Pubdate: Sun, 23 May 2004
Source: Philadelphia Inquirer, The (PA)
Copyright: 2004 Philadelphia Newspapers Inc
Page: C1
Author: John Timpane, Inquirer Commentary Page Editor
Cited: Drug Enforcement Administration
Bookmark: (Chronic Pain)
Bookmark: (Oxycontin/Oxycodone)
Bookmark: (Methadone)


Thousands With Chronic Pain Receive Inadequate Treatment, Despite New Drugs
And Technology. We Need To Take Another Look At How We Think About It.

Pain sure has a big future.

The question is: Can we give it less of one?

In the United States, which has (so we're told) "the world's greatest
health-care system," we're not all that good at managing pain.

This, one of the quietest scandals in the Western world, cannot moan
its name.

Thousands with chronic, intractable pain receive inadequate treatment.
That includes 40 percent of those with moderate to severe pain, 40
percent of all cancer patients, and 75 percent of surgical patients.
That includes the 26 million people between 20 and 64 with chronic
back pain, and the one in six of us who suffers from arthritis. Add
burn victims, trauma patients, all those for whom healing hurts.

It's enough to make you hold your head and cry: How can this be? Each
year we add to our vast weaponry against suffering. We've never had so
many powerful drugs, technologies (electrostimulation, surgical nerve
blocks), and other means.

Yet, we're stuck - because of the way we think about pain, the way we
react to people in pain, and the way we train doctors.

Can we get unstuck? Yes. To quote Richard B. Patt, president and chief
medical officer at the Patt Center for Cancer Pain and Wellness in Houston:
"We can do this. We can do better, and we know it."

The next decades may bring changes that will resolve this shameful
paralysis. Some will be technological, but not most.

Behold the patient in pain. She is surrounded by at least five
entities who ought to be helping her suffer less: the family, the
doctor, the hospital/HMO, the insurance company, and the state. In an
ideal world, all would work together. But this is a world of
suffering, and too often, each is at odds with the others:

The patient, the family, or both may be unwilling or ashamed to admit
to the pain.

The family, the doctor or both may be unsure of the degree of pain or
the right way to treat it.

There may be fears (usually unfounded) of addiction or

The doctor may be overworked, uninterested, or afraid of malpractice

The state may at times be overzealous in alleging abuse,
overmedication, or euthanasia. That makes doctors afraid of sanctions.

Here's what can change in the next two decades:

In with the old. Our population will become grayer and grayer, which
will shove chronic pain to center stage.

Admit the fact of pain. Sarah Kinsman, assistant professor of
pediatrics at the Children's Hospital of Philadelphia, says: "Some
societies are comfortable with people expressing pain. But we're a
society of really hardworking people who are less comfortable with
it." She thinks our culture's stigma on saying we hurt "will lessen as
medicine and science understand pain better."

Sure, pain is complex. Some pain is psychosomatic. And sure, a few
people have addictive personalities and lie to get drugs. But almost
always, when a human being says, "I hurt," she hurts.

It's hard to sedate our leftover Puritan notions, as in: "there's
virtue in suffering," "grown-ups suffer pain silently," "treat it only
when it's unbearable," and even "if you're suffering, you must deserve
it." With honor and peace to John Calvin, as of the year 2024, we'll
have given up pretending there's ever a good reason to withhold
relief. All of which will help families and doctors.

Change the curriculum. The word pain does not appear in the
Hippocratic Oath. Well, shame on Hippocrates. When we train doctors,
we must teach that treating pain is at the heart of their work, not
the periphery. For too long, medical schools have been turning out
doctors who are great specialists but less good at pain management.
It's changing, too slowly, fitfully, but it's changing. Perhaps, by
2024, the great shift will be complete.

Here's what that shift will boil down to:

Trust the patient. The preponderance of evidence says that the most
reliable source of information about the patient's pain is the
patient. I know: duh. But, for years, we have hesitated to accept this
sun-in-broad-daylight truth.

