Caution using the new “no pain no gain” approach

Caution using the new “no pain no gain” approach

Accepted Manuscript Caution using the new “no pain no gain” approach Jared Strote PII: DOI: Reference: S0735-6757(17)30274-7 doi: 10.1016/j.ajem.201...

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Accepted Manuscript Caution using the new “no pain no gain” approach

Jared Strote PII: DOI: Reference:

S0735-6757(17)30274-7 doi: 10.1016/j.ajem.2017.04.008 YAJEM 56602

To appear in: Received date: Accepted date:

8 March 2017 5 April 2017

Please cite this article as: Jared Strote , Caution using the new “no pain no gain” approach. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajem(2017), doi: 10.1016/j.ajem.2017.04.008

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ACCEPTED MANUSCRIPT

Caution Using the New “No Pain No Gain” Approach

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Corresponding Author: Jared Strote, MD, MS Division of Emergency Medicine University of Washington Medical Center Box 356123 1959 NE Pacific Street Seattle, WA 98195 206/598.0103 o 206/598.4569 f [email protected]

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Jared Strote MD, MS Division of Emergency Medicine University of Washington School of Medicine Seattle, WA

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Word Count: 369

Index Medicus Sub-headings: Analgesia

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This work has not been presented elsewhere. There was no funding or financial support.

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Reprints not available from authors

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Running Title: No Pain No Gain

ACCEPTED MANUSCRIPT Caution Using the New “No Pain No Gain” Approach

To the editor: 1

The recent article on opiate prescribing in the emergency department continues the ever-evolving discussion on this extremely important issue facing all emergency physicians. As an educator who has been around long enough to watch the pendulum swing from over- to possibly under-prescribing, I am concerned about how the information in the paper was presented.

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Although paying lip service to the potential benefits of opiates, the paper’s focus is heavily on the damage we do by prescribing. The underlying message is not only that opioid use should be significantly restricted but also that a concern for inappropriate use should be at the forefront of every patient encounter. Unfortunately, it still remains to be seen if such changes will greatly impact the opiate misuse epidemic, which is clearly multifactorial. But it will certainly result in some under-treatment of acute, painful conditions and, in the long run, significantly alter the patient-doctor relationship.

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The new messaging of fear, reflected in this paper, has resulted in a generation of residents that I see routinely viewing their patients adversarially, under-using opiates when they are clearly indicated, not appreciating the nuances of treating pain, and increasingly, not treating patients in pain as unique individuals. This is reminiscent of the way that my generation was taught to similarly think in black and white terms, prescribing opiates with abandon. Rather than create reckless and dangerous over-compassion, however, the effect of the current reactionary stance is to create physicians who may be responsible for less addiction but who are also less interested in or capable of reducing immediate suffering, a cornerstone of emergency medicine.

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One can only hope that, at this point, all physicians are aware of the dangers associated with the prescription of opiates. What we need now is a discussion of how to avoid swinging the pendulum too far in either direction: how to re-focus on compassionate reduction of suffering as a primary goal, with a full appreciation of potential risk and patient safety.

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The complexities of pain and addiction and their intersection with the patient-doctor relationship can be overwhelming and often involve elements beyond the limits of what can be accomplished in the ED. But one-size-fits-all approaches will not provide a satisfactory result in either direction.

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1. Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med 2017;35:337-41.