Physicians' Perspective:

CHRONIC PAIN - THE HIDDEN EPIDEMIC

While the science of pain control has progressed, the politics of pain
control remains in the Dark Ages.

In 1998, the American Pain Society (www.ampainsoc.org) published Chronic
Pain In America: Roadblocks To Relief. They report that 9% of American
adults (25 million) suffer from moderate to severe pain, 2/3 of whom have
had pain over 5 years.

In the Spring 2003 Journal of American Physicians and Surgeons, pain
specialist William E. Hurwitz, MD, wrote Pain Control in the Police State
of Medicine. His goal was to elaborate "on the kinds of policies that would
allow the medical profession to be more responsive to the mostly hidden
epidemic of untreated and inadequately treated pain." This is mandatory
reading for anyone who knows anyone suffering from chronic pain. (See
www.drhurwitz.com and look at announcements.) As may be deduced by Hurwitz'
title, America's problem with pain is also a problem with politics, public
policy and improper police interventions.

When I trained to be a doctor in the 1970's, opioids (drugs similar to
opium) were forbidden in treatment of pain lasting longer than six weeks.
Later, in the early 1980's, I went to a seminar on treating chronic pain.
One physician explained there was no such thing as chronic pain--a
confusing argument at best. He was followed by a narcotics officer who
explained that if we prescribed opioids for more than six weeks to someone
who wasn't terminally ill, we would be targeted for criminal investigation.

By the mid-1980's experts reconsidered opioids to treat chronic non-cancer
pain because of success in persons with cancer. Unfortunately, policy
makers do not keep up with evolving science.

Pain Relief vs. Substance Abuse

As our understanding progressed so did the terminology. Most experts now
agree that physical dependence is characterized by withdrawal symptoms upon
abstinence from a drug, and that tolerance is when a person must increase
the dose to maintain a therapeutic effect. Psychological dependence,
addiction--or the term I prefer, substance abuse--describes compulsive drug
use for non-medical purposes despite obvious harm. I avoid the term
addiction because it is often pejorative and judgmental, with moral
implications.

Understanding these terms is an essential foundation for understanding the
terms of the debate over pain control in America.

Research indicates that opioids prescribed for patients with no personal
history of substance abuse had a very low risk of abuse. Further studies
have indicated that those with a history of substance abuse and chronic
pain could be safely treated with opioids, and that such treatment reduced
illicit drug use while improving functional status.

In 1995, Oregon's 68th Legislative Assembly passed Senate Bill 671, the
Intractable Pain Act. This allows a patient to receive opioids for chronic
pain while promising the physician that opioid prescriptions would not be
the sole reason for the state Board of Medical Examiners (BME) to
discipline doctors. The BME can still discipline doctors who treat chronic
pain if they keep poor medical records or if they prescribe opioids in "a
manner detrimental to the public" or in violation of federal law.

Then, in 1997, the American Society of Addiction Medicine affirmed that
physicians are obligated to relieve pain and suffering in all their
patients, including those with concurrent substance abuse.

Around this time, Oregonians were passing, and then re-passing, the Oregon
Death with Dignity Act, and then we passed the Oregon Medical Marijuana Act
in 1998.

In my opinion, the public leads and policy makers follow.

Waiting for the Policy Makers

Sadly, having science and good intentions on one's side does not guarantee
success when dealing with regulatory bodies like the BME, so practicing
physicians remain skeptical and fearful about prescribing opioids for pain.
In spite of increasing expert support for prescribing opioids for chronic
non-cancer pain, doctors have received "mixed signals" from regulatory and
policing agencies. This means many patients are still not getting adequate
pain treatment and many physicians are frightened to treat chronic pain
because they fear loss of state medical or federal narcotics licenses.

Things are worse under the Bush Administration. Inexplicably, Republicans
seem committed to rolling back the clock when it comes to helping patients
with chronic pain. Because of prohibition policies in our War on Drugs that
treat substance abusers as criminals instead of sick people who need
treatment, federally coordinated efforts to stop diversion of opioids to
underground markets now target doctors whose specialty is medical pain
management. The federal Drug Enforcement Administration (DEA) lies about
this to doctors while agents pay intimidating visits to pharmacists and
doctors "advising" them how to practice.

The most alarming trend to me is that while an investigation by the BME can
result in loss of license and a civil suit can result in loss of money and
assets, the Bush/Ashcroft DEA is now pursuing federal criminal charges
against doctors who prescribe opioids for chronic pain. Dr. Hurwitz has
recently been arrested on federal charges that could yield life in prison
for trying to help patients in pain. Although he has not been convicted,
his assets have been seized. It is clear the feds want to break him and
other medical pain specialists. Dr. Hurwitz maintains he is following
accepted scientific principles and that doctors who practice science-based
medicine in good faith should not fear federal criminal charges. I agree
and so do several medical and patient advocacy groups. See:
http://stopthedrugwar.org/chronicle/305/galvanization.shtml

In addition, the Oregon BME still opposes our Medical Marijuana Act and the
Bush/Ashcroft administration pursues efforts to overturn the Oregon Death
with Dignity Act while seeking to remove federal narcotic licenses from
doctors who recommend medical marijuana. With these sorts of messages and
threats, it is a wonder any patient gets adequate pain management.

Prescription for Remedy

To fix the problem of untreated and under-treated pain in chronically ill
patients, we must vote out the Bush/Ashcroft party and re-examine our
nation's War on Drugs. What are we gaining besides over-funding the
doctor-busting narcotics agencies while laying off police who actually
protect us from violent criminals? Why are we willing to sacrifice civil
liberties, healthcare, education, a clean environment, and solid
infrastructure in a self-destructive pursuit of a "drug-free America"? We
need drug education and drug treatment--not another war.

We can no longer be passive when drug warriors threaten the practice of
compassionate scientific medicine and make the chronically ill do without
necessary medication. For the compassionate, I ask you to inform yourself,
contact your representatives, and vote. For those who need more convincing,
I ask you to consider that anyone is only one accident away from a life
with chronic debilitating pain.