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: FEAR OF OPIOID ABUSE CAN LEAD TO UNDERTREATING PAIN

Dilemma Can Cause 'Opiophobia' In Mds, But Don't Miss Window To Prevent 
Chronic Pain

MONTREAL - The treatment of pain has improved in the past decade and 
patients' pain, be it acute or chronic, is now taken more seriously than it 
ever was, say specialists.

But improvement in the treatment of pain is hampered, both by a lack of 
resources to build multi-disciplinary teams and by the fact that for many 
physicians, prescribing opioids--by some measures the most effective 
treatment with the fewest side-effects--is a medical no-go area.

The fear that patients might either abuse the drugs themselves or that the 
medications might end up on the black market are possibilities that 
physicians have to confront, or risk depriving patients of treatment they 
should receive.

Multidisciplinary Approach

There is no question that the multidisciplinary approach to the treatment 
of pain is the ideal, said Dr. Gilbert Blaise, professor of anesthesiology 
at the Universite de Montreal, who runs pain clinics at both the McGill 
University Health Centre and the Centre Hospitalier de l'Universite de 
Montreal.

"Pain is a complex condition, frequently not well-understood by physicians, 
and has many dimensions to it.

"We are beginning to understand the neuroscience behind it, but its 
complexity requires input from physio- and occupational therapists and 
psychologists, as well as from physicians."

According to a 2001 Canadian survey, 29% of the adult population 
experiences chronic pain, lasting more than six months, from conditions 
such as spinal pain, low back pain, fibromyalgia, postoperative pain and 
complex regional pain syndrome.

"As patients age, the more pain they get. Spinal pain, for example, will 
eventually affect 100% of patients," said Dr. Blaise, who has set up a 
patient pain association in Montreal called ABC Douleur.

But even among children, at least 20% experience long-term pain, noted 
anesthesiologist Dr. Allen Finley, who treats children and adolescents at 
the IWK Health Centre in Halifax.

Problem Of Major Proportions

Specialists who work in the field agree that pain, particularly chronic 
pain, constitutes an unsolved health problem of major proportions that 
undermines quality of life and imposes an enormous financial burden on society.

Four years ago the Canadian Pain Society launched a "patients' charter" 
informing the public that they were entitled to expect and receive 
appropriate pain killing medications and have their pain treated in a 
timely manner.

"Not treating pain adequately not only slows recovery, but if left 
untreated can become chronic, at which point it is no longer simply a 
symptom of disease but becomes a medical problem in its own right," said 
Dr. Roman Jovey, incoming president of the Canadian Pain Society.

"The trouble is that waiting lists for pain clinics are at least one year 
and there is a window of opportunity of two to three months for injured 
patients (for the best chance) to prevent them developing chronic pain."

But in addition to the lack of resources problem that dogs all chronic 
conditions in Canada, is the public relations minefield that physicians 
enter, whether they like it or not, as soon as they consider prescribing 
opioids.

The prospect is so nerve-wracking that it has led to its own pathology, 
dubbed "opiophobia."

'Worst Way To Administer'

"It is because of institutional opiophobia that doctors and nurses are 
trained to give the lowest dose of opioid for the longest time 
interval--just about the worst way to administer it," said Dr. Jovey a GP 
whose practice is now 60% to 70% pain management and 30% to 40% addiction 
medicine.

"A common fallacy is that you should 'only take it when you absolutely have 
to because it is addictive.'

"This results in a situation where people under-dose themselves because 
they are scared, or have to take too much to deal with the acute pain.

"There is a rule of thumb in pain management that it takes less medication 
to prevent the return of pain than it takes to treat it once it is out of 
control."

The principles of trying to minimize the addictive potential of opioids are 
first to use long-acting opioids, and second to keep to a strict time 
schedule, he advises.

"The amount of opioids you take today should not necessarily depend on how 
much pain you are experiencing today. This helps avoid the psychological 
mindset that can occur if you only take the painkiller when you have pain.

"If a person waits for the pain to become severe they will overshoot the 
amount ideally required, leading to excessive side-effects. This is then 
followed by a 'trough' effect on blood levels, leading to a yo-yo cycle 
that can exacerbate the risk of addiction in a susceptible person."

It can even lead to an iatrogenic condition known as "pseudo-addiction," 
which can be misinterpreted by the physician as drug-seeking behaviour but 
is in fact caused by under-treatment of pain that resolves when the 
appropriate level of pain relief is provided.
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