Pubdate: Tue, 04 Nov 2003
Source: Boston Globe (MA)
Copyright: 2003 Globe Newspaper Company
Contact:  http://www.boston.com/globe/
Details: http://www.mapinc.org/media/52
Author: Judy Foreman, Globe Columnist
Bookmark: http://www.mapinc.org/oxycontin.htm (Oxycontin/Oxycodone)
Bookmark: http://www.mapinc.org/people/Limbaugh (Limbaugh, Rush)
Bookmark: http://www.mapinc.org/soros.htm (Soros, George)

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.'

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Judy Foreman, who can be contacted at  will address the 
scientific understanding of pain in her next column, in two weeks.
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