Reflecting on pain control.

To the Editor We read with interest the two Reflections articles regarding pain control by Veysman in recent issues. 1,2 We understand the importance of treating pain as an integral part of compassionate medical care. We suggest, however, that not every patient that comes to the emergency department complaining of pain may actually have pain. The author suggests that the physical examination is useless in the evaluation of pain. The resident who was holding the ice cube, or the patient with true pain, would have most likely had some suggestion that he or she was in pain on physical examination. 3,4 It is equally unreasonable to shock a test subject because an experimenter says to, as it would be to give every complaint of pain a supply of narcotic pain medicine because it is the de rigeur thing to do. We suggest that instead of political correctness, emergency physicians use clinical correctness. A proper detailed history is essential, and a physical examination and assessment of the patient’s response should suggest that his or her pain is appropriate for the clinical condition. In the sciatica case presented by Dr. Veysman, we believe that the history is somewhat suspect. He reports 1 year of sciatica resulting from trauma. The vast majority of such patients would have their pain resolved so long after an injury. 5 The patient has no primary care physician, yet has a diagnosis. He has a chronic sciatica yet moves furniture around. We would suggest that such a history does not make sense. We often hear from colleagues that it is ‘‘easier just to give the prescription’’ even when they suspect drug-seeking behavior. While we agree that giving the benefit of the doubt is important, we also advocate that feeding narcotic addiction is also a grave disservice to our patients. In the environment where we work, there are multiple hospitals within a few-mile radius that do not share a unified medical record. Surprisingly often, when a patient provides a suspicious history, a simple phone call to another ED or nearby pharmacy more often than not confirms that some patients receive multiple prescriptions from multiple providers at multiple facilities. It is easy to suggest that malingering is a rare occurrence and that we should simply treat any complaint of pain. However, to do so would ignore the fact that the problem of drug dependency and illegal diversion is steadily increasing. 6‐8 A recent estimate is that a lifetime risk of nonmedical use and abuse of prescription medications is 20% for persons aged 12 years or over, which is 48 million people in the United States. 9 As cost in health care becomes a greater concern, the cost of diversion must be addressed. Resources saved on curbing diversion could be better served on those who truly need our help. 10 We are actively involved in helping our state to develop its prescription monitoring program, with the goal of allowing practitioners to determine which patients have recently filled narcotics prescriptions, regardless of where they were written or filled, and then to provide appropriate resources and counseling once a potentially addicted patient is identified. We believe that this solution represents a logical and fair approach. To ignore this situation would be as bad as ignoring a patient with a true painful condition. In this case, the painful condition of the one becomes the painful condition of us all.