DIAGNOSING A PATIENT AS A FAKER

Even When Patients Describe Pain In Vivid Detail, Doctors Have Few
Tools To Determine What's Real

A patient walks into the examining room and says, "Doctor, my back
hurts and nothing works-except my Percocet." Now, the physician must
decide: Is this pain for real?

Despite decades of research, doctors have few tools to measure pain
objectively. Generally, they ask patients to rate it themselves from
one to 10, or point to the cartoon face on the wall chart whose
expression best matches how they feel.

"We don't have a pain-o-meter," says Joel Saper, director of the
Michigan Head Pain and Neurological Institute in Ann Arbor, which
draws about 10,000 patients a year, including some of the nation's
toughest migraine cases.

Dr. Saper estimates that 15% to 20% of them are faking-or at least,
aren't as incapacitated as they say. Some are dependent on painkillers
or seeking to resell them, he says. Some want a doctor to certify that
they'll never be able to work again and deserve disability payments.
Some, he thinks, don't really want to get well because they
subconsciously find power in their pain.

Even when pain is real, it's highly subjective. "Two people can have
the same nerve compression, but one guy will be bedridden and the
other guy will be saying, 'Nah, I'm fine,' " says David Kloth, an
anesthesiologist and past president of the American Society of
Interventional Pain Physicians.

Evaluating patients' pain is posing a greater dilemma than ever for
doctors, given two colliding health-care trends.

On the one hand, opioid painkillers-the most commonly prescribed
medications in America-have become a major drug of abuse. With
prescriptions up 48% since 1999, opioids are now the nation's
second-leading cause of accidental death, after car crashes, according
to the Office of National Drug Control Policy.

On the other hand, the Institute of Medicine, which advises the
government on health issues, reported last week that pain is all too
often undertreated in the U.S. For many of the 116 million Americans
afflicted with chronic pain, help is delayed, inaccessible or
inadequate, the IOM found.

Many patients feel stigmatized even asking for help. "I hear from
people all the time who say they are at a loss to communicate how bad
they feel to their doctors-without being eyed as potential criminals,"
says Karen Lee Richards, a co-founder of the National Fibromyalgia
Association. Like many people with fibromyalgia, a complex disorder in
which even mild sensations are interpreted as pain, Ms. Richards was
told for years that she was probably just getting older.

Some doctors say they have to look at every patient as a potential
drug abuser, since there are no typical ones-although there are
suspicious patterns. "Sometimes it's the patients with elegant clothes
and three kids who call a week after a filling and say they need pain
medication. That's when my radar goes up," says George Kivowitz, a
dentist in New York City and Newtown, Pa. Insisting that the patient
come in to be re-examined usually ends the conversation, he says.

Some physicians make patients take periodic urine tests and sign
treatment contracts, promising to take medications only as prescribed
and not seek drugs from other sources, or face expulsion from the practice.

In 38 states, doctors can also check prescription registries to see
whether patients are getting similar drugs from other physicians in
the state. A nationwide version, passed by Congress and signed by
President George W. Bush in 2005, has been stalled by lack of funding.

Several bills before Congress would require doctors to undergo
additional training in opioid use and abuse as a condition of renewing
their license to prescribe them.

"I always ask a patient, 'How are we going to show that this
intervention has helped?' " says Scott Fishman, president of the
American Pain Foundation who wrote a widely used guide to responsible
opioid prescribing. "The person who is just trying to get opioids will
say, 'Ah, later, dude' and go somewhere else."

Experts also say it's critical for primary-care physicians, who treat
80% of pain issues, to take time to know a patient's history and
circumstances. The lower-back pain he's experiencing may be magnified
by an unhappy work situation or pressures at home.

"The answer may not be a neuropathic pain drug but reassurance and
counseling," says Perry Fine, a professor of anesthesiology at the
University of Utah and president of the American Academy of Pain
Medicine (AAPM). But connecting all those dots is very difficult, he
concedes, when the typical office visit lasts less than 12 minutes.

There's growing recognition that acute pain and chronic pain require
very different approaches. Acute pain is a warning signal to stop
something that's harmful, experts say. In chronic pain, that alarm
keeps sounding and producing pain long after the original cause is
gone, probably due to a malfunction in the central nervous system.

Chronic pain, in turn, can cause changes in the emotional and
attention centers of the brain, and lower pain tolerance even further.
Antidepressants are helpful in some cases. There is little evidence
that opioids are effective at alleviating chronic pain, yet some
doctors keep prescribing them, in ever higher doses.

Many pain-management centers now have a multidisciplinary team
including anesthesiologists, neurologists, physical therapists and
psychologists evaluate patients. At University of California, Davis,
where he is chief of pain medicine, Dr. Fishman says, "We start from
the beginning and assess where the pain is, what it's robbed the
patient of, and how treatment might help," says Dr. Fishman. "It's not
a quick visit."

Some centers typically stop all of a patients' pain medicine and start
over. If they protest, "I say, 'If the drugs were working, you
wouldn't be here,' " Dr. Saper says.

At his migraine center in Michigan, some patients with intractable
pain are admitted and observed around the clock. "We can learn a lot
that you don't see in an office visit such as how they party in the
cafeteria and how they argue with their spouse," he says. One patient
who said her chronic migraines made her unable to work was overheard
planning an ambitious honeymoon in Europe. Dr. Saper refused to sign
her disability form. "We make some patients angry," he says, "but
about 75% of the people who come to us improve and are grateful."

Pain psychologists also play a key role, especially when physicians
can't minimize patients' pain and have to help them live with it
instead. Therapists often wish they were brought in sooner. "Many
patients feel like the doctors are saying to them, 'There's nothing we
can do from a medical standpoint, so it must be mental,' " says Robert
Twillman, a veteran pain psychologist who is now director of advocacy
for the AAPM. He often tells patients that whatever the initial cause,
the pain must be taking an emotional toll as well, which is in their
own power to change.

Many centers focus on improving function rather than eliminating pain.
Sean Mackey, chief of Stanford University's division of pain
management, doesn't even ask patients how much pain they are in.
Instead, he asks, " 'If I could wave a magic wand and take away all
your pain, what would you be doing in a month?' We may not be able to
measure a patient's pain, but we can define some goals and work toward
them," he says.

[sidebar 1]

Lasting Aches

Chronic pain affects 116 million Americans (one-third of the
population) and costs $550 billion to $635 billion a year in medical
bills and lost productivity. The most common types people reported in
a survey:

- - Low back pain 28%

- - Knee pain 20%

- - Severe headache or migraine - 16%

- - Neck pain 15%

- - Shoulder pain 9%

- - Finger pain 8%

- - Hip pain 7%

Source: Institute of Medicine; 2011 survey of U.S. adults reporting
that they had pain in the past three months

[sidebar 2]

Use and Abuse

Opioids are the most commonly prescribed drugs in the U.S. Hydrocodone
(Vicodin) is the No. 1 drug.

- - Prescriptions rose nearly 50% from 2000 to 2009; milligrams
prescribed per person rose 400% from 1997 to 2007.

- - 15% to 20% of doctor visits in the U.S. involve an opioid
prescription.

- - Four million Americans a year are prescribed a longacting
opiod.

- - Abuse of opioid pain relievers is the second-leading cause of
accidental death in the U.S., after car crashes.

- - Fatalities rose from 3,000 in 1997 to 12,000 in 2007.

- - Emergency-room visits due to prescription-drug overdose rose 500%
from 2005 to 2010.

Source: Archives of Internal Medicine, 2011; Office of National Drug
Control Policy