Treating Pain in the Wake of the Opioid Epidemic

As if by gravity, our emergency department, like a planet, pulls pain into its mass. Stowed in the chests, joints, backs, and groins of patients; in their cuts, fractures, burns, and abscesses; pain arrives from every corner of Brooklyn by rail, car, ambulance, and foot. It constitutes our atmosphere. In the pediatric emergency wing, pained squeals interflow with cries of hunger, boredom, or fear. Down the long hallway, bellows of pain emanate from the adult triage area and from behind curtains, where medications are subsiding, blood is being drawn, or a catheter is threaded into a bladder. Among the eighty or so languages uttered in our hospital, the word I learned first was not “hello,” but “pain.”

Occasionally, I come across patients like the frenetic, harried, middle-aged woman I’ll refer to as Rachel. Rachel had been waiting in our emergency department for two hours before I had a chance to see her. When I called her name, she shot up from her chair, tugged down her mask, and delivered a pressured speech into my face before I could introduce myself.

Caught off guard, I tried to piece together shards of a shattered and chaotic story: the gist was that a car accident nearly two decades ago had kindled years of chronic neck, back, and joint pain that her current regimen of opioids like morphine and oxycodone could no longer quell. Both her primary care doctor and her pain management specialist were refusing to ramp up the doses of her prescriptions. She confessed that she had tried every narcotic available except for heroin (she hated needles). Pronouncing them correctly, she enumerated each one. In desperation, at one point she had tried scoring opioids on the street and been raped. Now in my care, she begged me not to send her back to the streets.

Photograph by towfiqu Barbhuiya / Alamy Stock Photo

Every part of me wanted to help her, but as an emergency medicine doctor, my tools are limited. Just as every baker works with dough, technically any doctor can prescribe any medication. But if you walk into a bagel shop and ask for pizza, you will likely leave empty-handed. In general, the management of chronic pain is outside the scope of emergency medicine doctors like me. For a host of reasons, including healthcare system resource management, the psycho-social complexity of chronic pain, and the inability to schedule follow-up appointments, we focus on immediate threats to life, limb, organ, or fertility. If those threats are ruled out, we connect patients to the appropriate specialists, who are better equipped to handle the problem.

Was Rachel’s pain an emergency? Chronic pain has been linked to depression, decreased productivity, and addiction, but its treatment requires long-term relationships with healthcare providers. In that sense, it stands apart from acute pain, which can signal problems that require an urgent, one-off surgery or procedure – a laceration that would hemorrhage without stitches, or an appendix that might burst without excision.

I listened closely to Rachel’s story for anything I could treat. Wondering whether her pain might be an acute exacerbation of a chronic cause, I offered her a cocktail of non-opioid medications that works well for most of my patients – anti-inflammatory tablets and creams, a muscle relaxer, as well as a nerve-numbing agent. She not only refused them but seemed insulted, as though I had low-balled her in a salary negotiation. She said that none of those medications ever worked for her. What about the rape, or the possibility of addiction that could benefit from rehab or a medication management program? How about the potential for housing insecurity that might require placement into a shelter? She waved off help with those, too.

After seeing her stand up and sit down more gingerly than any patient I had treated with severe back pain, I reviewed her past medical records and noted that two weeks prior, a colleague of mine had seen her for the same issues. Security had eventually escorted her out.

One of the problems of pain is that it must be believed before a healthcare provider can treat it: it cannot be measured. Rachel’s mistake was that her car accident had transpired in an era of open-handed opioid prescribing, but her pain persisted into an age of sharp reversals in those practices. Eighteen years ago, when her injuries were acute, the now-defunct American Pain Society was crusading against a purported epidemic of under-treated pain. “The Fifth Vital Sign” campaign aimed to make pain as “visible” to doctors and nurses as the more objective – and impossible to fake – measurements of blood pressure, heart rate, respiratory rate, and oxygen saturation. By now, most of us have seen the charts with increasingly uncomfortable smiley faces and have become familiar with the 1–10 “pain scale.” If pain were more visible, the logic went, doctors would treat pain more often, and the problem of pain would be solved.

The campaign coincided with and turbo-charged the widespread dissemination of prescription opioids like oxycodone for chronic pain. These opioids were manufactured by companies like Purdue Pharma who, incidentally, paid several members of the American Pain Society to speak at pharmaceutical industry conferences. Hospital regulatory agencies swiftly adopted the campaign’s principles, and in doing so, operationalized and mandated the assessment and treatment of pain.

