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.' - - Judy Foreman, who can be contacted at will address the scientific understanding of pain in her next column, in two weeks. - --- MAP posted-by: Jackl