Pubdate: Tue, 22 Jan 2002
Source: San Jose Mercury News (CA)
Copyright: 2002 San Jose Mercury News
Author: Jane E. Brody, New York Times
Note: Jane Brody writes about health for the New York Times.


Chronic pain suffered by 30 million Americans robs people of their dignity, 
personality, productivity and ability to enjoy life. It is the single most 
common reason people go to doctors.

Yet chronic pain, whether caused by cancer or a host of non-malignant 
conditions, is seriously undertreated, largely because doctors are 
reluctant to prescribe -- and patients are reluctant to take -- the drugs 
that are best able to relieve persistent, debilitating, disabling pain that 
fails to respond to the usual treatments.

These drugs are called opioids -- narcotics -- and many studies have 
indicated that ignorance and misunderstanding impede their appropriate use.

"Some patients who experience sustained unrelieved pain suffer because pain 
changes who they are," wrote Dr. C. Richard Chapman of the University of 
Utah School of Medicine and Dr. Jonathan Gavrin of the University of 
Washington School of Medicine.

Chronic pain, they wrote in the Lancet medical journal, results in "an 
extended and destructive stress response" characterized by brain hormone 
abnormalities, fatigue, mood disorders, muscle pain and impaired mental and 
physical performance.

Neurochemical changes caused by persistent pain perpetuate the pain cycle 
by increasing a person's sensitivity to pain and by causing pain in areas 
of the body that would not ordinarily hurt.

Dr. Jennifer P. Schneider, a specialist in addiction medicine and pain 
management in Tucson, Ariz., agrees. "When patients feel hopeless and think 
they will never get relief, it makes chronic pain and its effects that much 
worse," she said.

Far too little has been done to correct the misunderstandings that stand in 
the way of using opioids to control chronic pain. Nowadays, doctors are 
more inclined to use narcotics for pain relief in patients with advanced 
cancer, assuming erroneously that "since they're dying anyway, it won't 
matter if they become addicts." But the reluctance to use opioids for 
non-cancer-pain patients persists, and patients are equally likely to 
resist taking them.

"Like most doctors, most patients are relatively uninformed about the 
safety of using narcotics for pain, thinking they're dangerous drugs that 
will do bad things to them," Schneider explained. "They don't understand 
the difference between physical dependence and addiction, and as a result 
they're afraid they'll become addicts."

In three studies involving nearly 25,000 patients treated with opioids who 
had no history of drug abuse, only seven cases of addiction resulted from 
the treatment.

Physical dependence, whether to an opioid or to an immune-suppressing drug 
like prednisone, involves reversible changes in body tissues. To avert 
withdrawal symptoms, the medication must be stopped gradually. Addiction is 
mainly a psychological and behavioral disorder. Schneider described the 
hallmarks of addiction, whether to alcohol or narcotics, as loss of control 
over use, continuing use despite adverse consequences and obsession or 
preoccupation with the substance.

Unlike an addict, whose life becomes increasingly constricted by an 
obsession with drug use, a patient using the drug for pain experiences an 
expansion of life when relief comes from this life-inhibiting disorder, 
Schneider said. An addict gets high by taking the drug in a way that 
rapidly increases the dose reaching the brain. But opioids properly used 
for pain do not result in a "rush" or euphoria. When given for chronic 
pain, opioids should provide a steady amount throughout the day.

Nor do pain patients require ever-increasing amounts of opioids to achieve 
pain control, because patients in pain do not become "tolerant" to properly 
prescribed opioids. Higher doses are needed only if an inadequate amount of 
the drug is given in the first place or if the pain worsens.
- ---
MAP posted-by: Terry Liittschwager