PAINKILLER PHOBIA INFLICTS NEEDLESS SUFFERING

When The Feat Of Addiction Outweighs The Pain

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

On the one hand, we grossly undertreat it: Management of chronic pain and
the pain of dying patients is arguably the most egregiously neglected field
of medicine.

On the other, as a society, we are obsessed with the war on drugs, and the
fear of addiction to 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 because doctors won't prescribe the drugs and
pharmacies won't stock them.

The basic problem is obvious: Some of the drugs that most effectively treat
pain are the same ones that are commonly abused. And those relatively few
who do get addicted, like talk-show host Rush Limbaugh, show that the fear
is more than theoretical.

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.

That compulsion comes from the withdrawal symptoms associated with taking
large, uneven doses of narcotics, said Dr. Kathleen Foley, a neurologist at
New York's Memorial Sloan-Kettering Cancer Center. Taking drugs in regular,
consistent doses, as prescribed to treat pain, does not lead to addiction,
she said.

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, Foley said. 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 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. "

But the fear of addiction remains - as much among doctors as patients.

"Every bit of evidence suggests that we have been undertreating pain," said
Foley, also director of the Project on Death in America, which is 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 the United States 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.

Dr. John Klippel, medical director of the Arthritis Foundation, said many
of the 70 million Americans with rheumatoid or osteoarthritis also suffer
needlessly. Rheumatoid-arthritis patients uncomfortable with narcotics can
be treated by addressing the underlying inflammatory disease itself, with
so-called disease-modifying antirheumatic drugs such as methotrexate, he
said. In addition, nonsteroidal anti-inflammatory drugs such as ibuprofen
(Motrin) and COX-2 inhibitors (like Vioxx and Celebrex) can help.

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

Recently, the American Academy of Pain Medicine and leading doctors
announced a new initiative called Top Med, which will make a free Web-based
"virtual textbook" available 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 this
year 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, or JCAHO, the group that
accredits the vast majority of the nation's hospitals, mandated that
hospitals 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) have
launched pain initiatives to reduce 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. Nationally, there is a controversial bill pending in
Congress dubbed NASPER, for National All Schedules Prescription Electronic
Reporting Act, that would do much the same.

Klippel of the Arthritis Foundation said what it should come down to - for
arthritis patients and others in chronic pain - is quality of life.

Patients should realize, he said, that "the potential for addiction is
really minimal, and that the risk-benefit ratio of pain medicines .. is
quite acceptable.'

Judy Foreman, who can be contacted at foreman@globe.com, will address the
scientific understanding of pain in her next column, in two weeks.