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In an era when prescription drug abuse is on the rise, doctors still don’t have a good way to measure pain objectively, The Wall Street Journal reports. The most common way to measure pain is to ask patients to rate it themselves on a scale of one to 10, or to match up their pain to a cartoon face that shows an expression similar to what they are feeling.

Joel Saper, Director of the Michigan Head Pain and Neurological Institute in Ann Arbor, told the newspaper, “We don’t have a pain-o-meter.” His estimate is that between 15 to 20 percent of patients seeking relief from pain either don’t have pain or have less pain than they say they do. There are a variety of reasons why patients fake pain. While some are dependent on opioids or want to resell them, others want to get out of working and collect disability. Still others find power in their pain, Dr. Saper says.

Even among patients with real pain, level of tolerance for pain varies widely. Doctors must balance the abuse of prescription painkillers with the real need of patients in pain, the article notes. An estimated 116 million Americans suffer from chronic pain. Low back pain is the most common type of pain, affecting 28 percent of the population. Knee pain is second, affecting 20 percent, according to a new report by the Institute of Medicine called Relieving Pain in America.

Some doctors ask patients who they feel are at risk of prescription drug abuse to sign an opioid contract. This agreement establishes an understanding that the patient will only receive opioids from that doctor and only one pharmacy. The patient may be asked to submit to urine drug screening, and is told that if their medication is lost, it will not be replaced. Stolen medication will only be replaced if the person brings a police report.

Many states also have prescription drug databases that doctors can check to find out whether patients are receiving similar drugs from other doctors in the state.

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