“Doctor, make my pain go away.” I hear this plea, in one form or another, from patients on a daily basis. Yet it presents physicians like me with a troubling conundrum.
Our nation, embroiled in an ever-deepening opioid addiction crisis, needs more options for patients with pain. We need more innovation, more safe and effective non-opioid alternatives, and more research focused on finding these solutions.
In the meantime, we need policies that encourage awareness, education, insurance coverage and access to the broad range of balanced pain management options. Many of these alternatives are grossly underutilized due to barriers in medicine that are only increasing.
Balanced options can include innovative delivery solutions that allow medication to work better for longer periods of time, such as novel, long-acting local anesthetics or pain medications. Or medication delivered to the gut later to prevent early digestion, as with some anti-epileptic medications. A balanced approach can also include more commonly prescribed medications such as anti-depressants and treatments for the sleep disturbances. And then there are non-pharmacologic interventions: osteopathic manipulation, acupuncture, physical therapy, aquatic therapy, chiropractic care, therapeutic massage, and talk therapy.
But we also need physicians who can give patients their time.
I think specifically of one of my patients, Karen. I had prescribed her a mild opioid pain medication for her intractable pain condition. It alleviated her pain, but after a few months I could see it was time for her to move on. “What do you thing about transitioning off opioids?” I asked. She was ready.
In the weeks and months that followed, I was one-part doctor, one-part life coach for Karen. I didn’t give her a prescription; I just gave her my attention. With a supportive network of family and friends at home, and me at the clinic, she successfully left opioids behind.
In an ideal world, this type of physician-patient experience would be the norm. But instead we find physicians more conflicted than ever before. From clinic and hospital administrators, we face the pressure to see the most patients in the shortest period of time. Keeping our clinic doors open means meeting our numbers.
From policymakers, we face the increasing pressures of value-driven care initiatives. Since implementation of the Affordable Care Act, health care has become a target for value propositions, often driven by quality metrics. In laymen’s terms, that’s checking boxes. Have you asked the patient about his or her weight? Check. Have you asked the patient if he or she is a smoker? Check.
For federal policies intended to improve quality of care, value metrics can ironically limit meaningful time spent between physicians and their patients. Taking time to delve into a discussion of multimodal options and balanced pain treatment seems impossible.
Pain patients are arguably some of the most complex patients out there. You need time to ask the right questions and really listen to each patient’s answers. And yet physicians walk into an exam room feeling pressed to meet the metrics. Check the boxes. And hurry it up.
So when patients say to you, “Doctor, make my pain go away,” it can seem merciful, expedient, perhaps even like the only option available to just prescribe a medication. Those who argue that opioids are prescribed too often, in too large of quantities and for too long are not necessarily wrong. But I urge them to see that this is not the result of physicians’ ill will or carelessness. It’s sometimes a byproduct of a system where competing demands rob physicians of the time they really need with their patients.
Quality care is crucial. But it doesn’t necessarily stem from outside metrics and systems, often presented with the promise or threat of financial implications. Sometimes value’s in the basics – the right questions, a real conversation and the ability to access the treatment path each patient needs.
Just the other week, my hospital administrator gently chided me, “Gupta, you’re spending too much time with your patients.” I said, “I’ll take that as a compliment.”
Anita Gupta, DO, PharmD, is a 2017-18 Public and International Affairs Fellow at Princeton University’s Woodrow Wilson School. She also is a Special Government Employee of the FDA Anesthetic, Analgesic Drug Product Advisory Committee and a steering committee member for the Alliance for Balanced Pain Management.