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Everybody Hurts: Why Pain Statistics Should Give You a Headache

Everybody Hurts: Why Pain Statistics Should Give You a Headache

Picture of William Heisel

Numerous articles in peer-reviewed journals about pain as well as media coverage of pain begin with the premise that far more people suffer from pain than are adequately treated for it. This broad trend may be true, but the specific numbers sometimes used to justify this assertion merit more scrutiny.

You may have read that 75 million Americans suffer from chronic pain. Or 100 million Americans. Or 150 million. You may also have read that only a small fraction of that massive number receive pain treatment.

The St. Petersburg Times wrote that “between 40-million and 80-million Americans suffer chronic pain, and many do not receive enough treatment.”

The Washington Times wrote recently about “the approximately 75 million Americans who suffer from acute and chronic pain.”

The Tampa Bay Times reported that “more than 100 million American adults live with chronic pain, translating to more than 5.5 million people in Florida. These are our neighbors who can't mow their lawn anymore; our co-workers who show up to work but miss deadlines and important meetings; our relatives who opt out of family events.”

How do we know that tens of millions of people are in chronic pain and can’t get treatment?

Pain is subjective, which makes it much harder to measure than other conditions. You can give one blood sample and both you and your doctor will know that you have been infected with syphilis, hepatitis C or West Nile virus. You cannot take a blood test to find out if you suffer from chronic pain.

For example, trends in HIV infections, AIDS cases and AIDS-related deaths in the U.S. have been documented through blood tests. Most states report cases of HIV to the U.S. Centers for Disease Control and Prevention, which then uses that data to make estimates for the whole country.

Then there are the conditions that can be measured in other ways. We all have seen stories about the supersizing of everything from movie theater seats to ambulance stretchers to coffins because of America’s obesity rates. But the basic trends in obesity are far from anecdotal. They can be found in regular and consistent surveys that both ask a broad and representative sample of people about their weight and actually take weight measurements for sub-samples of the population.

When you look at where pain statistics originate, though, you see sources being cited that are all over the map in terms of scientific scope and rigor. The studies can be from time periods decades apart. They can be based on surveys that were done once in a very specific population in one geographic area. And the individual surveys ask very different questions about the type, duration and degree of pain that are then bound up together to draw the same conclusion: a stunning number of people suffer from pain that prevents them from living normal lives.

Then health writers too often echo that same conclusion. And the answer to that conclusion has been too simplistic: we need more opioid painkillers.

Deaths from prescription drug overdose are something that can be documented, and they are on the rise. The Centers for Disease Control and Prevention reported in January 2012:

Prescription drug abuse is the fastest growing drug problem in the United States. The increase in unintentional drug overdose death rates in recent years has been driven by increased use of a class of prescription drugs called opioid analgesics. Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined. In addition, for every unintentional overdose death related to an opioid analgesic, nine persons are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics.

By repeating the estimates for the number of people suffering from chronic pain and allowing these pain estimates to go unchallenged, health writers become part of the drum beat for shifting resources and changing policies in a way that drums up more business for painkiller makers, feeds the growing prescription drug abuse problem and does little for the people who actually suffer from chronic pain.

I know that ferreting out the source for every scientific fact can be tough. So over a few posts, I will attempt to track down one pain prevalence citation in one journal article.

Image by Wonderlane via Flickr

Comments

Picture of John Lynch

I've commented elsewhere on Reporting on Health about this subject and will repeat some of what I've said here because it's germane to your timely and extremely important post. There are three aspects of this issue I'd like to address:

1. Studies have shown that opioids decrease pain tolerance over time and thereby worsen patients' experience of chronic pain.Their depressant effect on the central nervous system can also increase mood and anxiety disorders in many patients, further exacerbating their experience of pain;

2. Complications of opioid use include tumor proliferation. This was first reported in 1986. While it's true there have been conflicting reports, this has been attributed to differences in dosages and means of administration rather than underlying mechanisms of action themselves.

The evidence indicating cause for concern is sufficient in 2012 to cause anesthesiologists to reassess their use of opioids in managing cancer-related treatments and post-surgical pain. To quote from a report on the University of Chicago Medicine website (www.uchospitals.edu/news/2012/20120321-opioid.html):

"In a commentary in the journal (Anesthesiology), (researchers) summarize results from multiple studies to argue that opioids...appear to have a significant and direct proliferative effect in cancer cells aside from their effect suppressing immunity."

