Pubdate: Tue, 17 May 2005
Source: Medical Post (Canada)
Copyright: 2005 The Medical Post
Contact:  http://www.medicalpost.com/
Details: http://www.mapinc.org/media/3180
Author: Susannah Benady
Bookmark: http://www.mapinc.org/find?232 (Chronic Pain)

Pain Management Update

PAIN: OPIOIDS: TWO SIDES OF A DOUBLE-EDGED SWORD

Note: Two specialists are reported here: Dr. Roman Jovey, Canadian Pain 
Society, and directly below that, Dr. Graeme Cunningham, Homewood Centre.

Opioids have the benefit of few side-effects, and screening helps catch 
those at risk of addiction, says pain specialist

By Dr. Roman Jovey, Incoming president, Canadian Pain Society

Patients with moderate to severe pain from injuries, cancer or other 
medical conditions should not be denied medications that can relieve their 
pain, nor should they feel afraid or ashamed to take the medication they 
need because these legitimate products have become stigmatized as "drugs of 
abuse."

If you look at all the drugs to treat pain, opioids are physically the 
safest pain relievers available, as long as physicians are diligent about 
screening patients and monitoring them.

Opioids are safer than over-the-counter acetaminophen, which has been 
associated with liver toxicity, increased risk of high blood pressure and 
stomach ulcers.

Virtually all the alternatives have more side-effects--some coxibs have 
been withdrawn, antiepileptics used to treat neuropathic pain have also 
come under suspicion recently and the older NSAIDs (nonsteroidal 
anti-inflammatory drugs) resulted in the deaths of an estimated 1,900 
Canadians every year due to GI side-effects. One-third of the cost of 
arthritis treatment is due to NSAID side-effects.

In contrast, opioids have never been shown to cause organ damage when taken 
therapeutically--only when misused.

One of the principles of decreasing the addictive potential of opioids is 
to use long-acting opioids dosed via a strict time schedule.

The goal is not to eliminate pain, but to decrease it to a evel where the 
individual can improve function.

The information we have at present suggests it is extremely rare for a 
physician to "create an addict" using opiods to treat pain, unless the 
patient has a biogenetic predisposition.

Seven per cent of people in our society suffer from a chemical addictive 
disorder and another 3% to 7% abuse chemicals to induce euphoria, according 
to data from the U.S. National Survey on Drug Use. People being treated for 
pain are a slice of general life, so the same percentage applies to them.

There are a few steps physicians can take to screen for possible addiction 
tendencies.

First, I use a questionnaire to assess for any previous serious alcohol or 
drug problems.

Questions include whether the patient has ever felt they needed to cut down 
on or felt guilty about their drinking or drug use, or been annoyed by 
others' complaining about their drinking or drug use, or had a drink or 
taken a drug in the morning to decrease hangover or withdrawal symptoms.

One positive response to any of those questions would suggest caution. Two 
or more positive responses may have a sensitivity varying from 60% to 95% 
and specificity from 40% to 95% in diagnosing serious alcohol or drug problems.

I also use a treatment contract or prescribing agreement. It outlines the 
expectations that the physician has of the patient managing the medication 
and confirms to the patient that the doctor will be monitoring the process. 
It also includes rules such as no double-doctoring, using only an agreed 
pharmacy and using the medication only as prescribed.

I also periodically order urine drug screening.

Although I am an addictionist and also manage chronic pain, I have been 
fooled by a patient for more than a year. He was a good actor, out to 
deceive me from the start. The patient repeatedly lost prescriptions, or 
ran out early. But as he was out to deceive, he was lying and one time I 
finally caught him in a lie.

I immediately stopped treating him and offered to refer him for addiction 
treatment, but he refused.

Don't blame the drug; addicts result from loose prescribing, addiction 
specialist notes

By Dr. Graeme Cunningham, Psychiatrist and director of the addiction 
division at the Homewood Centre in Guelph Ont.

I would never say, don't use opioids. Use them by all means, but follow 
proper guidelines, such as those published by the College of Physicians and 
Surgeons of Ontario.

Many physicians fear that if they give a prescription for opioids they'll 
lose their licence. That's the perception and it's not right they should 
feel like that.

You manage people in pain by improving their function--it's very legitimate 
and there's no reason why that shouldn't be done. So you take a number of 
steps from the most intrusive to the least intrusive. And one of those 
steps is the use of opioids.

But this has taken on a mystique and hysteria that it doesn't deserve.

There's one group of physicians saying they can use nothing but opioids. 
There's another group saying that if they prescribe opioids they'll lose 
their licence. Both are equally untrue.

My patients are the treatment failures and from my perspective, what I see 
is the loose prescribing. To be perfectly crass, 60% of the addicts that I 
care for have their doctor as their drug dealer.

Some doctors get over-involved in wanting to help patients and don't set 
healthy limits. If a doctor has his or her own personal difficulties, the 
boundaries can become blurred.

This is a very demanding and needy population of patients. And some doctors 
need to be needed. They will unconsciously keep their patients sick so they 
carry on being needed. Obviously, if they had the insight they wouldn't do 
it. But it can get out of hand without the doctor even realizing it.

Ten per cent of the population is highly susceptible to addiction--these 
people experience an intense reward and the memory of that reward is deeply 
entrenched in the primitive part of the brain and they chase that reward 
for the rest of their lives until they learn abstinence.

You can't tell who these people are, although it tends to be inherited, so 
it might be in the family history. A person with a blood relative two 
generations back with an addiction history is at four times a greater risk 
of developing an addiction. Low self-esteem, lack of self-worth and other 
psychosocial elements are also contributing factors.

There is a general lack of understanding about what addiction really is.

The terms "tolerance" and "withdrawal" continue to appear in the DSM IV as 
diagnostic features of alcohol and drug dependence. That's tragic because 
tolerance and withdrawal are normal physiological symptoms.

All patients will develop tolerance to certain medications and will 
experience withdrawal if they suddenly don't get it.

Anyone who has worked in palliative care knows what tolerance is, as does 
any physician whose patient has to stop benzodiazepines after 30 days. 
Withdrawal will occur, but they are not addicts. They don't have the 
co-existent drug-seeking behaviour, although they sure as hell don't feel good.

Tolerance and withdrawal have nothing to do with addiction. Addiction is a 
primary entity in and of itself--a chronic neurobiological disorder with 
physical, emotional and spiritual features.

Demoralization is what addicts have--it's physical, emotional and 
spiritual. It is characterized by the four Cs: loss of control, compulsion, 
craving and continued use in spite of negative consequences.
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MAP posted-by: Beth