CHN 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.

Cheryl Eckstein

CHN 

bulletOpioids for persistent non-cancer pain
bullet Should opiods be used for chronic pain? YES 
bulletLinks to other pain articles
bulletPainkiller phobia inflicts needless suffering
bulletStudy: Morphine kills pain -- not patients

bulletBMJ  2005;330:156-157 (22 January), doi:10.1136/bmj.330.7484.156

Editorial

bullet

Opioids for persistent non-cancer pain

A team approach and individualisation of treatment are needed

Epidemiological studies from Australia and Denmark indicate that about 19% of the population is afflicted by chronic pain that is not caused by cancer.1 2 The prevalence of chronic pain that interferes with daily activities is 12.6%.1 In most Western countries, opioids are established in treating pain due to cancer, and they are increasingly used to manage chronic pain not due to cancer. Opioids are effective analgesics, but they also have a strong reinforcing potential-fear of addiction and diversion restrict their medicinal use. Good clinical trials, guidelines, and responsible prescription are needed to ensure the availability of opioids for those patients who may benefit.3 4

A recent systematic review included 11 randomised and controlled trials on oral opioids in non-cancer pain.5 The review showed that opioids provided pain relief for both neuropathic (postherpetic neuralgia, diabetic neuropathy) and musculoskeletal pain (osteoarthritis). Large differences between individuals in the response to opioids in all conditions implied that the effectiveness of the treatment should be tested in each individual. Adverse effects were common and included constipation, nausea, vomiting, somnolence, sedation, dizziness, itching, dry mouth, and headache. The studies were of short duration (four days to eight weeks in each treatment arm). Some studies included an open label phase for up to two years, but only a few patients continued to use opioids.

When treating pain due to cancer, alleviating symptoms is the main goal, whereas in the management of chronic non-cancer pain the goal is to keep the patient functional, both physically and mentally, with improved quality of life. Relief of pain may be an essential factor in this and opioids are only one aspect of the overall rehabilitative strategy for the patient. In a few instances, such as when an elderly patient is waiting for a hip replacement, opioids can be regarded as a fairly straightforward means of alleviating pain for a limited period. The more chronic and complex the problem and the younger the patient, the lesser is the role opioids have in the rehabilitation plan. A multidisciplinary pain clinic will try other analgesics (including antidepressants and anticonvulsants), non-steroidal anti-inflammatory drugs, weak analgesics, transcutaneous nerve stimulation, cognitive behaviour therapy, and exercise programmes.

Opioids are not effective in every patient with pain. Randomised controlled trials indicate that no criteria have been identified that predict good response to opioids in any particular condition. Also, these trials were of short duration and included a selected group of patients. Many questions regarding safety, such as long term effects on hormonal and immune function, development of tolerance and increased pain sensitivity, addiction and diversion of drugs were not answered by these trials.6 Therefore, each patient who is considered for treatment with opioids needs to be assessed for both efficacy and safety. Good monitoring serves the individual patient and provides valuable information from areas that cannot be studied in randomised and placebo controlled studies, such as tolerance, addiction, and diversion of drugs.

Patients need to be informed of the possible benefits and risks of opioid treatment, and they need to be monitored carefully. This takes time. Treatment of young patients and patients with psychosocial problems or addictive behaviour should be initiated in multidisciplinary pain clinics that have the resources and expertise to assess these problems. However, primary care doctors should always be involved in the decision making as they will usually take responsibility for the patients in the long term. Multidisciplinary pain clinics should be available for consultation if problems occur. These clinics should also follow and audit to ensure that information gained over the years is used to reassess the appropriateness of the treatment.

Opinions regarding the medicinal use of opioids have always been polarised. History shows how too liberal use has led to heightened regulatory control, reluctance of doctors to prescribe opioids, and under-treatment of pain. Guidelines are needed to prevent history repeating itself. The British Pain Society published its recommendations for the appropriate use of opioids for persistent non-cancer pain in March 2004.4 The document includes information for the patient, who is an important partner in the treatment plan. The recommendations were carefully worked out with consultations of the royal colleges of anaesthetists, general practitioners, and psychiatrists. They are based on what is known about the effectiveness of opioids in the treatment of chronic non-cancer pain. The recommendations acknowledge the lack of data in many important areas of clinical research; in these areas they are based on clinical experience. The recommendations provide an excellent balanced framework. Individual pain specialists and primary care doctors now need to work within this framework and collect data through good monitoring. Such data will be valuable when the recommendations are reviewed in March 2007.

