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Personal Health

Let's Get Serious About Relieving Chronic Pain

By JANE E. BRODY

Published: January 10, 2006

Patients with debilitating pain from chronic illness,

accidents, surgery or advanced cancer have long had

problems getting adequate medication to control their

pain and make life worth living.

Stuart Bradford

More Personal Health Columns Now the federal

government, and especially the Drug Enforcement

Administration, is working overtime to make it even

harder for doctors to manage serious pain, including

that of dying patients trying to exit this world

gracefully.

In an article in the current New England Journal of

Medicine titled " The Big Chill: Inserting the D.E.A.

into End-of-Life Care, " two specialists in palliative

care, Dr. E. Quill and Dr. Diane E. Meier,

state that despite some physicians' commitment to

treat pain and despite the effectiveness of opioid

drugs like OxyContin and morphine, " abundant evidence

suggests that patients' fears of undertreatment of

distressing symptoms are justified. "

They continue, " Although a lack of proper training and

overblown fears of addiction contribute to such

undertreatment, physicians' fears of regulatory

oversight and disciplinary action remain a central

stumbling block. "

Obstacles to Relief

In addition to a case before the United States Supreme

Court, v. Oregon, that threatens to

undermine Oregon's Death With Dignity Act, the D.E.A.

has recently increased raids on doctors' offices,

confiscating files and arresting doctors on charges of

overprescribing narcotics to patients who are addicts

or drug dealers.

Most of these physicians are compassionate people

trying to help suffering patients but are sometimes

fooled by clever addicts, drug dealers or undercover

agents who fake their pain.

Should the court rule against Oregon, the D.E.A. could

turn to all physicians whose patients die while

getting prescribed opioids or barbiturates, even if

the drugs were administered only to relieve

intractable pain, not to hasten death.

Yes, there are bad apples among members of the medical

profession. There are some doctors who charge for

medical exams that they never do and provide phony

patients with prescriptions for narcotics to feed

their habits or sell on the street.

But should all physicians be subject to intense

scrutiny by the D.E.A. and risk arrest and

prosecution, leaving legitimate patients to suffer

intensely or scramble to find other doctors willing

to risk taking them on?

Doctors have no certain way to measure patients' pain

other than to ask them. Patients should be asked to

rate their pain, say, on a scale of 1 to 10, with 10

being the most intense they can imagine. " Model

Guidelines for the Use of Controlled Substances for

the Treatment of Pain " were established in 1998, and

every physician who prescribes narcotics should know

them by now. These guidelines emphasize that

documentation is critical to proper pain management.

With patients who are prescribed strong painkillers,

doctors first are supposed to obtain a medical

history, perform a physical examination, ask about

addictive behaviors and whether other treatment

options have been tried, and fully record what they

find.

Prescriptions for controlled substances like narcotics

cannot be refilled automatically. When a patient asks

for a new one, a well-documented follow-up visit is

necessary. The doctor should ask about the kinds and

amounts of painkillers being taking, side effects,

performance of daily activities and aberrant

drug-related behaviors.

Dr. P. Schneider, a pain management and

addiction medicine specialist in Tucson, gives this

example: " Back pain today is 4/10, walks the dog 15

minutes daily, constipation is controlled with

Senokot-S, patient is on schedule with his meds. " She

advises physicians, " If a patient lies about his

medical problems and turns out to be a drug abuser, at

least you've documented that you were acting in good

faith. "

A Fear of Prosecution

The growing number of arrests of pain management

specialists is exacting high costs for patients,

physicians and medical insurers. Some doctors order

costly but unnecessary diagnostic tests so they can

show the D.E.A. a reason for prescribing strong pain

medication.

Many doctors are simply unwilling to prescribe

narcotics, no matter how much a patient suffers.

Ignorance, as well as a fear of the D.E.A., plays a

role. For example, the surgeon who performed my

double-knee replacement a year ago told me, in

reference to OxyContin, a synthetic opioid: " I don't

like to prescribe these drugs. Patients have too hard

a time getting off them. "

(Page 2 of 2)

Well, sir, if you never prescribe them, then chances

are you never learned how to help patients stop them.

Many doctors and patients fail to understand the

difference between physical dependence and addiction.

More Personal Health Columns An addict uses a drug to

get high, becomes tolerant and needs ever-increasing

amounts to maintain that high. Patients taking

narcotics for pain don't get high; they get relief

from their pain, and when larger doses are needed, it

is usually because their pain has become more

intense, as often happens in patients with advanced

cancer or degenerative diseases.

Physical dependence occurs in almost everyone who

takes a narcotic for two weeks or more. The body

becomes adapted to the presence of narcotics (that is,

becomes physically dependent on them). A patient

cannot go off them abruptly without suffering serious

withdrawal.

A Gentle Weaning Process

I asked Dr. Schneider how to go off narcotics safely.

She suggested cutting back 10 milligrams every three

days (the exact amount would depend on the dose a

patient is on). If at any point in the weaning

process my pain became more intense, I was to go back

to the last dose, wait a week, then try to resume the

weaning.

As I neared the end, the cutback was five milligrams

every three days. Then the dose was down to nothing,

and no withdrawal symptoms, either.

Having heard only about those who, like Betty Ford,

got hooked on painkillers, many patients are afraid

of becoming addicted if narcotics are prescribed. But

it is the rare patient who becomes addicted, and it

is nearly always someone with a history of addiction,

typically to alcohol.

Even with dying patients, the families and physicians

often shy away from narcotics for fear of addiction,

as if it mattered whether someone near the end of life

- in desperate pain or extreme agitation - became

addicted to the morphine that could provide almost

instant relief.

Proper pain management for dying patients can

facilitate important communication between patients

and their loved ones and provide what most people

would call " a good death. "

" Pain is a common symptom in patients nearing the end

of life, " with up to " 77 percent of patients

suffering unrelieved, pronounced pain during the last

year of life, " Dr. J. Moynihan wrote in The

Mayo Clinic Proceedings in 2003.

In their current article, Dr. Quill of the University

of Rochester School of Medicine and Dr. Meier of

Mount Sinai School of Medicine stated, " Allowing

D.E.A. agents, trained only to combat criminal

substance abuse and diversion, to dictate to

physicians what constitutes acceptable medical

practice for seriously ill and dying persons " may make

doctors increasingly reluctant to prescribe needed

medications and " end up abandoning patients and their

families in their moment of greatest need. "

Lotacats

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