The Politics of Pain: The Controversy
Surrounding Chronic Pain and Opioids
By Anne-Marie Vidal
Anyone who lives with chronic pain is acutely aware of many physicians' difficulty in coming to terms with prescribing adequate pain medication. For us, this is more than a research or academic issue. We know first hand that pain is debilitating and can erode our standard of living and ability to earn an income. Inadequately treated chronic pain patients have difficulty functioning and poor attendance records at work. Indeed, the cost of chronic pain in the US is estimated at $40 billion annually. Yet, 50 million Americans with chronic pain are likely to be under treated.
Events of the past year make it hard to believe that this is or an oversight. In the spring of last year both the World Health Organization (WHO) and the Joint Commission on Accreditation of Healthcare organizations (JCAHO) issued statements on the far-reaching effects of pain and the incapacity it causes.
The WHO statement said in part: "Persistent pain is a major public health problem" accounting for "untold suffering and lost productivity around the world." A study of 5447 individuals across 15 countries was noted. In reviewing the relationship between pain and well-being, it was concluded "those with persistent pain were over four times more likely to have an anxiety or depressive disorder than those without pain. This association was observed in all study centers, regardless of geographical location.
Other studies have suggested that pain intensity, disability, and anxiety/depression interact to develop and maintain chronic pain conditions." Within weeks, the JCAHO addressed the suffering of millions of Americans due to chronic pain. Their June 2001 statement followed "The Leadership Summit on Pain Management: A Multidisciplinary Approach to Good Practices" and said in part that "excessive concerns about addiction and the side effects of pain medicines often result in reluctance to prescribe appropriate analgesics with the consequence that patients suffer needlessly from pain."
These declarations were almost immediately over shadowed as media attention was shifted to substance abuse when a Newsweek cover story trumpeted the new preferences of partying substance abusers, highlighting Oxycontin and Vicodin. This story was followed within 10 days by a headline story on CNN that was carried in the press nationally. Neither story mentioned that substance abusers doses of Oxycontin or Vicodin are often three or four times the amount prescribed therapeutically.
The popular conception that painkillers are addictive or the need of the self-indulgent began. Oxycontin became an unmentionable in doctor's offices, pain clinics and patients found themselves under new types of scrutiny. In support groups, the subject of pain and deteriorating functioning was discussed. Unable to concentrate, patients related stories of mishaps that ranged from overdrawn household accounts to small kitchen fires. One patient told me emphatically, "Suicide shouldn't be our only choice for pain control."
While dramatic, this remark is not over statement. Vermont stopped paying for Oxycontin for certain welfare beneficiaries. West Virginia's attorney general initiated legal action against Purdue Pharma LP the maker of Oxycontin, alleging aggressive and irresponsible marketing tactics in another state, patients were finger printed when having their prescriptions filled. A cyber acquaintance, a patient in Ohio, insured under a private disability plan received notice last summer that her pain medication, Oxycontin, would no longer be covered under her medical plan. The letter stated the drug was addictive and implied that her use of the drug was recreational and not rehabilitative. This patient acted quickly and took her insurance company to court and while successful in her right to have her pain medication as a benefit of her policy, the energy and delay in receiving her medication was burdensome.
There is an enormous difference between using Opioid medications to be able to function and using them to escape reality. According to National Institute of Health (NIH) statistics, less the a tenth of one percent of pain patients become addicts. Yet most of us will at a minimum face severe scrutiny if not outright derision if we ask a doctor for Opioid medications early in our treatment. There are also a variety of opioid medications, some with much more severe side effects than others. For instance short term acting opioids require repeated doses during the day; where as a longer term acting drug, the patient may need only one or two doses a day.
Gerald M. Aronoff, M.D, the medical director of the North American Pain and Disability Group in Charlotte, N.C., made a clear distinction between addiction and pain control. "A person's functioning improves with successful pain relief," he told Psychopharmacology Update. "When the line is crossed to addiction, functioning is not enhanced; it suffers," he said.
An April advisory on Oxycontin from the Center for Substance Abuse Treatment (CSAT), the government's breaking-news advisory for treatment professionals, added illumination on the distinction. "Addiction is characterized by the repeated, compulsive use of a substance despite adverse social, psychological and/or physical consequences. Addiction is often (but not always) accompanied by physical dependence, withdrawal syndrome and tolerance."
Dr. Aronoff also strongly supports educating health care providers at all levels as well as the public about pain management, drug use and addiction. He believes that the ability to prescribe Oxycontin should not be limited to pain management physicians.
The story of pain patient Marie Dabrowski that appeared at Salon.com April 4, 2002, dramatized the dilemma of patients who are chronically in pain. Titled "No Relief" the article by Damien Cove chronicled the misunderstanding that occurs when the war on drugs is aimed at pain patients. Ms. Dabrowski, who has fibromyalgia, had found long sought release from hurting in the form of treatment with Oxycontin. However in March of this year, her doctor, withdrew the medication. Ms. Dabrowski stated that the change had nothing to do with callousness or lack of concern, but with the fact that a proposed Virginia law designed to intensify examination of physicians who prescribe the drug frightened the doctor. In the end, she said, it was the likelihood of police questioning that pushed her doctor over the edge. Ms. Dabrowski stated her fears that the those chronically in pain could also be pushed beyond their endurance, "if the pain comes back they're going to commit suicide."
Doctors are faced with a quandary in prescribing these medications that go far beyond the exposure of the controversy surrounding these medications. State medical boards, professional associations and the Drug Enforcement Agency monitor prescriptions. A doctor seemingly dispensing too many narcotics risks possible investigation by these agencies. This type of pressure and possible scrutiny as a drug dealer understandably results in many doctors choosing to prescribe as few narcotics as possible. Purdue Pharma announced that Oxycontin would be re-constituted into a form that could not be crushed and used recreationally, nothing has been heard on that topic since the initial announcement. However, the controversy over pain medication is unlikely to end there.
When women, minorities and the elderly seek treatment for enduring pain, their needs are not received as well as the requests of white males contended a NY Daily News editorial column by Lenore Skenazy, "Pain and Prejudice" in February 2002. Ms. Skenazy's column stated that research is finding that" all too often, women, children, the elderly and minorities are just not given enough painkillers. The limited population receiving pain treatment, the editorial states, is middle aged white males;" demographics that happen to reflect the population of doctors.
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