Dealing With the Pain

The American medical system has devoted too little attention to the management of chronic pain, a condition that can make life unbearable for the elderly.

In early October, conservative radio talk show guru Rush Limbaugh made a startling confession to his 20 million listeners. Following unsuccessful spinal surgery several years ago, Limbaugh said, he became "addicted to prescription pain medication," including the morphinelike analgesic OxyContin. He also said he wanted to enter rehabilitation to kick his addiction "once and for all."

The news launched a glut of media coverage, as newspapers across the country used Limbaugh's confession as a springboard for articles with titles such as "Painkiller Abuse on Rise, With Deadly Side Effects" and "Addicted to 'Oxy': One Man's Struggle." The reports noted a growing push by drug enforcement officials to prosecute doctors for overprescribing pain medications, especially opioid drugs such as OxyContin. The media frenzy and its resulting fallout is frustrating many in the field of pain medicine. "There are doctors who will not prescribe opioids now because of the furor and the perception that the DEA is out to take away physicians' licenses," says Peter Staats, an anesthesiologist in the Division of Pain Medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland.

The focus on abuse of prescription painkillers is backward, say Staats and other experts. Powerful painkillers such as OxyContin do lead to addiction in a minority of patients, but they're also crucial to managing the most severe kinds of pain. A bigger problem, say pain specialists, is the American medical system's neglect of people who are experiencing devastating chronic pain. The blame falls not just on doctors but on medical insurers, which fail to appreciate the impact of chronic pain and adopt policies that interfere with its treatment, such as discouraging physicians from prescribing opioid analgesics.

According to the American Pain Society, pain is the leading reason that patients see their doctors, and it causes 50 million lost days of work annually. Most pain is acute, caused by injury or illness; it usually strikes quickly and recedes after medical treatment. But sometimes it is chronic, lingering long after the precipitating disease has been treated. Chronic pain "is widely believed to represent disease itself," according to the National Institute of Neurological Disorders and Stroke.

Estimates suggest that the yearly cost of treating chronic pain exceeds that of treating heart disease, hypertension, or respiratory illness. "This is a huge social problem," says neurosurgeon John Loeser of the University of Washington, Seattle. It disproportionately affects the elderly, who frequently suffer from conditions such as chronic lower back pain and neuropathic pain, a disorder in which damaged nerves generate a constant burning sensation. Seniors might even be extra-sensitive to pain thanks to physiological changes that accompany aging.

Many factors make pain management a difficult task. First, doctors have no way to measure pain objectively, like they monitor blood pressure, pulse, or other vital signs. Because pain can be hard to quantify, Loeser notes, doctors need to spend time with their patients, listening to what they're saying--or not saying--about their pain. Many stoic patients adopt a grin-and-bear-it attitude, and some paint a rosy picture to avoid being prescribed painkillers because they fear addiction. In addition to these considerable hurdles, pain management specialists say our health insurance system does a poor job of treating chronic pain in a manner that reflects its medical significance--as a serious disease and not a mere symptom.

Although pain cannot be measured directly, the Veterans Health Administration and the Joint Commission on Accreditation of Healthcare Organizations take the condition so seriously that they have dubbed it the "fifth vital sign," alongside temperature, pulse, respiratory rate, and blood pressure. Yet medical insurers have rarely shown a similar emphasis. In a national survey, researchers affiliated with Thomas Jefferson University in Philadelphia, Pennsylvania, found that fewer than half of the medical directors of managed-care organizations could state the prevalence of chronic pain among the patients they served. Furthermore, few respondents had implemented an "organized approach" to chronic pain management, such as referring patients to pain-management specialists and keeping tabs on the use of chronic pain medications.

The problem isn't simply a lack of attention or a failure to develop a systematic approach to managing pain. The policies that insurance companies use in deciding how to reimburse doctors also impede pain treatment. A 1994 study by researchers at the University of Wisconsin School of Medicine in Madison concluded that "lack of coverage and uneven reimbursement policies ... inhibit access to acute and cancer pain management for millions of citizens, in particular the poor, elderly, and minorities." Diane Hoffmann, a pain law specialist at the University of Maryland School of Law in Baltimore, says little has changed since then.

In a sense, gaps in insurance reimbursement for pain treatments mirror general deficiencies in our medical system: Insurers prefer to pay for procedures with concrete costs and results, such as operations, instead of more fuzzy aspects of care, such as intensive physician-patient time. Procedures with tangible outcomes are "far better reimbursed than evaluation, diagnosis, thinking about a patient's case, and educating the patient," says Anne Louise Oaklander, a neurologist at Harvard Medical School in Boston.

When it comes to pain management, says Oaklander, this system often pushes doctors to recommend temporary fixes that are guaranteed to be reimbursed, such as nerve-blocking agents that interrupt the body's transmission of pain messages to the brain. Instead, physicians should be taking the time to get patients on more reliable long-term medications, including opioids, which pain specialists consider essential. "The way Medicare and insurance companies approach pain is highly biased against the use of opioids," says Mary Baluss, director of the Pain Law Initiative in Washington, D.C.

Insurers have also been wary about treating pain because the condition is so subjective and many of the medications are costly. During a 1997 legislative debate over the Medicare budget, for example, Florida Democratic Senator Bob Graham floated an amendment that would categorize "severe pain" as an emergency medical condition. His proposal met with strong opposition from the American Association of Health Plans (AAHP), the chief lobbying group for the managed-care industry. Representatives from AAHP called pain a "highly subjective term" with a "vast difference in meaning among consumers."

The greatest irony, researchers say, is that insurers would save money if they did a better job of treating patients' chronic pain; that approach would keep people from ending up in the hospital and repeatedly returning to their doctors. Pain can lead to inactivity in the elderly, which in turn can cause weight gain and a host of related maladies. Furthermore, notes Oaklander, "at least 50% of the patients who have ongoing chronic pain will become depressed," leading to more medical problems.

"There are really good data on the fact that treating pain saves money in the long run," says Baluss. But insurers, she says, "haven't really gotten there yet."

Chris Mooney, a writer living in New Orleans, Louisiana, suffers from occasional lower back pain, but he can't prove it.