CHRONIC PAIN MISMANAGEMENT

Afflicted with chronic pain mismanagement Many drugs can alleviate
suffering, but doctors and patients often don't fully utilize them,
mostly because of addiction fears.

America is deeply conflicted about controlling chronic pain. We
grossly under-treat it. Management of chronic pain, which afflicts
more than 50 million people, and the pain of dying patients is
arguably the most egregiously neglected field of medicine. As a
society, we have become obsessed with the war on drugs - and the fear
of addiction to opioids (narcotic drugs containing opium or one of its
derivatives). Pain patients who were functioning well on morphine-like
drugs such as oxycodone (OxyContin) now are fearful of them. Or they
just plain can't get them.

Some drugstores, wary of robberies of OxyContin, are afraid to stock
it. Unscrupulous doctors have written excessive prescriptions for it.
Patients, such as talk show host Rush Limbaugh, abuse it. And in some
states, Medicaid regulations require doctors to get 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% said they were prescribing fewer opioids or
were switching patients to less-effective pain medications for fear
that the Drug Enforcement Administration 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," or the fear of addiction to opioids. That phobia
has led to serious problems with pain management, particularly chronic
pain.

"Every bit of evidence suggests that we have been under-treating
pain," said Dr. Kathleen Foley, an attending neurologist at Memorial
Sloan-Kettering Cancer Center in New York and director of the Project
on Death in America of the Open Society Institute, an operating
foundation supported by philanthropist 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
followed a 1995 study by the Robert Wood Johnson Foundation that found
that 50% 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 U.S. Supreme Court, in deciding in 1997
against a constitutional right to physician-assisted suicide,
highlighted the need for better pain control and palliative care. *
Risk of addiction is small 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 of patients in 93 burn facilities found no evidence
that patients became addicted to opioids. More recent data from pain
clinics suggest the addiction rate might be around 10%, 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, said 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.

"If you have intractable cancer pain, addiction should be the farthest
worry from your mind," he said. "Addiction is very unlikely. There are
wonderful medications that provide continuous relief over time." That
is true for noncancer pain as well, although aggressive control of
pain for nonlethal diseases is more controversial. Arthritis, both
rheumatoid and osteoarthritis, affects 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 to control the pain is to treat the
underlying inflammatory disease itself with disease-modifying
anti-rheumatic drugs such as methotrexate. In addition, nonsteroidal
anti-inflammatory drugs such as ibuprofen (Motrin) and Cox 2
inhibitors (such as Vioxx and Celebrex) can help.

Progress is being made Despite America's conflicted views, we may be
starting to overcome our collective phobia. Last month, the American
Academy of Pain Medicine and leading doctors announced a new
initiative called Top Med that will provide a free Web-based "virtual
textbook" to all medical students across the country.

It is sorely needed. Only 3% of medical schools have a separate,
required course on pain management and only 4% require a course in
end-of-life care, according to a 2000-01 survey of 125 medical schools
by the Assn. of American Medical Colleges. A survey this year shows
that most medical schools now cover these topics as part of existing
required courses.

There's more good news. In 2001, the Joint Commission for the
Accreditation of Healthcare Organizations, 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.

On a more grass-roots level, almost all states (including California)
have launched initiatives to reduce legislative barriers to effective
pain control. Many states also are 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. A biotech company
reports that it is working to develop a sticky gel cap version of
OxyContin that would be "abuse-proof."

Nationally, there is a controversial bill, the National All Schedules
Prescription Electronic Reporting Act, pending in Congress 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."

The next report on pain will appear Nov. 24.