Dreamland (16 page)

Among the people eager for a new approach to pain treatment was Webster’s nurse, Marsha Stanton. Stanton was raised a Christian Scientist, but went to nursing school. She grew into her career in the 1960s and 1970s, years when physicians and medical instructors insisted on the chary use of opiates, no matter the patient. “We were all—nurses, pharmacists, physicians—taught: Don’t overdose, don’t overdose. You give the smallest amount of medication over the longest period of time because you don’t want to give a patient too much, for fear of addiction.”

But during the 1980s, medications and technology were making new treatment possible. Old attitudes began to fade. From Utah, Webster, Michael Ashburn, Perry Fine, Brad Hare, and Richard Chapman emerged as pain clinicians and thought leaders, along with Portenoy and others in New York. Soon a critical mass was reached and an effervescent pain-management scene developed in Salt Lake. This new Salt Lake pain vanguard held monthly meetings that attracted a hundred people at a time to listen to speakers, discuss new techniques in pain management, and put the old days behind them.

“Salt Lake City became one of the meccas for the new and innovative kinds of things,” said Stanton. “We were interested in better patient care. What we had done for all these years wasn’t working. I remember lecturing many, many times and saying I feel so badly that I treated patients so poorly for so long. But we have the technology now that we didn’t have before.”

An idea advanced that pain counteracted opiates’ euphoric effect and thus reduced the risk of addiction. In a statement on its website, the American Pain Society claimed that risk of addiction was low when opiates are used to treat patients in pain. There appeared to be no ceiling on the dose of opiate painkillers a pain patient might take. Pain, the APS went on, acted against the tendency of opiates to stop the lungs from breathing. Thus, withholding the drugs “on the basis of respiratory concerns is unwarranted.”

Changes in attitudes and techniques in pain treatment were coming quickly. Anesthesiologists found a new role in medicine. Before, anesthesiologists left the patients after surgery. Now they could accompany patients through days or weeks of postoperative recovery, tending to new techniques, such as the epidural that Lynn Webster had given Dorothy. More anesthesiologists became pain specialists. Specialists required nurses. American Society for Pain Management Nursing formed in 1990, funded largely by the Baxter company, and within a couple years had more than two thousand members.

In 1996, the president of the American Pain Society, Dr. James Campbell, said in a speech that “if pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign.”

The American Pain Society trademarked the slogan “Pain: The Fifth Vital Sign” and used it to promote the idea that doctors should attend to pain as routinely as to the other vital signs.

In 1998, the Veterans Health Administration made pain a “fifth vital sign”—another gauge of a patient’s baseline health, along with pulse, blood pressure, body temperature, and respiration. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO)—which accredits sixteen thousand health care organizations in the United States—did the same. Hospitals were now to be judged on how they assessed, and treated, a patient’s pain. The California legislature required hospitals and nursing homes to screen for pain along with the other vital signs. The state’s Board of Pharmacy was by then assuring members that “studies show [opiates have] an extremely low potential for abuse” when used correctly.

From all this, the idea took hold that America was undertreating pain. Tens of millions of people, surveys reported, were in pain that wasn’t being treated. Pain’s undertreatment was viewed as an unnecessary epidemic, for medicine now had tools to treat it. A 2001 survey of a thousand people living at home with pain due to a medical condition reported: Half couldn’t remember what it felt like to not be in pain, 40 percent said pain was constant, and 22 percent said they suffered severe pain. Only 13 percent had seen a pain specialist.

Doctors and medical associations, however, were worried. Prescribing these drugs might lead to addiction. They demanded legal clarity. So, beginning with California, states passed laws exempting doctors from prosecution if they prescribed opiates for pain within the practice of responsible health care. Numerous states approved so-called intractable pain regulations: Ohio, Oregon, Washington, and others.

Soon what can only be described as a revolution in medical thought and practice was under way. Doctors were urged to begin attending to the country’s pain epidemic by prescribing these drugs. Interns and residents were taught that these drugs were now not addictive, that doctors thus had a mission, a duty, to use them. In some hospitals, doctors were told they could be sued if they did not treat pain aggressively, which meant with opiates.

Russell Portenoy, meanwhile, was made director of the Pain Medicine and Palliative Care department at Beth Israel Medical Center in New York City—the country’s first such department at a major hospital. From this vantage point, and with funding from several drug companies, he pressed a campaign to destigmatize opiates. The drug company Baxter and others produced intravenous patient-controlled analgesia (PCA) pumps, allowing patients to administer their own painkiller with the push of a button. In Tulsa, Oklahoma, two pediatric nurses—Donna Wong and her colleague, Connie Baker—sought a way of assessing pain in children who had trouble describing what they felt. Wong was incorrectly diagnosed with leukemia as a child, and subjected to painful operations without the aid of analgesics. She became a nurse. In the 1980s, with the smiley face fad in recent memory, the women devised a series of six faces a child could point to. The chart begins with a smiling face and ends with a tearful, grimacing face. The Wong-Baker FACES scale is now a standard in gauging pain in children. There are other versions for adults. Patients are asked to quantify their pain according to a scale—numbered from 0 to 10, 10 being worst. These scales were highly subjective, but they were about the only pain-measurement tools medicine had to offer.

Crucial implements in the revolution were Press Ganey surveys. Designed by a physician and a statistician, the surveys gauged patient satisfaction with their doctors. The surveys were a reasonable idea. They became widely used at U.S. hospitals in the 1990s as patient rights grew paramount and the JCAHO began aggressively measuring how hospitals treated patient pain.

