Bad medicine: pain

I knew the course of the lingual nerve but not the basics of pain management. I am still haunted by the yells of patients in pain in wards through the night. Pain management was barely taught, and doctors were fearful of powerful opioids. Rightly we have striven to improve training in pain management, especially in palliative care and after operations. The establishment of hospital pain clinics has played a key role, and patients have an absolute right to be free of pain. Opioids, however, are now prescribed widely in the community for a range of conditions, such as back pain, osteoarthritis, and a mix of “chronic pain syndromes.”

Since 2003 in Britain the prescribing of strong opioids in the community has risen by 70%; the United States is worse, with a 200% rise in prescribing of strong opioids in a decade. Perhaps this might reflect previous undertreated pain, but intuitively I think this cannot be the case. Rather the truth is that we are engaged in the widespread overdiagnosis of pain. Pain is subjective, with marked psychological elements, wide cultural variation, and a strong placebo response. And let’s not pretend that pain rating scores are scientific: they are not. For often there is a dissonance between the reported score and the patient’s presentation. Regrettably (but understandably) pain clinics have pursued a hospital model of care for pain without fully appreciating the implications of generating a “pain disability” and opioid dependence in the community.

Challenging this current practice seems dismissive of sufferers of pain, but if we don’t then we are truly failing patients. For the problems run deep, with attempts being made to stigmatise doctors who question the prescribing of opioids and use of the term “opiophobia,” which smacks of ignorance and intolerance. There is a diktat that prescribed opioids do not cause addiction. Indeed pain advocacy groups seek to explain away dependence on prescribed opioids with a new phrase, “pseudo-addiction,” where drug seeking behaviour is driven purely by a need to relieve pain. Many will not accept this as an explanation, because clinically we know that prescribed opioids do cause addiction. Furthermore, there is scant evidence of benefit of long term opioid use in non-malignant pain syndromes and increasing evidence of deaths linked to prescribed opioids.

We must open our eyes to the vested interests of the huge “pain industry.” The American Pain Society’s current campaign, “Dream no small dreams,” received $500 000 (£310 000; €350 000) from Endo Pharmaceuticals, which makes oxycodone and oxymorphone. The overdiagnosis of pain and the associated widespread prescription of opioids is a disaster in the making—not bad but terrible medicine.