Pain experts emphasize that the patient’s self-report is the most reliable source of information on pain—based on an understanding of pain as a complex, subjective phenomenon associated with actual or potential tissue damage and the patient’s perception of and emotional reaction to that sensation. The phenomenon of pain also includes emotional, social, psychological, even spiritual components and can be mediated by a host of other factors. But that doesn’t mean it isn’t real to the patient.
“Often, younger physicians take the attitude that if the pain is real, then administration of morphine will make it go away,” says Porter Storey, MD, FACP, FAAHPM. “In reality, pain doesn’t always respond to opioids, for all sorts of reasons. Hospitalists value clarity, and they use pain as a screen for all sorts of other problems. Their goal, often, is not so much the comfort of the patient as it is diagnosing, treating, and then discharging the patient from the hospital.” Dr. Storey is a palliative care physician in Boulder, Colo., and executive vice president for Medical Affairs at the American Academy of Hospice and Palliative Medicine (AAHPM).
Physicians need to be reminded, however, that unresolved pain in hospitalized patients has many negative consequences. These range from resistance to rehabilitation to depression to delayed hospital discharge, as well as reduced job satisfaction for the healthcare professionals who care for them.
Will Prescribing Analgesics Cause Addiction?
Fears about causing addiction haunt many pain management discussions. Requests for more medications, obsessing over the next scheduled analgesic dose, and even manipulative or drug-seeking behaviors can be misunderstood by physicians who lack training in the real nature of drug addiction. Actual cases of drug addiction created by appropriate, sufficient, and well-monitored opioid analgesic treatment are rare, pain experts say. There is an important caveat: the patient who brings a prior history of drug abuse to the current acute medical episode.
“There are no good data about iatrogenic addiction,” says Robert Brody, MD, chief of the pain consultation clinic at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. “People who do pain management, certainly including hospice and palliative care physicians, don’t really believe in it. In my own clinical experience, most patients don’t like pain medications and stop them as soon as they can.”
Addiction is more accurately understood as the inappropriate use of a drug for non-medical purposes. It refers to disruptive, drug-seeking behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.2 Addiction experts also describe addiction as a disease syndrome in its own right. Although that concept can sometimes be hard to accept by those who don’t have a lot of experience working with it, it is a useful paradigm to treat addiction as if it were a disease, says Ronald Crossno, MD, Rockdale, Texas-based area medical director for the VistaCare hospice chain.
Pain experts use the term pseudoaddiction for behaviors that are reminiscent of addiction but in fact reflect the pursuit of pain relief. Examples might include hoarding drugs, clock-watching, and exaggerated complaints of pain, such as moaning or crying. If it is pseudoaddiction, once the pain is brought under control, these behaviors cease. The term was coined in 1989 to describe an iatrogenic syndrome resulting from poorly treated pain.3-5
“Pseudoaddiction is a term you need to know,” Dr. Crossno asserted during a presentation on addiction pain at the recent annual conference of AAHPM in Salt Lake City in February. “It is at least as prevalent as addiction—and an indictment of how our healthcare system deals with pain.”