America is deeply conflicted about controlling chronic pain.
We grossly under-treat it. Management of chronic pain, which afflicts more than 50 million people, and the pain of dying patients is arguably the most egregiously neglected field of medicine.
As a society, we have become obsessed with the war on drugs -- and the fear of addiction to opioids (narcotic drugs containing opium or one of its derivatives). Pain patients who were functioning well on morphine-like drugs such as oxycodone (OxyContin) now are fearful of them. Or they just plain can't get them.
Some drugstores, wary of robberies of OxyContin, are afraid to stock it. Unscrupulous doctors have written excessive prescriptions for it. Patients, such as talk show host Rush Limbaugh, abuse it. And in some states, Medicaid regulations require doctors to get authorization before prescribing the drug.
The basic problem is obvious: Some of the drugs that most effectively treat pain are the same ones that are commonly abused. In one survey of New York doctors, 30% said they were prescribing fewer opioids or were switching patients to less-effective pain medications for fear that the Drug Enforcement Administration might investigate them.
At the root of our national ambivalence is what June L. Dahl, professor of pharmacology at the University of Wisconsin-Madison Medical School, calls "opiophobia," or the fear of addiction to opioids. That phobia has led to serious problems with pain management, particularly chronic pain.
"Every bit of evidence suggests that we have been under-treating pain," said Dr. Kathleen Foley, an attending neurologist at Memorial Sloan-Kettering Cancer Center in New York and director of the Project on Death in America of the Open Society Institute, an operating foundation supported by philanthropist 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 this country is woefully inadequate. These pronouncements followed a 1995 study by the Robert Wood Johnson Foundation that found that 50% 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 U.S. Supreme Court, in deciding in 1997 against a constitutional right to physician-assisted suicide, highlighted the need for better pain control and palliative care.
Risk of addiction is small
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. 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.
One 1982 study of patients in 93 burn facilities found no evidence that patients became addicted to opioids. More recent data from pain clinics suggest the addiction rate might be around 10%, 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, stomach and kidneys, said Foley of Sloan-Kettering. 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 even 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.
"If you have intractable cancer pain, addiction should be the farthest worry from your mind," he said. "Addiction is very unlikely. There are wonderful medications that provide continuous relief over time."
That is true for noncancer pain as well, although aggressive control of pain for nonlethal diseases is more controversial.
Arthritis, both rheumatoid and osteoarthritis, affects an estimated 70 million Americans, said Dr. John Klippel, medical director of the Arthritis Foundation. Yet many suffer daily because their pain is inadequately controlled.
With rheumatoid arthritis, one way to control the pain is to treat the underlying inflammatory disease itself with disease-modifying anti-rheumatic drugs such as methotrexate. In addition, nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) and Cox 2 inhibitors (such as Vioxx and Celebrex) can help.
Progress is being made
Despite America's conflicted views, we may be starting to overcome our collective phobia. Last month, the American Academy of Pain Medicine and leading doctors announced a new initiative called Top Med that will provide a free Web-based "virtual textbook" to all medical students across the country.
It is sorely needed. Only 3% of medical schools have a separate, required course on pain management and only 4% require a course in end-of-life care, according to a 2000-01 survey of 125 medical schools by the Assn. of American Medical Colleges. A survey this year shows that most medical schools now cover these topics as part of existing required courses.
There's more good news. In 2001, the Joint Commission for the Accreditation of Healthcare Organizations, the group that accredits the vast majority of the nation's hospitals, mandated that hospitals must assess and manage pain for all patients, something that, astonishingly enough, had not been done routinely.
On a more grass-roots level, almost all states (including California) have launched initiatives to reduce legislative 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. A biotech company reports that it is working to develop a sticky gel cap version of OxyContin that would be "abuse-proof."
Nationally, there is a controversial bill, the National All Schedules Prescription Electronic Reporting Act, pending in Congress that would do much the same thing.
Klippel of the Arthritis Foundation said what pain control -- for arthritis sufferers and others in chronic pain -- should ultimately come down to is quality of life.
Patients should realize, he said, that, when taken properly, "the potential for addiction is really minimal."
The next report on pain will appear Nov. 24.