Eija Kalso, professor of pain research and management

University of Helsinki and Pain Clinic, Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, PO Box 340, FIN-00029 HUS, Finland (eija.kalso@helsinki.fi )


Competing interests: EK has consulted, lectured, and participated in studies sponsored by Johnson & Johnson, Pfizer, and Mundipharma.

References


  1. Eriksen J, Jensen MK, Sj?ren P, Ekholm O, Rasmussen NK. Epidemiology of chronic non-malignant pain in Denmark. Pain 2003;106: 221-8.[CrossRef][ISI][Medline
  2. Blyth FM, March LM, Brnabic AJM, Cousins MJ. Chronic pain and frequent use of health care. Pain 2004;111: 51-58.[CrossRef][ISI][Medline]
  3. Kalso E, Allan L, Dellemijn PLI, Faura CC, Ilias WK, Jensen TS, et al. Recommendations for using opioids in chronic non-cancer pain. Eur J Pain 2003;7: 381-6.[CrossRef][Medline]
  4. The Pain Society. Recommendations for the appropriate use of opioids for persistent non-cancer pain. A consensus statement prepared on behalf of the Pain Society, the Royal College of Anaesthetists, the Royal College of General Practitioners and the Royal College of Psychiatrists. March 2004. www.britishpainsociety.org/pdf/opioids_doc_2004.pdf (accessed 14 Dec 2004).(CHN Editor's note: this document is not available online - SEE Links below)
  5. Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer pain: a systematic review of efficacy and safety. Pain 2004;112: 372-80.[CrossRef][ISI][Medline]
  6. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med 2003;349: 1943-53.[Free Full Text]

http://bmj.bmjjournals.com/cgi/content/full/330/7484/156?etoc

OPIOIDS DEBATE:
Dr. Steven Passik (PhD) is a psychologist from Brooklyn, N.Y., now living in Lexington, Ky., where he directs the symptom management and palliative care program at the University of Kentucky Markey Cancer Centre. He argues that opioids can be safely used for treating non- cancer pain, as long as they're given to the right patients, in the right treatment setting.
Pain specialist Dr. R. Norman Harden, originally from Georgia, is director of the centre for pain studies at the Rehabilitation Institute of Chicago. He opposes use of opioids for management of chronic non-cancer pain, saying the risks of adverse events and addiction are great, and better alternatives abound.
The two squared off in a lively debate before a full house at the American Pain Society meeting, held recently in Chicago. Medical Post staff writer Jenny Manzer reports.

 

bullet APS DEBATE: Should opioids be used for chronic pain? YES

CHICAGO – In Dr. Steven Passik's view, the question of whether to treat non-cancer pain with opioids is a non-starter.

Opioids should be considered if patients have moderate to severe pain and other avenues of treatment have been tried, and have failed, he said.

"In a way, I also think it's kind of outrageous that we're having this debate," he added.

Opioids have been vilified in the past, he noted. While he perceives the pendulum on opioid use to be returning to the centre, the drugs have been hit hard by the media recently, he said.

"Once again, (that has happened) in the absence of real data."

Dr. Passik (PhD) said the medications are getting a bad rap by irresponsible media reports, such as lurid stories about the abuse of oxycodone, dubbed "hillbilly heroin."

In his community of Lexington, Ky., one of the local papers ran an article decrying the fate of a homecoming queen who crashed her car into a cow, and, while recovering from her injuries, became addicted to opioids. There was no mention of her previous history of drug addiction in the story, he noted.

"Addiction is not caused by exposure to drugs solely. It's caused by exposure to drugs in the context of multiple risk factors. We need to teach doctors how to assess those risk factors and tailor the treatments based on perception of addiction risk."

Dr. Passik said the risks associated with opioids, such as tolerance, dysfunction and addiction, are manageable, and there are effective intervention strategies for most of them.

He admitted that in the past, physicians haven't done a good enough job of discriminating which patients should receive which drugs under which treatment settings.

Patients with no psychiatric issues and a low risk for addiction might be treated with opioids in the primary care setting. Others should see a specialist.

"We haven't been smart enough in selection of treatments," he said.

He said he doesn't deny prescription drug abuse is a huge problem. "We need to develop a literature on non-compliance issues," he said.