If anesthesiologists - the medical experts in pain management - are sufficiently concerned to reassess their use of opioids for cancer and post-surgical pain management, all physicians should think twice before prescribing them for chronic pain; and

3. Other pain treatments have proven more effective than opioids for chronic pain relief, at least for knee osteoarthritis. These include TENS, low level laser therapy, elector-acupuncture, steroid injections, and topical NSAIDs like Voltare gel. Even oral NSAIDs, which bring their own risk factors, were almost as effective as opioids (Sources: Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomized placebo-controlled trials. BMC Musculoskeletal Disord. 2007 Jun 22;8:51; Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomized placebo-controlled trials. Eur J Pain. 2007 Feb; 11(2):125-38).

In short, opioids are best reserved for select acute pain conditions, not for chronic pain that, by definition, will require a long-term treatment approach..Long-term reliance on opiods is a death-spiral of increasing dependency. heightened sensitivity to pain, and possible earlier death form cancer proliferation or other drug-induced complications. Unfortunately, increasing pressure on doctors to cut office visits short will hasten their reach for the prescription pad for a quick fix of temporary pain relief that will very likely violate their oath to "do no harm".

Picture of

"By repeating the estimates for the number of people suffering from chronic pain and allowing these pain estimates to go unchallenged, health writers become part of the drum beat for shifting resources and changing policies in a way that drums up more business for painkiller makers, feeds the growing prescription drug abuse problem and does little for the people who actually suffer from chronic pain."

I too hate to see numbers bandied about without thought. However, I believe you're overlooking a few things:

1. I believe the CDC stats can be traced in part to Purdue Pharmaceuticals' decision to lie about the addictive properties of its hot new pain med. http://www.pharmalot.com/2007/05/purdue_and_execs_634m_for_misb/. Why? Because they knew a less-addictive opioid would sell like hot cakes. And it did. For a while doctors, some of whom would not have prescribed a traditional narcotic and did not know how to monitor patients on narcotics, were writing scripts for these pills because it was supposed to be a lot safer.

2. Doctors who use their ability to write scripts for controlled narcotics to get rich quick. You could walk into their practices with a hangnail and walk out with a 60 day supply of Schedule II pills. At the right practice and for the right price, you could walk out with the doctor's DEA pad and write your own script. These practitioners don't care about the stats, right? You can also add to this number doctors who are just plain reckless.No, you can't tell them how to run their practice. So, no, they're not going to screen patients for addiction issues. No, they're not going to make patients to sign a compliance agreement. No, they're not going to conduct urine drug screens. Again, I don't think skewed pain stats make a difference here. (And then there are doctors who are just plain crazy: http://www.salerianbrain.com/questions-and-answers-the-witch-hunt-and-me/)

3. Coverage - I'd say sensationalized coverage - of pill mills grabs more eyeballs, gets a lot more attention and has a lot more impact than the stories you link. In Ohio, a few problem clinics in one county resulted in a huge clunker of a law that will render some practices unable to prescribe pain meds. And legislators did this, even though they probably had the same stats presented to them. However, passing a law to protect constituents from the scourge of drug abuse grabs headlines and across the country, more legislators are grabbing on to this issue to get a little of the limelight.

4. An Rx for narcotics is only one mode of treating pain at a doctor's disposal. For patients with musculoskeletal pain - and they take up a big chunk of chronic pain patients - doctors use everything from OTC meds to physical therapy to injections to alleviate pain. They don't reach for the Rx pad first because monitoring the patient on opioids is a hassle and frankly, they get paid a lot more for the pain injection than they do for the visit to reup a script. For a cancer patient there are implanted pain pumps that do dispense narcotics but can't be abused. So it is a mistake to make the leap from skewed pain stats to more scripts for controlled substances.

The bottom line is, responsible doctors were always wary about prescribing narcotics. They know the risks of these drugs and the Oxy debacle has made them even more skittish. They have to make their practices unattractive to doctor shoppers, keep an eye on their legitimate patients and worry about addicts who won't take no for an answer. But as the Tampa article notes, doctors around the country are now afraid to write scripts. I've spoken to doctors who are considering relinquishing their DEA numbers because they just don't want the hassle. These stats aren't going to increase their prescribing behavior because the fear of a DEA visit is driving it down.

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