Mayo Clinic Pain Articla

[Guest guest]

Chronic pain

Reassessing the role of morphine and other narcotics

October 10 1997

In police parlance, the word " narcotics " is synonymous with

" illegal substances. " But in medicine, narcotics such as

morphine are the most powerful pain-killing medications

(analgesics) in a physician's arsenal.

Medical boards and law enforcement agencies strictly

regulate prescriptions for narcotics, which can be addictive

and abused. Physicians historically have avoided prescribing

narcotics unless deemed absolutely necessary — and then

primarily for short-term treatment of acute pain or for

chronic pain associated with a terminal illness such as

cancer.

But many people live in severe pain that's debilitating and

chronic in nature — but not life-threatening. There is

mounting (although not universally accepted) evidence that

morphine and other narcotics can be beneficial without

causing addiction in many of these situations, as well. Such

pain can come from injuries or from conditions such as nerve

damage from diabetes. Chronic pain can disrupt a person's

entire life, making it very difficult to do simple, everyday

tasks.

Morphine is derived from opium, which comes from the poppy

plant. Although healers have been treating pain with

poppy-derived drugs (opiates) for perhaps 6,000 years, a

debate over their proper use continues to this day. Many

experts in pain management believe that narcotics are

underprescribed for many who suffer from chronic pain. There

are new time-released formulations of narcotics that may

pose lower risk of addiction. Still, definitive information

is lacking and many doctors avoid prescribing narcotics out

of concern that it could invite a medical board or criminal

investigation.

No precise guidelines

If you have high blood pressure or high cholesterol, chances

are that your doctor can give you a numerical goal to strive

for. But if your problem is chronic pain, there is no

medical chart to say how much pain should be relieved by

medications.

" There are challenges in measuring pain reduction because

pain is subjective, " says Mayo Clinic neurologist Rose

Dotson, M.D., a specialist in pain management.

Dr. Dotson stresses the need for a close, trusting

relationship between people with chronic pain and their

doctors to find the most appropriate treatment and, if pain

medication is indicated, what types and dosages of

medication. This is especially important when narcotics are

considered.

" As a physician, you have to be very careful in prescribing

narcotics to make sure that the patient is being treated

appropriately and to cover yourself legally, " Dr. Dotson

says. For example, a doctor may appropriately be wary of

prescribing a narcotic to a patient with a history of

substance abuse.

Dr. Dotson says there is developing evidence that addiction

to narcotics is unlikely in people with severe, chronic pain

who have no prior history of substance abuse. " Some of the

medical literature indicates that people who truly have the

pain take as much narcotic medication as they need for the

pain, and they do not take it for other effects, " she says.

" As opposed to them being 'high' or not being able to

function, usually what you see is that they are able to

function better because their pain is reduced.

" I've had patients in whom we've tried all non-narcotic

options and the medications were either not tolerated or not

beneficial, " Dr. Dotson adds. " When we put them on one of

the long-acting morphine medications, they did get back to

functioning and they did not say, 'I need more, I need more,

I need more ...' "

Narcotics are reserved for the most serious pain. Here are

some general criteria for the use of narcotics for chronic

pain:

Evaluating the cause — A physician familiar with treating

chronic pain evaluates the results of a variety of tests to

determine the underlying cause.

Assessing the severity — There are other tests, including

questionnaires, designed to measure the severity of the

pain. The physician must then determine whether the

underlying cause can be treated and whether pain-killing

medications are appropriate.

Testing alternatives — If pain medication is deemed

necessary, the doctor often will try non-narcotic pain

relievers first. If the non-narcotic medications work

sufficiently without serious side effects, there is no need

for narcotics.

Knowing the goal — If the physician determines that narcotic

medications are appropriate, the goal of treatment may still

be to eventually taper off narcotics in favor of

non-narcotic drugs.

Having realistic expectations — Many types of chronic pain

will not go away even with the most powerful narcotics. The

goal may not be elimination of pain, but rather a

significant reduction in pain — and an improved quality of

life.

Abiding by a 'contract' — A doctor prescribing a narcotic

may ask the patient in advance to agree to a plan outlining

appropriate use of the medication.