Of all the rotations I had to do as a resident, my least favorite was Pain Management. I never enjoyed that specialty. Pain being a rather subjective sensation, it is almost impossible to measure. What a patient says must be taken at face value unless there are circumstances and clinical signs that contradict his or her story. No matter how much empathy one has, there is always the feeling that some patients are not being truthful and that pain was being used as a bargaining chip. A chip to obtain narcotics and not work. Don’t get me wrong – there were patients who were truly in chronic pain but more often than not, those patients found a way to lead a life that was not totally ruled by their suffering.
It was during that rotation that I learnt the term, “Pain pays” and came to realize how true it is.
For the patient, pain brings attention, an excuse from working, doting on by a loved one and pain medications that often lend a high.
For the physician, it is cash from perform pain-alleviating procedures on these patients and the lure of a “pill mill”.
For the drug companies, selling all those pain pills spells profits.
Pain pays!
Shakespeare uses the term in his 1594 narrative poem, “The Rape of Lucrece”.
The poem tells the story of Tarquin, the son Lucius Tarquinius, King of Rome. Tarquin was a soldier in his father’s army besieging Ardea. One night, all the men bragged about how chaste and virtuous their wives were. To prove their claims, they all secretly retuned to Rome to see if each other’s wife was as described. The only wife who proved chaste, virtuous and was incredibly beautiful was Lucerne, wife of the soldier, Collatinus, a friend of Tarquinius’. Her chastity and virtue sparked something in Tarquinius. When they all retuned to Ardea, he stole back to Rome and went to Collatinus’s home.
Lucrece, seeing her husband friend and the king’s son, welcomed him and allowed him to spend the night. In the middle of the night, he entered her room, raped her and fled.
Prior to the act, he debated with himself whether he should commit the dastardly act. As he comes to the door of her bedroom he says to himself:
“Pain pays the income of each precious thing;
Huge rocks, high winds, strong pirates, shelves and sands,
The merchant fears, ere rich at home he lands.”
Lucrece summoned her father and husband the next day back to their home in Rome. She asked them to avenge what had happened to her, told them the story and then stabbed herself to death. Her husband and father carried her body to the public square and told the people of Rome what had happened. The Tarquinius family was chased out of Rome, ending the monarchy.
Did pain really pay?
For a while, Tarquinius may have enjoyed the bitter fruits of his act but his win led to death and misery for all involved.
Before the 1990s, doctors used opioids rather sparingly. One can say that pain was under-treated. Narcotics were mainly given to cancer patients. Then in 1980, Hershel Jick published a study claiming that the use of narcotics in 11,882 in-patients led to only 4 cases of addiction. Six years later, Portenoy published his study looking at the use of narcotics in non-cancer patients. He claimed there were no adverse effects. He studied 38 patients on which he based his claims!
Even though both studies were highly flawed, they dramatically changed medical thinking and then practice. Portenoy formed the American Pain Society and preached that the risk for opioid addiction was less than 1% – a number he would later confess that he grabbed out of thin air!
The society came up with “Pain as a 5th vital sign” slogan and it caught on.
Into this fray was dropped the drug Oxtcontin by Purdue Pharma in 1996. With aggressive marketing, they promoted this new drug.
The Joint Commission got behind pain the 5th vital sign. By 2004, doctors who under treated pain faced sanctions. Opioids were being prescribed to all, even outpatients. Later Endo Pharma and Johnson & Johnson would join the opioid party with their own portfolio of synthetic opioids.
Purdue Pharma claimed that oxycontin was a slow-release formulation and would never lead to addiction. Well, we know better now. They had to pay $635 million in fines in 2007 for misbranding and reformulate the dug but by then it was too late.
By 2012, sales of opioids were more than $9 billion a year and in 2013, opioid overdose surpassed car accidents as the number one cause of accidental death.
These patients are now not just sticking to prescribed narcotics but using heroin, cocaine as well as illegally made fentanyl and karfentanyl of unknown potency!
Like Tarquinius, pain did pay the income of each precious thing. The drug companies got rich. Doctors ran “pill mills” where they prescribes opioids like candy… and got rich. Whatever misgivings these players may have had was only like “ the merchant who fears, ere rich at home he lands”.
Like Tarquinius, doctors and the pharma companies took from these patients something really valuable. Almost as valuable as what was taken from Lucrece. They took away their will to not fall prey to opioid addiction. They took away their independence and sense of worth. They made them dependent. All those years of easy narcotics made all these patients highly susceptible to addiction to heroin and cocaine.
Lucrece killed herself shortly after her defilement. These patients are however dying slowly albeit in large numbers. However the misery their fading lives cause is as profound as that which Lucreces’ father and husband felt.
How his all this going to end?
Are the drug companies and doctors going to get banned from our cities?
Already, states like Ohio are suing the drug companies to force them to finance the care of all these addicts. Will doctors be held liable too?
Whatever happens, I hope we all learn that pain is not a means to amass wealth but rather a sign that the sufferer needs help.