When the feat of addiction outweighs the
pain
By Judy Foreman, Globe Columnist,
11/4/2003
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.
© Copyright 2003 Globe Newspaper Company.
Editor's comment: One only has to visit
one message board on chronic pain to find chronic pain, and cancer
pain is still
seriously under-treated. Fear of pain is causing some people to join
or support groups who are under the umbrella of the so-called right to die
organizations. These are people who will offer advise or help the person with
assisted death. I personally believe many of those who have a fear of pain
have witnessed a loved one suffering needlessly, and they do not want to endure
the same. I appreciated a comment from a pain patient
who said pain is pain, whether it is from cancer or someone bashing in
your skull. You do not withhold proper pain medication from
someone because they are not in a so-called terminal state. I am not
advising that the use of opioids is good for everyone who suffers chronic
pain, but I am angry that far too many who really need proper pain treatment
are not getting it because some fool doctor fears his patients will become
drug addicts. Yes I know, some doctors who have prescribed opioids had
patients overdose and commit suicide, but the majority of true pain patients
are not looking for a way to end their lives, but a release from the pain so
that they can go on with their life. Certainly the doctor should know a
patient's history and condition before handing out a triplicate
prescription. Sadly, there are many unwarranted stigmas tagged on to
patients who use opioids for pain management. The Internet has many
good articles that will help patients and their family understand what
chronic pain is;, how it affects those who are suffering, and the various
mediations used to help control pain. I hope this page helps you.
Please also check my main page for other articles on this subject.
