Pubdate: Tue, 22 Jan 2002
Source: New York Times (NY)
Section: Health
Copyright: 2002 The New York Times Company
Author: Jane E. Brody

Personal Health


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, contributing to an overall cost to the 
economy of billions of dollars a year.

Yet chronic pain, whether caused by cancer or a host of nonmalignant 
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, which are natural and synthetic compounds 
related to morphine, generally known as narcotics. Many studies have 
indicated that ignorance and misunderstanding seriously impede their 
appropriate use.

Studies suggest that about half of patients with cancer-related pain and 80 
percent of those with chronic noncancer pain are undertreated as a result. 
These patients suffer needlessly, as do their loved ones.

"Some patients who experience sustained unrelieved pain suffer because pain 
changes who they are," say 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.

"This constellation of discomforts and functional limitations can foster 
negative thinking and create a vicious cycle of stress and disability," the 
researchers wrote. "The idea that one's pain is uncontrollable in itself 
leads to stress. Patients suffer when this cycle renders them incapable of 
sustaining productive work, a normal family life and supportive social 

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 in an interview.

Abundance Of Misinformation

Far too little has been done to correct the misunderstandings of both 
patients and doctors 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 noncancer-pain patients persists, and 
patients are equally likely to resist taking them should they be prescribed.

"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," Dr. Schneider explained. "They don't 
understand the difference between physical dependence and addiction, and as 
a result they're afraid they'll become addicts."

As Dr. Henry McQuay, a pain specialist at the University of Oxford in 
England, put it: "Opioids are our most powerful analgesics, but politics, 
prejudice and our continuing ignorance still impede optimum prescribing. 
What happens when opioids are given to someone in pain is different from 
what happens when they are given to someone not in pain. The medical use of 
opioids does not create drug addicts, and restrictions on this medical use 
hurt patients."

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.

Dr. Schneider was distressed last month by a segment of "48 Hours" on CBS 
depicting a woman who had been taking the sustained-release opioid 
OxyContin. The woman said that although the drug had relieved her chronic 
pain, she stopped taking it because she feared becoming an addict. But 
instead of tapering off gradually, she quit cold turkey. As any pain expert 
would predict, she suffered withdrawal symptoms typical of physical 
dependence on a narcotic: aches all over, tearing eyes, runny nose, 
abdominal cramps and diarrhea.

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.

Dr. 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 obtaining and using the 

The Benefits Of Relief

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, Dr. 
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 are typically given in a form that provides 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 itself worsens with time.

Tolerance does develop to some of the common side effects of opioids, 
including sedation, respiratory depression and nausea, although 
constipation tends to persist as long as the drug is taken. But an opioid 
taken to relieve chronic pain does not block acute pain sensations that 
might result, for example, from surgery or an injury. A broken arm or 
gallbladder surgery will hurt just as if no opioid were being taken and 
will require additional treatment with some other analgesic, Dr. Schneider 

Of course, round-the-clock narcotics are only one aspect of proper 
treatment for chronic pain that fails to respond adequately to lesser 
drugs. As Dr. Schneider explained, chronic pain is "a primary disorder" 
that can itself cause disabling complications, including difficulty 
sleeping, muscle spasms and depression.

Thus, pain specialists commonly prescribe a low-dose antidepressant like 
Elavil to promote sounder sleep, muscle relaxants and anticonvulsants to 
relieve spasms, anti-inflammatory drugs, full-dose antidepressants to 
counter depression and an increase in physical activity to improve mood and 
reduce feelings of incapacity.

Patients may also be referred to psychologists for cognitive-behavioral 
therapy, physiatrists (for exercises and pain-relieving injections), 
physical therapists, hypnotists, biofeedback specialists and even 
acupuncturists, Dr. Schneider said.

To help reduce the risk of drug abuse, Dr. Schneider and many other pain 
specialists insist that before receiving opioids for chronic pain, patients 
sign a "contract" that, among other things, insists that only one doctor 
and one pharmacy be used to provide opioids and that no change in dose be 
made without prior consultation with the prescribing physician.

The contract also states that there will be "no early refills," no matter 
what the excuse, and that patients must agree to undergo random urine drug 
tests if the doctor suspects the drug is being abused.
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