The management of pain symptoms has undergone an intense evolution in the 35 years that I’ve been a registered nurse in Hawaii, first as a burn care nurse where I cared for patients who were in constant and unimaginable pain for long periods of time; later as an emergency room nurse where the patients had more acute problems and short-term pain management needs; and also as a worker’s compensation case manager where injured workers could require a more mid-to-long term management plan for chronic pain.

In the past year, more and more information has been made public regarding prescription pain killer dependence, abuse, overdose and death. A staunch patient advocate, I put my blinders on and continued to believe in the patient’s independence in healthcare decision-making, irritated that the DEA and state and local legislative and enforcement agencies, and even insurance companies, seemed to be attempting to hamstring patients and providers by regulating, documenting and overseeing what should be a provider-patient relationship and decision-making process.

In the face of what some saw as harassment, certain providers began refusing to prescribe narcotic analgesics, leaving patients without a workable pain management plan. I was incensed at witch hunting and intimidation tactics that were hurting patients. Or so I thought.

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About 11 people per every 100,000 in Hawaii’s population overdoses on painkillers.

Via Wikimedia Commons

On Dec. 16, 2014 everything changed. I received a phone call from my nephew, telling me that his mother, my sister Marcia, had died accidentally as a result of a prescription pain killer overdose. My nephews found countless prescription receipts for OxyContin and Percocet in her apartment.

Every 30 days, in a steady stream of same-physician-signed paper, my very petite sister had been receiving what was essentially a legal fix of oxycodone that seemed too much for any one person. I got the message, and in the days and weeks following I took a new and closer look at pain management and addiction in Hawaii, my second home state.

The data are in and the alarm has been sounded. Hawaii has a problem with legal drug addiction, and we don’t quite know what to do about it. We aren’t alone — our national affinity for opioid pain killers and their related morbidity and mortality (illness and death) has become an epidemic in the eyes of the Centers for Disease Control and Prevention.

Opioids are highly addictive synthetic narcotic pain killers that are used to treat moderate to severe pain. You may know them more commonly as Percocet or OxyContin (oxycodone), Vicodin (hydrocodone), Dilaudid (hydromorphone) or Fentanyl.

According to the CDC’s 2013 Prevention Status Report, the United States has seen a quadrupling of opioid prescriptions and sales between 1999 and 2010 along with a corresponding increase in opioid overdose deaths and a sevenfold increase in substance abuse treatment admissions for opioid addiction. Opioid overdose deaths now outnumber deaths from cocaine and heroin combined and exceed the number of deaths from motor vehicle accidents. That’s a pretty grim picture.

Although Hawaii’s overdose death rate is lower than the national rate for 2010 — 10.9 per 100,000 locally versus 12.4 nationally — the information is not to be minimized or ignored. There’s nothing glorious or even acceptable about losing valuable people to an avoidable complication of pain management.

It’s absurd to think that patients who are in the midst of an acute pain episode can readily make decisions about longer term pain management.

The study and practice of pain management was once the exclusive domain of the physician-patient relationship. The physician evaluated the patient’s condition and recommended or even insisted upon a certain medication and/or course of action. Nowadays, pain management has evolved into a multidisciplinary model and may include the likes of pharmacy, nursing, neurology, psychology, neuroscience, anesthesiology, physical and massage therapy, acupuncture, chiropractic, naturopathy, yoga and meditation and, most importantly, the patient.

In today’s Patient-Centered Medical Home, the patient is the consumer of, and decision-maker for, her or his health care — which leaves all of the providers and ancillary caregivers scrambling to find a collaborative and doable plan for each individual patient that will be agreed upon by all. Or not. Each of the disciplines I mentioned may have a different belief and practice for managing different types of pain, and the patient suffers it simply by being overwhelmed. The easy answer in the face of too much information is simply to request and receive more prescriptions for opioids.

Honestly, with all the variables and combinations of pain stressors, and all the options for treatment, it’s absurd to think that patients who are in the midst of an acute pain episode can readily make decisions about longer term pain management, just as it’s difficult to imagine the person’s primary provider will have the time, education and communication skills to assist the patient through the maze.

In terms of preventing narcotic abuse and addiction, it appears that health care may be dropping the ball in the initial phase of pain management. Typical health care providers are not pain management specialists and may not be adept at evaluating and treating pain beyond an initial course of narcotics and home remedies, which sometimes grows into chronic narcotic use and addiction.

Communication barriers between providers and patients abound, whether from health literacy or language or cultural issues, making patient education a significant stumbling block. The lack of referral for psychological counseling during treatment for an acute phase of care leaves the patient’s emotional issues unaddressed. Emotional issues, brought on by such events as loss of income or job loss because of an injury, can affect the person’s perception of pain and the success of treatment.

How do you educate and convince a person to not drive a car while taking narcotic medication when they have to go out on job interviews because they were fired for missing work after this injury? Communication is essential.

At the unfortunate other side of this, should the patient run into trouble and become addicted to narcotic pain medications, we have treatment available that is covered by both private insurance and Medicaid, thanks in part to the Affordable Care Act. For example, the Queens Medical Center has an opiate addiction treatment program that uses suboxone drug therapy to reduce the symptoms of drug dependence. Another example is the Ku Aloha Ola Mau program which has treatment available in Honolulu, Hilo and Puna that includes many outpatient services and psychological therapy.

Lisa Cook, executive director at Ku Aloha Ola Mau, reveals that, “The worst enemy in treating addiction is that people feel stigmatized. As many as one in seven people can be susceptible to addiction after injury or surgery, and there is help available. Private help.”

Whether through better patient education or exploration of alternative pain management strategies, Cook urges physicians and patients alike to consider using our community’s resources in treating pain without creating addiction.

It’s not a sign of pain management success if our EMS personnel have to administer Narcan to save the lives of people who’ve overdosed. We need to address this at the front end instead of waiting and then treating addiction or mourning death.

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