The Politics of Pain
By: Judy Foreman
11/04/03
 
This is the first of  a two part column on pain. 

America is seriously schizophrenic about controlling chronic pain, which afflicts more than 50 million people and costs the country $100 billion a year.So On the one hand, we grossly under-treat it: Management of chronic pain and the pain of dying patients is arguably the most egregiously neglected field of medicine.

On the other hand, as a society, we have become obsessed with the war on drugs -- and the fear of addiction to opioids (narcotics). Pain patients who were functioning well on morphine-like drugs such as oxycodone (OxyContin) are now fearful of them -- or just plain can't get them.

Some drug stores, wary of robberies of OxyContin, are afraid to stock it. Some unscrupulous doctors have written excessive prescriptions for it. Some patients, like talk show host Rush Limbaugh, abuse it as well. And in some states, Medicaid regulations require doctors to get prior authorization before prescribing the drug. The basic problem is obvious: Some of the drugs that most effectively treat pain are the same ones that are commonly abused. In one survey of New York doctors, 30 percent said they were prescribing fewer opioids or were switching patients to less-effective pain medications for fear that the Drug Enforcement Agency (DEA) might investigate them. At the root of our national ambivalence is what June L. Dahl, professor of pharmacology at the University of Wisconsin-Madison Medical School, calls "opiophobia" -- the fear of addiction to opioids. That phobia has led to serious undertreatment of pain -- particularly
chronic pain.

"Every bit of evidence suggests that we have been under-treating pain," said Dr. Kathleen Foley, an attending neurologist at the Memorial Sloan-Kettering Cancer Center and director of the Project on Death in America of the Open Society Institute, an operating foundation supported by George Soros. In the last five years alone, three major reports from the Institute of Medicine, an arm of the National Academy of Sciences, have concluded that pain control in this country is woefully inadequate. 

These pronouncements follow a 1995 study by the Robert Wood Johnson Foundation that found that 50 percent of people had moderate to severe pain in the last three days of life. A separate study found similar rates of untreated pain in dying children. Even the US Supreme Court, in deciding in 1997 against a constitutional right to physician-assisted suicide, highlighted the need for better pain control and palliative care. Though the fear of addiction is great, in reality, the risk is small, when patients take drugs in the doses prescribed by physicians.

"Addiction," to be sure, is a loaded word. Researchers prefer to speak of physical dependence, which does occur in patients taking opioids, and psychological dependence, which typically does not. It is psychological dependence -- a compulsion to seek more and more of the drug, despite the harm it causes -- that lay people usually mean by "addiction." One 1982 study on patients in 93 burn facilities found no evidence that any patients became addicted to opioids. More recent data from pain clinics suggest the addiction rate might be around 10 percent, but people who attend pain clinics are not typical of all pain patients. 

Moreover, though opioids can cloud the mind, they don't damage vital organs such as the liver, stomach and kidneys, notes Foley of Sloan-Kettering. And once doses are adjusted correctly and monitored by a doctor, patients on opioids for chronic pain often function "at high levels," including taking care of families and even driving, she said.
Dr. James Rathmell, chairman of the committee on pain medicine for the American Society of Anesthesiologists and professor of anesthesia at the University of Vermont College of Medicine in Burlington, puts it even more forcefully.

Fears of addiction? "Forget it," he said. "If you have intractable cancer pain, addiction should be the farthest worry from your mind. Addiction is very unlikely. There are wonderful medications that provide continuous relief over time." That is true for non-cancer pain as well, although aggressive control of pain for non-lethal diseases is even more controversial. 

Arthritis, both rheumatoid and osteoarthritis, affect an estimated 70 million Americans, said Dr. John Klippel, medical director of the Arthritis Foundation. Yet many suffer daily because their pain is inadequately controlled.

With rheumatoid arthritis, one way of controlling the pain is by treating the underlying inflammatory disease itself, with drugs called DMARDS, disease-modifying anti-rheumatic drugs such as methotrexate. In addition,non-steroidal anti-inflammatory drugs such as ibuprofin (Motrin) and COX -2 inhibitors (like Vioxx and Celebrex) can help.

And despite America's conflicted views, there are signs that we're overcoming our collective phobia. Last month, the American Academy of Pain Medicine and leading doctors announced a new initiative called Top Med which will provide a web-based "virtual textbook" available free to all medical students across the country.

It is sorely needed. At the moment, only 3 percent of medical schools have a separate, required course on pain management and only 4 percent require a course in end-of-life care, according to a 2000-2001 survey of  125 medical schools by the Association of American Medical Colleges. A new survey (2003) shows that most medical schools now cover these topics as part of existing required courses.

There's other good news, too. In 2001, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the group that accredits the vast majority of the nation's hospitals, mandated that hospitals must assess and manage pain for all patients, something that, astonishingly enough, had not been done routinely until then. On a more grass roots level, almost all states (including Massachusetts, California and Maryland) have launched pain initiatives to reduce legislative barriers to effective pain control.

Many states are also establishing electronic systems to monitor prescribing and dispensing of controlled substances -- a tricky business because the idea is to protect against abuse while not restricting access for people who need opioids. Nationally, there is a controversial bill pending in Congress dubbed NASPER (National All Schedules Prescription Electronic Reporting Act) that would do much the same thing. Klippel of the Arthritis Foundation said what pain control -- for arthritis sufferers and others in chronic pain -- should ultimately come  down to is quality of life.

Patients should realize, he said, that, when taken properly, "the potential for addiction
is really minimal.”

Judy Foreman is a Lecturer on Medicine at Harvard Medical School.  Her column appears every other week. Past columns are available on www.myhealthsense.com.

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