I distinctly remember the first day we were advised to start using pain as the 5th vital sign. During in-service, we were taught that pain is whatever the patient said it was, and any requests for narcotic pain medication were to be processed. We were also familiar with the pain scale, as it was one of our patient assessment tools. The pain scale was used alongside a doctor’s assessment, and was meant to be an objective measure based on a patient’s report. Other vital signs could be objectively measured by thermometer, Sphygmomanometer, EKG etc. However, now we were taking the patient’s word regarding how they were feeling. In theory, not a bad idea as everyone may have a different pain threshold, or experience. But in reality, we were opening a veritable Pandora’s box and the start of an Opioid Crisis.
The familiar faces of the pain scale began showing up in every part of our environment – In our documentation, questionnaires, the walls of patient rooms, and the ER walls. It was in the 1990’s and although part of a nurse’s job is to be a patient advocate, I and many of my fellow nurses were concerned about this new part of our assessment. Not only were we being instructed to accept what the patient was telling us about their pain, but also educating the patient now included the pain scale, and the process to request pain medication. Outcomes showed increased usage of narcotic and opioid prescription medication by patients.
Everyone was getting in on the action. Not just physicians like General surgeons and Orthopaedic surgeons – but dentists, primary care physicians and emergency room doctors. Just about anyone who was able to write a script for narcotics was prescribing opioid pain medication. Providers were advising patients to start with OTC pain medication, however, they were also providing patients with scripts for medium strength and opioid pain medication. The average patient would fill all of their prescriptions and generally take the strongest one to ensure they had no pain.
That was just the beginning…
Routinely, on admission when questioned about what medication they were taking, patients would advise that they were taking Percocet or Darvocet every 4 hours. When advised that that was not the normal way that medication was prescribed, patients would state that they were aware, but their pain was so bad, they had to increase their dosages. Patients would also become upset if the doctor pointed out that they were not taking their medication the way it was prescribed.
When doctors were given a medication list, they would prescribe opioids the way they should be taken. Generally 1-2 tablets every 4 to 6 hrs. The onus remained on the nurse to explain the way the medication is prescribed by the treating provider. It should be noted that these medications have since been pulled from the market, and have been replaced by Oxycodone, Hydrocodone, and Oxycontin.
Increasingly, we began to admit patients who wanted narcotic and opioid medication. Patients would request medication hours before they were due another dose. Anyone familiar with the pain scale knows that a smiling face does not equate to a high level of pain, but unfortunately, well-informed patients knew that it didn’t matter how they looked, as long as they requested their pain medication they would get it. When we tried to administer the medications as prescribed, we were faced with angry, abusive patients. This started happening more and more frequently.
Patient satisfaction surveys and the opioid crisis
Fast forward to the 2000’s, when patient satisfaction surveys became more popular. Nurses were under great pressure to ensure their patients were kept happy. A big part of satisfaction scores were hinged on whether patients were getting their pain medication, especially when and how they were administered.
We created a population of patients that felt really good when they took opioid pain medication. Patients began asking for more and they were being provided with it. Emergency rooms began to fill up with people who ‘just needed some pain medication’. You even began to see ‘repeat offenders’ – people who were in the ER previously, returning in a week stating that they lost their scripts or medication, and needed more. Unfortunately the same patient behaviors were also reflected at retail pharmacies.
With this population of patients having such a great need for pain medication, the 2000’s heralded the era of pain management providers – medical specialties for people with chronic pain. Pain clinics began popping up around the country, and people began travelling across state borders to obtain pain medication. According to Tedeschi, in 2015 the United States had 27,000 deaths that were caused by the use of opioid pain medication or heroin. In fact, Tedeschi notes that the medical community is divided between those who believe in using opioids to treat chronic pain, and those who believe that opioid medication is not the best treatment. It’s also worth noting that patients in search of pain relief easily make the jump from legal prescription pain medication to illegal, but perhaps more easily accessible ones like heroin. Currently there is very little research on the use and/or abuse of opioid analgesics, and given the sheer numbers of people who suffer from chronic pain, be it chronic back pain, knee pain, migraines, or post-op pain, there appears to be very little progress regarding how to resolve this opioid crisis and epidemic.