CHRONIC-PAIN MANAGEMENT IS A SORELY IGNORED TOPIC

America is seriously divided about controlling chronic pain, which
afflicts more than 50 million people and costs the country $100
billion a year.

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 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.

The problem is obvious: Some of the drugs that most effectively treat
pain are the ones commonly abused. In one survey of New York doctors,
30 percent said they were prescribing fewer opioids or switching
patients to less-effective drugs for fear that the Drug Enforcement
Administration will investigate.

"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 head of the Project on
Death in America.

In the past 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 the United States is woefully
inadequate. Also, the U.S. Supreme Court, in deciding in 1997 against
a constitutional right to physician-assisted suicide, highlighted the
need for better pain control.

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. It is psychological
dependence - a compulsion to seek more and more of the drug - that
laypeople usually mean.

A 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 that the addiction rate might be around 10 percent,
but people who attend pain clinics are not typical of all pain patients.

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, Foley said.

Despite America's conflicted views, there are signs we're overcoming
our phobia.

Last month, the American Academy of Pain Medicine and leading doctors
announced a new initiative called Top Med that will provide a
Web-based "virtual textbook" available free to medical students across
the country. It is sorely needed. 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.

There's other good news. In 2001, the group that accredits the vast
majority of the nation's hospitals required that hospitals assess and
manage pain for all patients.

Almost all states (including Maryland) have launched pain initiatives
to reduce legislative barriers to effective pain control.

Many states are also establishing electronic systems to monitor the
prescribing and dispensing of controlled substances - a tricky
business because the idea is to forestall abuse but provide access for
people who need opioids.

Nationally, a bill pending in Congress called the National All
Schedules Prescription Electronic Reporting Act would do much the same
thing.

Ultimately, says Dr. John Klippel, medical director of the Arthritis
Foundation, the issues comes down to quality of life. Patients should
realize, he said, that, when medicine is taken properly, "the
potential for addiction is really minimal."