As it turns out, more attention to pain does not diminish it, and the effort backfired. By the time I graduated medical school in 2020, drug-involved overdoses hit a record high, then broke that record the following year after two decades of accelerating gains that the former CDC director Tom Frieden called “doctor-driven.” The so-called epidemic of under-treatment had morphed into an epidemic of addiction.

Doctors have been put in the uneasy position of having to choose between feeling naive or miserly when relieving pain.

Part of the problem is that attempts at standardizing metrics for pain are doomed to abstraction. Pain is a deeply intimate experience: anxiety, depression, fear, and a history of physical or emotional trauma can all subdue or intensify it. What’s more, it can be all but impossible to distinguish from an even more complex phenomenon: suffering. To muddy the waters further, patients are expected to sort out a doctor’s attempts at gauging their pain from the reasonable assumption of what I will do with their answer. When patients are asked to rate their pain, the variety of responses I hear, including “eleven out of ten,” suggests that they often interpret the question not as “How bad is your pain to you,” but rather “How quickly do you want medication?” To patients, the focus on a number must feel like haggling: offer a number too low, and you might get nothing; too high, and you lose credibility.

When I was still a medical student, one or two of my professors floated the idea of “framing” the pain scale by offering examples at either end of the spectrum, and in our emergency department, I still overhear early learners explain to patients that “a ten is the worst pain you could imagine, like child birth, an amputated arm, or a kidney stone.” This rhetorical device requires patients to engage in an imaginative feat of abstract pain arithmetic in the very midst of their throes: they must simultaneously concentrate harder on their pain to grade it like a movie or a restaurant while inhabiting the hypothetical body of someone else experiencing something with which they have absolutely no experience.

It goes without saying that at some point in my life, I experienced the worst pain I’ve ever had. Was it a ten out of ten? I can conceive of worse pain, but it is hard to conceive of a maximum and impossible to know whether my maximum, if such a thing exists, has any basis in comparison to that of someone else. In short, the pain scale’s number doesn’t act like a number: it has no units, can’t be added, and may not even be linear. As C. S. Lewis writes in “The Problem of Pain”:

Suppose that I have a toothache of intensity x: and suppose that you, who are seated beside me, also begin to have a toothache of intensity x. You may, if you choose, say that the total amount of pain in the room is now 2x. But you must remember that no one is suffering 2x: search all time and all space and you will not find that composite pain in anyone’s consciousness. There is no such thing as a sum of suffering, for no one suffers it. When we have reached the maximum that a single person can suffer, we have, no doubt, reached something very horrible, but we have reached all the suffering there ever can be in the universe.

The non-numerical alternative, the smiley face scale, which still lingers on the whiteboards of many hospital rooms, might skirt the awkward algebra but is equally abstract. To make pain “visible,” it requires nurses to convert actual screams, cries, contortions, visible injuries, and human facial expressions into a green, yellow, or red cartoon.

Now, I simply ask my patients if they would like pain medication. After they receive it, I ask them if they would like more. Then I begin a discussion about what to expect, given their injury, in the likely course of their pain, the treatment options in the emergency department, and how those options work. In these discussions, I find that patients often evince a wisdom that medical bureaucracies lack. Not everyone wants medicine. I find that most patients have an intuitive grasp of the economics of pain and sense that a trade-off exists: relief from pain can sometimes come at the cost of side effects or over-sedation. Some patients even share the (usually unfounded) concern that medication will only mask their pain, allowing the underlying disease to machinate insidiously inside them.

For other patients, there is no avoiding a tenor of bargaining. With the power vested in us as prescribers, doctors are the legal gatekeepers of medications that have fueled addictions more powerful than many of us can reverse. We must therefore be convinced to give or withhold potent therapies as if they were ours to sell with or without a discount. In my dialogues with patients about pain management options at my disposal, a handful of patients attempt, using various stratagems, to eliminate every option but opioids. Common tactics include declaring unlikely allergies to a host of first-line medications – some will claim, for example, that the ingredients in Tylenol or Motrin send them into anaphylaxis, which is exceedingly rare. Others attempt to build a case by initially declining opioids in order to seem reluctant to use them, then later ask for them by name. (One colleague of mine quipped that patients who claim to have a “high pain tolerance” are the first to ask for narcotics.) Some show scars of old injuries or surgeries and assert that they are new.

All of this puts doctors in the uneasy position of having to choose between feeling naive or miserly when relieving pain. The addictive power of opioids has made it more worth an anxious two-hour wait in an emergency department, more worth the potential for withdrawal, and more worth lying. In doing so, opioids have contaminated the dynamics of trust in the doctor-patient relationship. Should we take everyone’s word at face value and risk perpetuating an addiction crisis? Or should we deny patients’ requests for prescription opioids and risk sending them into the myriad hazards of the streets for even more dangerous and unregulated substances?