Trust the drugs, give up the myths. Much of our hesitation involves
not aspirin, but our most powerful analgesics, the opioids, drugs such
as morphine, fentanyl, methadone, and oxycodone. We have many other
ways of treating pain, but they are less controversial. The opioids
work - boy, do they - but they've also been implicated in abuse and
addiction for, oh, thousands of years.

They are potent and can be addictive if abused. Fear of that has
caused too many to suffer needlessly. So let's pluck a few myths out
of our minds like petals off a poppy.

People confuse addiction (a chronic neurobiological disease that
includes powerful craving and compulsive self-dosing) with dependency
(physical withdrawal symptoms, which are rare under careful
supervision) and tolerance (in which the body gets used to a drug, and
more and more is needed to achieve the same effect - something that
does happen with opioids). People think the opioids lose their
effectiveness. Not so. People think they are lethal. They can be if

Addiction is rare in chronic pain patients who take their medicine as
prescribed. Studies peg the incidence at less than 1 percent. We know
these drugs well; careful regimens for their use are well-established.
And even if it should occur, addiction is reversible and can be treated.

That 1 percent wrecks it for the remaining 99. Abusers tend to get on
TV. Because of Rush Limbaugh, Courtney Love, and others, the world is
now leery of OxyContin (a preparation of oxycodone), and prescription
rates have fallen for it and for many opioids.

Work for a standard measure of pain. The best means, as just
mentioned, is the patient. But we also have other ways. Most common is
the visual analogue scale, or VAS. This is simply a 1-to-7 or 1-to-10
scale from "none" to "excruciating." VAS works pretty well; that's
less well-known than it should be. When I point to 7, I mean 7. Trust

But pain scales, the way they are used, and the degree to which they
are relied on, differ from hospital to hospital, state to state.
Something of a movement is under way, however, to require hospitals to
standardize their pain scales. And the Federation of State Medical
Boards of the United States Inc. just recommended a revision of
guidelines for pain management. This is a very influential group; 22
states have adopted all or part of the federation's current standards.
Let's listen.

By 2024, maybe the definition of painful won't change when we cross
state lines or go from one hospital to the next.

The brain scan may help. Neurobiology is producing astonishing images
of the brain's response to pain. PET scans and functional MRI are
showing how complex - and real - that response is. Our coming
understanding will make it harder to explain pain away, and it may
contribute to our change in culture, our common standard. Then maybe
we'll trust the patient.

Untwist the tort. Some folks are worried about evil doctors who
prescribe inappropriately. They do exist - again, way down in the
single digits. But should all doctors have to suffer for it? Somehow
we have to ease the doctor's fear of malpractice or government
surveillance. Some say tort reform will accomplish that, but it won't
be enough by itself.

We're scouting physicians a little too much as if it were the war on
terror. The Drug Enforcement Agency has been increasingly vigilant
against overprescription, diversion of drugs, or euthanasia. In a
Village Voice article, Ronald Myers, president of the American Pain
Institute, says: "The war on drugs has turned into a war on doctors
and pain patients... . Such is the climate of fear across the medical
community that, for every doctor who has his license yanked by the
DEA, there are a hundred doctors afraid to prescribe proper pain
medication for fear of going to prison." Clearly, merely "getting
tough" has bad side effects. Again, a common pain standard could set
forth the goal: to prevent abuse of opioid analgesics while making
them available for doctors to use in legitimate settings.

Dignify humanity. A life of constant pain is not a life of high
quality. What we all want is to live our lives authentically, under
our own power, with full understanding and choice.

But when it strikes, pain changes everything. Time slows. Pain robs us
of concentration and drive. To paraphrase Job's wife, it makes us
curse God and want to die.

Pain, in other words, robs us of dignity, robs us of authenticity. If
pain prevents you from walking, or writing the poem you could write,
or devising the theorem, or cooking the dinner, or appreciating your
children or a summer's day, are you really able to be your authentic

When pain separates us from what we could be, what we truly would be
were there no pain, suffering for its own sake holds no virtue. People
are worthy of reverence and loving-kindness. We declare as much when
we ease pain. In the next 20 years, may we leave our fear of doing one
of the best things we can do. When we ease pain, truly we do so for
God's sake.
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MAP posted-by: Larry Seguin