Rx abuse: We largely rely upon subjective assessments of pain. “How much does it hurt on a 1 to 10 scale?” I have always been surprised that a patient will tell me that his pain is a 9 while calmly sitting there (and yes, affect is not the barometer of suffering but it is an important factor). Or tell me that “the pain is so bad I cannot sit for more than 30 minutes and then proceeds to sit for several hours without observable signs of discomfort.
We know there is no objective measure of pain, only our observations and the patient’s description. Yet, when we doubt the patient, we fail to deliver adequate care since we cannot know the degree of suffering and the limitations imposed by the pain. We have measures of rx abuse.
What is our concern? For one thing, we are fearful that we are being manipulated, that the patient has his own agenda and knows we cannot really determine how bad he feels. We are also concerned that the patient is engaged in drug abuse to create a state of euphoria…to “get high” or to resell the medication…to stockpile it as a lethal means of self hard…to save it for those times when access to the medication is blocked. Keeping drugs off the market, and drug testing to determine compliance, changes the doctor-patient relationship from one of support to an amalgam of suspicion and distrust.
There is little doubt that people differ in their pain threshold and pain tolerance. The stories are legendary of the man who ignores one or more heart attacks while another goes to the ER when chest pain is nothing more than indigestion. Some people are capable of ignoring a broken limb while others are bedridden over a sprain.
One problem is our human bias, in which the patient who stoically handles pain is perceived as strong, and those who cannot manage are seen as weak and unworthy of respect. While we struggle with the imprecision of a patient’s subjective complaints of pain, reliance upon our observations (also subjective) is equally flawed.
A recent paper (American Academy of Neurology (AAN) 66th Annual Meeting. Abstract P4.349. Presented April 30, 2014) discussed the potential to find the genetic markers for pain tolerance. If/when genetic markers are found that objectively measure pain tolerance, hopefully that marker will be another, not a deciding, factor in accepting our patients’ complaint of severe pain as genuine, regardless of their stoicism.