Guidelines from medical societies over the past few years have recommended careful consideration of the dose and duration of opioid prescribing, with a preference for short courses of the lowest possible dose, decreasing the overall quantity. But there are significant qualitative differences between opioids as well. Pharmaceutically speaking, when it comes to pain relief, known as analgesia, any two opioids are interchangeable with a simple conversion calculation. For example, 15 milligrams of oral morphine should theoretically provide the same pain control as 3.5 milligrams of hydromorphone. However, opioids’ side effect profiles can vary. At high doses, morphine can cause itching, nausea, dizziness, drowsiness, and headache. For terminally ill patients who eventually become inured to the effects of narcotics over time and require increasing amounts of opioids for the same relief, these side effects can become a barrier to its use.

First synthesized in post-World War I Germany, a modified version of morphine, known as hydromorphone, was found to have a smoother side effect profile and was better tolerated at high doses. But side effect profiles alone do not explain the craving for some opioids over others. Yet another crucial distinction between narcotics is their differing ability to generate a sense of euphoria – a highly addictive, dopamine-driven aura of wellbeing, also known as a “high.”   

If analgesia is the antidote to pain, euphoria is the antidote to suffering. But the trade-offs for euphoria, as with pain, are formidable. Whereas some of the downsides to analgesia include over-sedation, organ injury, and the loss of breathing reflexes, the major risk of chemically induced euphoria is addiction. When patients like Rachel come to our emergency department complaining of pain without any impairment in their ability to sit or stand, they may be experiencing not pain but dysphoria.

In 2017, our emergency department joined a handful of other departments across the country in becoming an early adopter of a program to remove or reduce the usage of the more euphoria-generating opioids. The shift was made possible by the aggressive employment of other more targeted and less habit-forming modalities of pain relief, including ice, creams, gels, ultrasound-guided nerve blocks, ketamine, inhaled aerosols, other intramuscular and intravenous medications, physical therapy, and acupuncture. The change has also encouraged us physicians to more closely interrogate what kind of pain we’re treating and how our therapies work, as well as going some distance toward restoring the relationship of trust with patients.

For those who legitimately require opioids, the stigma of potential addiction can erode their sense of dignity when they must persuade a skeptical physician to renew their prescriptions. For these patients, and for patients like Rachel, for whom doctors introduced habit-forming medications and then withheld them years later, it’s hard for me to escape the sense of guilt by association. If by becoming a doctor I have inherited a windfall of trust built by generations of doctors before me – the kind of trust in which patients allow me to perform sensitive physical exams and even disclose information they might not tell their spouses – I feel as though I have also come into a legacy of betrayal. I have never prescribed opioids for chronic pain, but the white coat is a symbol and a uniform of a guild, and I wear it. Offering help with addiction and espousing harm reduction techniques only goes so far in mitigating that guilt. And guilt flows in both directions: an unintended consequence of the newfound restraint in the use of euphoria-generating opioids is the flight of patients with sickle cell disease – a syndrome characterized by bouts of excruciating pain that also happens to be common in communities that are already medically underserved, stigmatized, and seen as drug-seeking.

Emergency medicine physicians need to strike a balance between analgesia and the ability to cause euphoria. But regardless of the medications prescribed, we should recognize that key elements for the treatment of pain are conversation, connection, and consistency. Currently, the medical community is attempting to avoid overcorrecting for the opioid epidemic by withholding medications that can be useful in the right circumstances. We need to familiarize ourselves with the whole spectrum of pain therapies, then engage in thoughtful discussions with patients to pass on our knowledge of the options for pain management, how they work, and the overarching goals of care.

I spent more time counseling Rachel than any other patient on the night that I met her. She interrupted me at the bedsides of other patients while I was mid-conversation or mid-exam with them. More than once, she loomed over me while I worked at my desk. I did not call security, but I ultimately did little else for her. Refusing everything I offered, she accused me of sending her back onto the streets to use needles and be raped. I felt that she was blaming a bagel shop for letting her starve because it didn’t serve pizza. I still think about her and wonder if I could have said or done anything differently. Before I could discharge her, she finally left without a word, then returned an hour later to try her luck with a different doctor. I’m not sure when I’ll see Rachel in the future, but I’m sure that I’ll continue to struggle with treating her, or someone like her, again.