You wake up early, ready to start your day at the office, knowing full well that your healthcare practice has changed dramatically over time. You are already stressing out, thinking about having to see a multitude of patients, each of whom has differing complaints, symptoms and histories that you have to review, then record, in a detailed, cumbersome, electronic heath record (EHR) you were trained in and are now required to use. You feel frustrated, knowing full well that you will, most likely, spend little time with each patient because of your large caseload and the note-taking and administrative demands placed on you.
You get to your office and begin your first encounter by greeting your patient, then reviewing their record and medication list. You refine it if any medications or medication amounts, have changed, as indicated in the patient’s EHR. Next, you ask and record their present symptoms. As you listen to the patient, you type away on your laptop, as they tell you their concerns. You know you don’t want to fall behind with seeing patients and note-taking because it will only mean that you’ll be going home later than usual or you’ll have to catch up recording notes later or the next day.
Suddenly, you become irritable, recognizing that the symptoms your patient is describing are similar to those described during their previous visits. Typically, they are complaints of their experiencing chronic, physical pain, much of which you surmise, have had no clear, physical evidence to support them. You realize that it isn’t going to be so easy for you to recommend anything new. You’ve advised so many options before to which the patient never complied. Nothing is working. In the past, you may have prescribed medications like NSAIDS, muscle relaxants, or opiates or, have performed certain procedures, or advised them to do healthy activities, like simple stretching, exercise or cut down their weight or alcohol intake. You may have authorized or reviewed their x-rays, blood tests or MRIs to try to substantiate the rationale for their physical complaints. A majority of the medical tests seemed useless because the patient still complained of having chronic pain. You’ve even made periodic referrals to specialists, like orthopedic surgeons, physical therapists, or chiropractors, knowing full well the patient’s level of treatment adherence was minimal. If you are a physician or Clinical Nurse Specialist, you wonder if your patient is looking for a quick fix of an opioid medication you once prescribed so easily, but can’t anymore, because of federal and state regulations that restrict them. You even wonder if they’re looking for a marijuana card or begin to mistrust them, wondering if they’re looking for disability, a process that will require more of your precious, limited time to procure documentation that includes completing detailed forms. You feel more frustrated and helpless! No matter what advice you recommended to the patient.
After talking to, and examining them, it seems obvious to you that their pain persists. There is no perfect answer you can give them to rid themselves completely of their pain. You feel so helpless that you may recommend that they go to a pain management center because you’re clear there’s nothing more you can do for them.
Sound’s familiar? If so, then you are not alone! The number of patients reporting physical symptoms of chronic pain, or pain that lasts longer than three to six months, is increasing exponentially each year. Approximately 100 million individuals in this country complain of having chronic, physical pain. Worldwide, the number is 1.5 billion people or 3-4.5% of the global population. Chronic pain has become one of the top 5 major medical conditions for which patients seek treatment. It costs the United States between $560-$635 billion dollars annually, $261-$300 billion of which is due to incremental costs in health care and $297-$336 billion of which is due to lost productivity. Almost 2 out of 3 patients report pain impacts their quality of life. 77% report feeling depressed while 86% report not sleeping well.
The most serious condition is the exponential increase in drug overdoses from prescription opioid medications and from street drugs like heroin mixed with toxic fentanyl. According to the Boston Globe (February,2018), “US deaths linked to opioids have quadrupled since 2000 to roughly 42,000 in 2016 or about 115 lives per day.” “Overall, more than 60,000 people died from drug overdoses, according to the Center for Disease Control”. Bloomberg News reported that the drug, Oxycontin, generated $1.8 billion in sales in 2017 for its maker, Purdue Pharma LP.
From 2011 to 2015, overdose deaths from opiates increased 130 percent just in Boston, Massachusetts. In 2015, the rate of overdose deaths linked to fentanyl use was 16.2 deaths per 100,000 residents compared to 1.1 deaths in 2011.
Despite the major focus on opiates by the Federal and State governments opiate usage is just one serious problem facing Americans and people worldwide. A study reported in Clinical Psychiatry News (February 2018) that, of 3,862 individuals who committed suicide in 18 states in 2014, 40.8% had antidepressants in their system followed by alcohol (40%), and Benzodiazapines (32.6%). Opiates was ranked fourth (30%). There seemed to be a higher correlation between the use of antidepressants to and alcohol than between any other substances.
More and more patients appear to be living a ‘passive suicide’ lifestyle as a way to cope with their having chronic pain. Many of them are overweight, prone to diabetes or cardiovascular conditions, get little to no exercise, and continue to drink excessive amounts of alcohol and/or smoke tobacco daily. The NY Times revealed that nearly 40% of Americans were obese in 2015 and 2016. Between 2012 and 2013, the rate of alcohol use disorders increased 53 percent. The Center for Disease Control anticipates that the level of cocaine use will increase 540% in 2018 from 2017.
As a licensed professional who has worked in the mental health field for over 46 years, I have become deeply concerned about what is happening to you, as a healthcare provider, given your level of stress between all the changes in the healthcare system, the need to keep up with the frenetic pace of seeing your patients daily and, your requirement to document copious, electronic health record notes. I hear many of your colleagues’ concerns, almost daily, listening to them commiserate during lunch hour about the extent of stress they are undergoing. Their concerns underscore the seriousness of information provided by a chief psychiatrist who represented the Physicians Health Services, Inc., a corporation of the Massachusetts Medical Society that specializes in helping physicians who are experiencing burnout, at a local seminar. He acknowledged that their service caseload had increased dramatically in 2017, with more than 400 physicians and medical students being helped for mental health and substance abuse problems. One in three professionals were self-referred because of occupational stress, difficulties balancing work and family and, difficulty dealing with stress and financial pressures. Many of them are on active monitoring contracts for substance abuse.
I believe that one of the main reasons many professionals in the healthcare community are overstressed is because they place unrealistic expectations on themselves to help so many patients change their behaviors, especially when it comes to more difficult conditions like chronic pain. These professionals want to see their patients improve, if not conquer, their pain, because that’s what they were trained to do. And this includes you! As a healthcare provider, your positive desire to find the right treatment or cure for pain patients may not be so easy Why? Because the definition of chronic pain and the treatment expectations and strategies are changing dramatically, as you’ll read in this book.
My hope is that you can find the information in the coming chapters helpful enough to become less stressed. By changing your perspective about the paradigm of ‘pain’ as being much more than simply physical symptoms, it is my hope that you can reduce your high, self-standards, and the expectations of your patients to change; that you realize you are ‘good enough’ in doing everything possible to help them.
Your treating chronic pain requires an ongoing team effort of which you are an integral member. Your having the support of other healthcare providers as extended team members can help you reduce your stress, given the multi-dimensional and subjective nature of chronic pain and the fact that treating chronic pain implies simply trying to reduce it over time, in a manner similar to many other bio-psycho-social medical conditions.”
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