Physicians' Perspective: Chronic Pain-The Hidden Epidemic
By Rick Bayer
While the science of pain control has progressed, the politics of pain control remains in the Dark Ages.
In 1998, the American Pain Society (www.ampainsoc.org) published Chronic Pain In America: Roadblocks To Relief. They report that 9% of American adults (25 million) suffer from moderate to severe pain, 2/3 of whom have had pain over 5 years.
In the Spring 2003 Journal of American Physicians and Surgeons, pain specialist William E. Hurwitz, MD, wrote Pain Control in the Police State of Medicine. His goal was to elaborate on the kinds of policies that would allow the medical profession to be more responsive to the mostly hidden epidemic of untreated and inadequately treated pain. This is mandatory reading for anyone who knows anyone suffering from chronic pain. (See www.drhurwitz.com and look at announcements.) As may be deduced by Hurwitz title, Americas problem with pain is also a problem with politics, public policy and improper police interventions.
When I trained to be a doctor in the 1970s, opioids (drugs similar to opium) were forbidden in treatment of pain lasting longer than six weeks. Later, in the early 1980s, I went to a seminar on treating chronic pain. One physician explained there was no such thing as chronic paina confusing argument at best. He was followed by a narcotics officer who explained that if we prescribed opioids for more than six weeks to someone who wasnt terminally ill, we would be targeted for criminal investigation.
By the mid-1980s experts reconsidered opioids to treat chronic non-cancer pain because of success in persons with cancer. Unfortunately, policy makers do not keep up with evolving science.
Pain Relief vs. Substance Abuse
As our understanding progressed so did the terminology. Most experts now agree that physical dependence is characterized by withdrawal symptoms upon abstinence from a drug, and that tolerance is when a person must increase the dose to maintain a therapeutic effect. Psychological dependence, addictionor the term I prefer, substance abusedescribes compulsive drug use for non-medical purposes despite obvious harm. I avoid the term addiction because it is often pejorative and judgmental, with moral implications.
Understanding these terms is an essential foundation for understanding the terms of the debate over pain control in America.
Research indicates that opioids prescribed for patients with no personal history of substance abuse had a very low risk of abuse. Further studies have indicated that those with a history of substance abuse and chronic pain could be safely treated with opioids, and that such treatment reduced illicit drug use while improving functional status.
In 1995, Oregons 68th Legislative Assembly passed Senate Bill 671, the Intractable Pain Act. This allows a patient to receive opioids for chronic pain while promising the physician that opioid prescriptions would not be the sole reason for the state Board of Medical Examiners (BME) to discipline doctors. The BME can still discipline doctors who treat chronic pain if they keep poor medical records or if they prescribe opioids in a manner detrimental to the public or in violation of federal law.
Then, in 1997, the American Society of Addiction Medicine affirmed that physicians are obligated to relieve pain and suffering in all their patients, including those with concurrent substance abuse.
Around this time, Oregonians were passing, and then re-passing, the Oregon Death with Dignity Act, and then we passed the Oregon Medical Marijuana Act in 1998.
In my opinion, the public leads and policy makers follow.
Waiting for the Policy Makers
Sadly, having science and good intentions on ones side does not guarantee success when dealing with regulatory bodies like the BME, so practicing physicians remain skeptical and fearful about prescribing opioids for pain. In spite of increasing expert support for prescribing opioids for chronic non-cancer pain, doctors have received mixed signals from regulatory and policing agencies. This means many patients are still not getting adequate pain treatment and many physicians are frightened to treat chronic pain because they fear loss of state medical or federal narcotics licenses.
Things are worse under the Bush Administration. Inexplicably, Republicans seem committed to rolling back the clock when it comes to helping patients with chronic pain. Because of prohibition policies in our War on Drugs that treat substance abusers as criminals instead of sick people who need treatment, federally coordinated efforts to stop diversion of opioids to underground markets now target doctors whose specialty is medical pain management. The federal Drug Enforcement Administration (DEA) lies about this to doctors while agents pay intimidating visits to pharmacists and doctors advising them how to practice.
The most alarming trend to me is that while an investigation by the BME can result in loss of license and a civil suit can result in loss of money and assets, the Bush/Ashcroft DEA is now pursuing federal criminal charges against doctors who prescribe opioids for chronic pain. Dr. Hurwitz has recently been arrested on federal charges that could yield life in prison for trying to help patients in pain. Although he has not been convicted, his assets have been seized. It is clear the feds want to break him and other medical pain specialists. Dr. Hurwitz maintains he is following accepted scientific principles and that doctors who practice science-based medicine in good faith should not fear federal criminal charges. I agree and so do several medical and patient advocacy groups. See: http://stopthedrugwar.org/chronicle/305/galvanization.shtml
In addition, the Oregon BME still opposes our Medical Marijuana Act and the Bush/Ashcroft administration pursues efforts to overturn the Oregon Death with Dignity Act while seeking to remove federal narcotic licenses from doctors who recommend medical marijuana. With these sorts of messages and threats, it is a wonder any patient gets adequate pain management.
Prescription for Remedy
To fix the problem of untreated and under-treated pain in chronically ill patients, we must vote out the Bush/Ashcroft party and re-examine our nations War on Drugs. What are we gaining besides over-funding the doctor-busting narcotics agencies while laying off police who actually protect us from violent criminals? Why are we willing to sacrifice civil liberties, healthcare, education, a clean environment, and solid infrastructure in a self-destructive pursuit of a drug-free America? We need drug education and drug treatmentnot another war.
We can no longer be passive when drug warriors threaten the practice of compassionate scientific medicine and make the chronically ill do without necessary medication. For the compassionate, I ask you to inform yourself, contact your representatives, and vote. For those who need more convincing, I ask you to consider that anyone is only one accident away from a life with chronic debilitating pain.
Rick Bayer, MD is board-certified in internal medicine, a fellow in the American College of Physicians, and practiced in Lake Oswego for many years. Co-author of Is Marijuana the Right Medicine For You? A Factual Guide to Medical Uses of Marijuana, he was a chief petitioner for the Oregon Medical Marijuana Act in 1998, and manages www.omma1998.org that includes a medical cannabis/marijuana bibliography.
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