Commentary

Steve May: Great pains

Editor’s note: This commentary is by Steve May, who is a licensed independent clinical social worker specializing in behavioral health and addiction medicine. He is a member of the Selectboard in Richmond where he resides.

It starts with a smiley face. A fleeting moment when a nurse or medical assistant asks about your pain level. Serious people, doctors, nurses, social workers all asking about pain in a way that demands that one place their constant throbbing somewhere between a grimace and a frown on a pain scale. We all deserve something more than a tool which seems to have been designed by Mr. Yuk and the folks at poison control.

Our collective conversation about addiction and opiates has been focused on access to painkillers. Until recently, they have been too easy to get and have been overprescribed. In more recent times, we’ve made a concerted effort as a state to address the underlying symptoms driving the opiates epidemic and its consequences.

What’s been missing from this conversation is a serious look at the largest driver in this epidemic: pain. Pain, pain management to be more specific. The very mention of it conjures images of some strip mall pill mill doling out prescriptions for oxycodone by the fistful. That’s the problem. This opiates crisis was in no small measure created by patients seeking relief from pain. Maybe they got hurt on the job, maybe they got hurt attempting to capture past glories on playing fields, maybe they got hurt in the course of daily life. Our answer for these people was to include​ a prescription for painkillers … and hope for the best.

Patients deserve better. Pills alone will not fix pain issues for patients. Doctors overprescribing meds for extracted molars, bum knees and tennis elbow has taken a tremendous toll, creating a generation of addicts and the carnage that goes with it. The simple truth is they hurt … docs gave them pills … the patients liked them a lot … when the patients ran out, they bought them on the street until they realized that pills were expensive and heroin was cheaper. Eventually cheaper wasn’t cheap enough. And in many cases, the underlying pain is still there. But now, we use to self soothe.

Doctors overprescribing meds for extracted molars, bum knees and tennis elbow has taken a tremendous toll, creating a generation of addicts and the carnage that goes with it.

 

Pain is the orphaned child of modern health care. We have no strategy for addressing pain as a medical concern. We act as though every pain is exactly the same. It’s not. Attacking the question of pain is central to addressing the opiate epidemic. No matter how zealous doctors were in writing scripts for opiates, they were responding to individuals suffering from the consequences of pain in one form or another. Painkillers were not prescribed for the hell of it by doctors. Patients presented with legitimate health concerns.

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We have as a state attempted to limit how and when pain meds can be used. We have prioritized the use of muscle relaxants and other less habit-forming interventions. We have liberalized rules about who can write a script for agonist drugs like buprenorphine and Suboxone in an effort to support people in their recovery. This all may represent good public policy, but this also is an example of treating the symptoms and not the problem.

In all of these discussions, we as a society have failed to ask how patients found themselves in need of a painkiller in the first place. This crisis began on prescription pads of Vermont’s doctors and ultimately it will end there too. Vermont needs to attack pain as the primary public health concern as pain is the underlying catalyst that created the opiate epidemic. No pain, no pills. This will require a tremendous public health commitment. We need a consensus plan committed fundamentally to changing the way we treat pain clinically and a plan to change the way we conceive of pain publicly.

In crisis there is both opportunity and danger. This moment demands that we move beyond simply trying to put out fires. Perpetual crisis is not a strategy for success. We as a state in general, and as a public health infrastructure in particular, need to go deeper and recognize the central role pain played clinically in creating this crisis. Because this is true, circumstances demand that we reimagine the role pain played in our current care regime. Vermont can and should take this opportunity to step into the void and commit to becoming a global leader on pain and pain management.

Vermont is uniquely situated to be at the center of a new consensus on pain. This is going to require a commitment to building on our existing infrastructure. The University of Vermont Medical Center and UVM School of Medicine amongst others are well placed to lead this fight. Moving beyond traditional medical approaches will be essential, integrating allied health provides more opportunity for varied approaches to pain management ranging from acupuncture to homeopathy and therapeutic massage.

To be certain this effort will not be cheap. Any initiative has a cost in terms of dollars and cents, but in the middle of a public health crisis of mammoth proportions, the financial costs pale in comparison to the toll taken in blood and treasure by not acting. Failing to have accounted for the actual cost failing to address pain issues really take on Vermont families and Vermont’s economy is the true cost to the people of this state.


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