As I open the next chart, I begin to mutter under my breath, “Chronic pain … this one is not going to be easy.” A series of irrational and unfair scenes pass through my mind. My cortisol level surges and I pull up the drawbridge of empathy.
Having been an Emergency Physician for over 30 years, it was not until recently that I realized how much I burdened certain patients with unfair misconceptions. If the chief complaint for a patient is “low back pain,” “chronic neck pain” or “medication renewal,” a common indication that this patient might be suffering from chronic pain or substance use disorder (SUD), I would make assumptions without even having laid eyes on the patient. And my “care” would consist of admonishment to get a pain management specialist or to their primary care provider soon, and an impatient reminder that this is not the place to come for an opioid prescription.
Simply put, I was stigmatizer. Thankfully, that changed nearly two years ago.
As Chief Medical Officer of the GE Foundation, we made a funding commitment to addiction medicine and behavioral health care with a focus on the opioid crisis in Massachusetts. This marked the start of my journey and education to better understanding the needs of these patients. I realized quickly that my perception for many years had been wrong and that my patients would be better served if I changed my attitude and adjusted my approach.
In truth, most patients with chronic pain would rather not be my next patient. These patients don’t choose the unrelenting pain they experience each and every day. They did not opt-in for this disorder. They did not wake up one morning and say, “I want to be an addict.” So as I learned more, I realized that my perception had, for many years, been wrong and that my patients would be better served if I changed my attitude and approach.
Flipping the switch
Today, I approach patients with chronic pain or SUD like I would any other patient with a challenging condition. What can I do to help them today? I recently had several patients on high doses of opioids from chronic pain, who were likely physically dependent or addicted to these powerful medications. Now I take their issue as seriously as I would a patient with pneumonia or a myocardial infarction, gathering a detailed history, procuring as accurate a medication list as feasible and doing a more complete examination.
Then I call for help. As I would for that seriously ill patient with pneumonia, I call for consultation. While some emergency departments don’t have a pain specialist or an addiction medicine specialist on call, I found it easy to call a nearby academic medical center and page the on-call pain specialist. This type of call is now a standard part of my practice and, each time, the response has been thoughtful, intelligent and caring with very helpful clinical advice. My patients are now receiving effective pathways to pain reduction with a direct connection to a pain specialist, who can help them and, hopefully, change their longer-term trajectory.
Treat acute pain differently
In addition, I now treat acute pain quite differently. It starts with taking a few more minutes to talk with the patient about their pain, explaining that pain is a natural part of illness or injury and setting the expectation that the goal is to reduce their pain to a manageable level, not eliminate completely. In adjusting expectations, it is important for patients to understand they will still experience pain. During waking hours, they might need to accept some pain, but we can together plan the best path for reducing pain at night to allow for a restful sleep.
With this level of explanation, most patients are grateful and willing to accept these new expectations and a reduced-opioid approach to pain. Ice, elevation, rest, acetaminophen and non-steroidal anti-inflammatory agents as the core regimen with opioids reserved for intolerable pain and, if needed, to enable a restful night. A recent study demonstrated that non-opioids pain relievers (acetaminophen and ibuprofen) were as effective for acute pain as three different opioid combinations in acute pain. Most patients, cognizant of our national opioid crisis, are relieved to know that a revised approach with limited or no opioids can work.
Addressing our stigma together
Stigma is largely caused by the fear of the unknown or the “other.” I am fortunate that my immersion in the crisis has more easily enabled me to address my own stigma toward patients with chronic pain and SUD and to have a richer sense of empathy. The challenge is now to enable access to the necessary knowledge and resources for all providers, so they too can be comfortable with patients with chronic pain or SUD.
Together, we need to reduce the fears that clinicians may have and close the gaps in their knowledge and accessible resources. This will allow all of us to let down our drawbridges of empathy and care for these patients with the same compassion as we do every day for all the other patients to whom we are introduced by the very next chart.
David M. Barash, M.D. is the Executive Director of the Global Health Portfolio and Chief Medical Officer for the GE Foundation. David is a practicing emergency medicine physician with more than 30 years’ experience. David received his Bachelor’s and Medical degrees from Cornell University. He is the author of several clinical publications and patented innovations.