Worries over addiction keep doctors on defense

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Worries over addiction keep doctors on defense

Chronic pain afflicts about 86 million; diagnosis difficult

By Jenks

FLORIDA TODAY

The medical missionary Dr. Albert Schweitzer once described pain " as a

more-terrible lord of mankind than death itself. "

Melbourne resident Isabelle Larato wouldn't disagree.

For three years, the pain spikes from a pinched nerve in Larato's spine left

her in agonizing pain, unable to cook or prune the bushes outside her home.

Injured in a car accident, the 83-year-old didn't find relief until

recently. Even then, she may have to return in six months for another nerve

block, should the pain break through to her lower back again.

Chronic pain, which medical professionals define as persistent, intractable

pain lasting weeks, months or even years, afflicts, to some degree, about 86

million Americans, according to the American Chronic Pain Association in

Rocklin, Calif.

Some of those it afflicts found themselves caught up in the news media's

glare recently, when Dr. Sarfraz Mirza, a local pain doctor, was arrested

outside his Sarno Road clinic earlier this month on 11 counts of trafficking

in OxyContin, a pill form of the opiate oxycodone, and delivery or sale of

other controlled substances.

The national pain association places a $90 billion annual price tag on

industry and business losses from chronic pain because of sick time, reduced

productivity and the direct medical costs of caring for employees whose pain

is so debilitating they are unable to work.

" By definition, pain is subjective, " said Dr. Jay, a neurologist and

pain-medicine specialist who is a past president of the Florida Academy of

Pain Medicine. " The problem is, you may come in and say, 'I get headache

pain every day,' and I examine you and can't find anything wrong. "

Nevertheless, Jay stressed, " Pain is what a patient says it is. "

Chronic pain arises from a number of sources: specific diseases, such as

cancer, AIDS or arthritis; medical conditions like headaches or back pain;

injuries of the central nervous system, such as stroke orspinal-cord trauma;

and nonspecific complaints are more difficult to pin down, but no less real.

Because of its myriad faces, however, managing chronic pain can be difficult

for patient and physician alike.

Especially tricky are the issues surrounding narcotic or opiate use to

restore function and quell pain: Prescription drugs, such as OxyContin, or

various morphine compounds, are regulated as controlled substances by the

U.S. Drug Enforcement Administration.

Some doctors also worry patients will develop a physical dependence on these

drugs.

But that can lead to undertreatment of patients' pain.

" Dare to break bones, grow old and hurt -- dare to have pain, " said Erma

, a Melbourne resident whose pain odyssey took her to Mirza for help.

A self-described " short, fat, old woman, " suffers from " eight or

more legitimate reasons for disabling chronic pain, " including spinal

arthritis, severe headaches and painful inflammation in her shoulders and

neck, stemming from damage to the nerve roots.

When adequately medicated on small doses of OxyContin, she said, " I am a

fully functioning person engaged joyously in life -- not juiced up, nodding

off on drugs. "

Yet, too often, chronic-pain patients, such as herself, are stigmatized as

" drug-seeking addicts, " she said.

Treatment ladder

In a hospice setting, where patients are expected to live less than six

months, opiate use rarely is controversial.

" Death can be peaceful, or it can be screaming to the end of life, " said Dr.

ph Hurlbut, medical director of Wuesthoff Brevard Hospice & Palliative

Care in Viera, who treats dying patients with short- and long-acting

narcotics.

" We treat little pain with little medicines and big pain with big

medicines, " he said, noting that, if pain escalates, the World Health

Organization's three-step ladder for treating pain in terminally ill

patients is followed.

The WHO ladder starts with non-opiates, such as Tylenol and nonsteroidal

anti-inflammatory drugs for mild to moderate pain, then progresses to

opiates for those in moderate to severe pain.

For chronic pain sufferers not in danger of imminent death, however, Hurlbut

acknowledged, " unquestionably, pain is undertreated. "

Although Florida is no more, nor less, aggressive than other states when it

comes to pursuing physicians who may overprescribe narcotics for pain, he

said, physicians fear " trouble with authorities, " especially with OxyContin,

which easily can be diverted for illicit use.

And they also fear malpractice, if they undertreat a patient's pain, he

said.

" Doctors have the fear of God if they undertreat, " subjecting them to

possible legal action in the present malpractice environment, or " if they

overtreat, they may be arrested, " agreed Jay, who runs the Headache and

Neuropain Care Institute in Tamarac, Broward County.