Through all this, patients were getting used to demanding drugs for treatment. They did not, however, have to accept the idea that they might, say, eat better and exercise more, and that this might help them lose weight and feel better. Doctors, of course, couldn’t insist. As the defenestration of the physician’s authority and clinical experience was under way, patients didn’t have to take accountability for their own behavior.

All this happened in about a decade. In a country where doctors once feared opiates, a culture of aggressive opiate use was emerging by the mid-1990s. This had support from several quarters: pain specialists and medical school professors, the JCAHO, the drug companies, even hospital lawyers, and so on. Ideas cross-pollinated at the pain conferences that now sprouted around the United States—supported by the pharmaceutical companies that had new medications and technologies to sell. Like-minded people met and questioned old therapies and authorities. At the core of this culture was the idea that these painkillers were virtually nonaddictive when used to treat pain.

Proponents of this approach tried to embed it with nuance. The VHA cited patients’ homelessness, PTSD, injuries, and substance abuse in advising that “the complexity of chronic pain management is often beyond the expertise of a single practitioner.” Primary care doctors should consult pain specialists and multidisciplinary pain clinics. One paper in the International Association for the Study of Pain called pain assessment not an isolated event but an “ongoing process,” which evolved with new evidence and patient input.

“The fifth vital sign” was a “concept, not a guide for pain assessment,” one report read. Along with the pain number scale, a doctor ought to ask numerous questions about a patient’s pain history, the pain’s location, severity, impact on daily life, as well as the patient’s family history, substance abuse, psychological issues, and so on. In fact, pain was really
not
a vital sign, after all, for unlike the four real vital signs it cannot be measured objectively and with exactitude. The National Pharmaceutical Council advised that “the manner in which information is elicited from the patient is important. Ideally, the clinician should afford ample time, let the patient tell the story in his or her own words, and ask open-ended questions.”

Time was the key. Chronic-pain patients took more time than most to diagnose. Problem was doctors had
less
time. Just as patient rights were emphasized and surveys were circulating asking them to judge their doctors’ performance, patients were in fact losing their most precious medical commodity: time with their doctors.

With the managed care movement of the 1980s and 1990s, insurance companies cut costs and reduced what services they’d pay for. They required that patients give up their longtime physicians for those on a list of approved providers. They negotiated lower fees with doctors. To make up the difference, primary care docs had to fit more patients into a day. (A
Newsweek
story claimed that to do a good job a primary care doctor ought to have a roster of eighteen hundred patients. The average load today is twenty-three hundred, with some seeing up to three thousand.)

“The way you’re reimbursed in a day, if you actually take the time to treat somebody’s pain, you’d be out of business,” one longtime family doc told me. “By the model you’re stuck in, you can’t do it. The hospital will get rid of you. If you’re by yourself, you can’t pay for your secretary.”

So as the movement to destigmatize opiates and use them for chronic pain gained energy, the seeds of discontent were already being sown. These drugs were advertised mostly to primary care physicians, who had little pain-management training and were making their money by churning patients through their offices at a thirteen-minute clip. Not much time for nuance. Not much time for listening, or for open-ended questions that might elicit long and complicated answers. On the contrary, just as Valium helped doctors deal with anxious patients in the 1960s, opiates helped a harried doctor with what was now the largest drain on his time: chronic-pain patients. As the movement gained strength from new drugs and devices, the crucial ingredient in pain management—the amount of time a doctor could spend with each patient—fell. Digging through all this, I found at least two studies that showed that prescribing of all kinds rose as doctor visits shortened. Not surprising. As every doctor knows, nothing cuts short a patient visit like a prescription pad.

The Press Ganey patient surveys, it turned out, had an unintended effect in this context. It was to subtly pressure doctors to write unnecessary scripts for opiates. A doctor reluctant to write them was more likely to get a poor patient evaluation. Too many bad scores and a hospital began asking questions.

“I get raises, and keep my job, based on whether I’m keeping my patients happy,” said a nursing supervisor I spoke with. “When the Joint Commission surveyed us they looked through charts looking at pain. They were looking at other things, but pain was the number one thing. They just hammered and hammered on pain. You had to control everybody’s pain. The [Press Ganey] scores were one way they measured how the doctors were doing.”

And there was another problem. No one had done serious, long-term studies of whether opiates actually were nonaddictive when used by such patients. Years later, in fact, there still is no evidence of how many chronic-pain patients can be successfully treated with opiates without growing dependent, then addicted. Determining who is a good candidate for opiate treatment is a mystery, and particularly difficult when doctors have no pain-management training and only thirteen minutes with each patient.

The new pain movement pushed past these doubts. It acquired a quasi-religious fervor among people seared by the nontreatment of pain of years past. A pendulum began to swing. The cruelty of earlier times discredited those who might question the emerging doctrine of opiates for chronic pain. Pain specialists working toward a new day felt gratitude to pharmaceutical companies for developing the drugs and devices that made possible the humane treatment of pain. Among them was Purdue Frederick, which in 1991 formed an associated company, Purdue Pharma, that in turn grew into a leader in timed-release pain medications. Purdue was unknown to the public, but well-known to pain specialists. It was leading the way with new tools in pain treatment, MS Contin above all, but with other drugs on the way. The company also had attempted to control theft by developing a database to aid law enforcement investigations into pharmacy robberies.

“For those of us doing pain management, that was the ultimate; Purdue was
the
company,” Marsha Stanton said. “They had done everything right. They’d blown onto the market. They had supported the clinicians, supported the education. They had done everything we thought they should have.”

Purdue, in particular, funded pain researchers, many of whom saw the company as an innovator and ally. This included Russell Portenoy. Portenoy, in turn, spoke frequently and with passion at conferences of primary care doctors, urging them to consider new approaches to pain that included opiates, and timed-release opiates in particular.