with the blowing winds of stigma, high service utilization, and limited science. We “fire” patients from practices, bandy about labels such as “drug seeking,” with little consideration of the route of the individual’s decline into prescription drug addiction or our role in prevention. Health care providers often start, sustain, and fuel addiction to prescription drugs. Health care providers, at some fixed, imprecisely defined point, pull the plug, washing the patient into a vicious cycle of desperation and deceit in order to sustain access to that which their brain and mind so firmly believes is needed. We need to do better with all of the pain. We have the science to predict those who will most likely become addicted to prescription drugs and those for whom the risk is low. We know from decades of research much of the genetic, structural, and neurochemical underpinnings of addictive disorders. Lying in ancient, deep areas of the brain, the reward pathways are becoming more clearly understood and new treatments are emerging with increasing frequency. Despite growing