" The bottom line is, most doctors are not trained well to use opiates, " nor

do they receive much training in pain management in medical school,

although, recently, there has been some improvement, Jay said.

In addition, insurance problems surrounding more-costly interventions, like

physical therapy, may prevent appropriate rehabilitation for pain, he said.

Jay and others stressed the best way to manage persistent, chronic pain is

through a multidisciplinary approach.

That means doctors from various medical specialties, including psychologists

to address the emotional side of pain, are " all housed under one roof " with

nurses and allied health professionals, such as occupational and physical

therapists.

" Pain is a multifactorial problem, " said Dr. Stern, an

anesthesiologist at Health First's Pain Management Center in Palm Bay, a

department of Holmes Regional Medical Center in Melbourne. " Every individual

needs a different formula " for treatment.

Acupuncture option

One of Stern's patients, in fact, undergoes weekly treatments with

acupuncture, an ancient Chinese technique involving needle punctures at

various " acupoints " throughout the body to relieve pain.

Although still considered an alternative therapy, experts think acupuncture

works by triggering the release of natural painkilling substances the body

produces called endorphins, thus blunting the perception of pain.

It also, in theory, interrupts pain signals traveling along the spinal cord

from peripheral nerves and the pain source to the brain. Endorphins are just

one of numerous chemicals, known as neurotransmitters, found naturally in

the brain and spinal cord that enable pain to pass through and on to

neighboring cells.

For Pursley, whatever the actual mechanism, acupuncture has brought

relief, enabling her to get away from taking any painkilling drugs -- most

of which she's allergic to -- for at least three days. It also allows her to

get more than two hours of sleep a night and wake up refreshed the next day.

Like Larato, Pursley was injured in a car crash in the fall of 2000. The

accident left her with a severe neck injury that has been the source of

searing pain ever since.

" I have bulging in my neck and bone spurs. That's why I hurt so much -- with

pain down my shoulders into my lower back, " the Palm Bay resident said.

Although she may try surgery later this month, Pursley is realistic.

" There are no guarantees it will work, " she said.

Despite the unlikely prospect of a permanent cure for chronic pain any time

soon, some physicians, including Stern, think pain management of the

chronic-pain patient has improved during the past five or six years.

Through a greater awareness of the problem, increasing emphasis on

accreditation for pain-management programs and a flurry of pain-management

fellowships, which allow more physicians and allied health-care

professionals to specialize in pain, " we are moving to better treatments, "

according to Dr. Aranibar, a co-director of Wuesthoff Pain Management

on Merritt Island.

" OxyContin is just another long-acting opiate, " he said. " From my point of

view, others (drugs) work just as well, but don't run the same risk of being

diverted, " for snorting or injecting on the street.

Not only are there several other long-acting morphine drugs able to quiet

pain, he said, but methadone works as an effective analgesic at a fraction

of the price -- about $30 a month, compared with $200 to $300 monthly for

other opiates.

Duragesic patches, containing the opiate fentanyl, provide still another

alternative, especially if a patient has difficulty swallowing, Aranibar

said.

Like his colleagues, Dr. Jay Olsson, an osteopathic physician and

physiatrist, described OxyContin as a " good drug with a bad name. "

" If it's used slowly like you're supposed to, you don't get a high, " said

Olsson, medical director of the pain-management program at Health South Sea

Pines Rehabilitation Hospital in Melbourne.

In the Sea Pines' pain program, dubbed " back on track, " patients are slowly

weaned away from all narcotic use, if possible, and trained to deal with

pain through biofeedback techniques or other measures, such as increasing

exercise.

" When I treat people with chronic pain, if they are using narcotics, I can

take them off quickly without any real withdrawal problems, " Olsson said.

" But, if I don't replace it (the narcotics) with something else, they still

have pain. "

Typically, it takes four to five weeks, usually in an inpatient hospital

setting, to wean a patient off narcotics, while simultaneously controlling

their pain, he said.

Some patients with intractable chronic pain -- often those with neuropathic

pain arising from injury to nerves in the peripheral or central nervous

systems -- can't function without the potent help of a narcotic drug,

however.

In these individuals, providing there is careful documentation, opiates are

deemed appropriate by most physicians, although many require contracts with

their patients for their use.

" I tell my patients: 'You can have one time the dog eats your prescription,

or one time you lose it, but after that you're out of luck,' " Olsson said.