Dr. Passik developed a tool for evaluating treatment outcomes in pain patients. He then road-tested it on 388 pain patients being treated with opioids across the U.S. He called his formula the four As: analgesia, activity of daily living, adverse effects and aberrant drug-taking (addiction-related outcomes).

Using the formula, he found that overall, the patients reported a 58% reduction in pain, as well as improvement with activities of daily living. Side-effects were tolerable.

In the group, aberrant drug-taking behaviour, such as frequent early renewals, was common. However, only about 10% of the group had drug-taking behaviours their physician considered to be worrisome.

Some of the aberrant behaviours may indicate the patients had under-medicated pain, said Dr. Passik.

He said if the 10% figure holds up in a larger study, it will provide compelling evidence that rates of problematic behaviour among opioids users are similar to rates of addiction in the general population.

He said a clamp-down on opioid use would hit the poor and people in rural areas the hardest, since there are almost 50 million pain patients in the U.S. and only about 5,000 pain experts.

Many opioids are affordable compared to other treatments, and there are a lot of people without the money or the means to get to a pain expert, he said.

Dr. Passik said one of the biggest testaments to the efficacy of opioids is the millions of patients doing well on them—including his mother in Brooklyn, who takes them for diabetic neuropathy and osteomyelitis.

In his presentation at the meeting here, he showed a slide of his mother posing in Greenwich Village with his daughter. He included the caption: "Nice Little Old Jewish Lady on Opioids."

There was no way his mother could have tackled the trains and stairs to get to Greenwich Village without opioids, he said.

He acknowledged there is a strong need for better data on opioids, including published, placebo-controlled randomized controlled trials.

"I think the pain management community has woken up to the need to do these studies," he said, noting several papers on opioids and cognitive functioning presented at the meeting.

HEALTH SENSE
bullet Source: Should opiods be used for chronic pain? YES   Medical Post, April 22, 2003 Volume 39 Issue 16

bullet

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.

© Copyright 2003 The New York Times Company

SOURCE Painkiller phobia inflicts needless suffering

Study: Morphine kills pain -- not patients

CLEVELAND, March 21 (UPI) -- U.S. scientists have found the belief that morphine is a lethal drug that causes death when used to control a dying patient's pain is a misconception.

Two studies at the Cleveland Clinic's Taussig Cancer Center, led by Professor Bassam Estfan, focused on patients in a specialist palliative care in-patient unit. The patients, all with severe cancer pain, were treated with morphine. Their vital statistics were monitored before and after the pain was controlled.

Estfan reported no significant changes were observed. He said the morphine did not cause respiratory depression, the mechanism by which lethal opioid overdose typically kills.

"Unlike many other drugs, morphine has a very wide safety margin," wrote Dr. Rob George of University College London in a commentary on Estfan's research. "Evidence over the last 20 years has repeatedly shown that, used correctly, morphine is well tolerated, does not cloud the mind, does not shorten life, and its sedating effects wear off quickly.

"Doctors should feel free to manage pain with doses adjusted to individual patients so that the patients can be comfortable and be able to live with dignity until they die."

The studies appear in the journal Palliative Medicine.

Copyright 2007 by United Press International. All Rights Reserved.

http://www.sciencedaily.com/upi/index.php?feed=Science&article=UPI-1-20070321-15595200-bc-us-morphine.xml

bulletLinks to other pain articles

 ARTICLES REGARDING CHRONIC PAIN AND USE OF OPIOIDS 

RECOMMENDATIONS FOR THE APPROPRIATE USE OF OPIOIDS FOR PERSISTENT NON-CANCER PAIN

Pain Medicine

http://www.blackwell-synergy.com/doi/abs/10.1046/j.1526-4637.2002.02003.x?cookieSet=1&journalCode=pme

Chronic Pain Coping Inventory (CPCI)

http://www1.va.gov/hsrd/for_researchers/measurement/instrument/instrument_reviews2.cfm?detail=65

Chronic pain as a disease: Why does it still hurt?

http://www.chninternational.com/chronic_pain_as_a_disease.htm

DYING FOR RELIEF by Cheryl Eckstein

http://www.chninternational.com/dying_for_relief_.htm

Pain and the undertreatment of pain

http://www.chninternational.com/pain_and_undertreatment_of_pain.htm

 

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