Pain medicine regresses 100 years

Prescription Drugs and Pain Management | Drug War Facts

I’ve skimmed this entire long document and selected the pieces I find most pertinent:

(War on Pain Doctors)

The government is waging an aggressive, intemperate, unjustified war on pain doctors.

This war bears a remarkable resemblance to the campaign against doctors under the Harrison Act of 1914, which made it a criminal felony for physicians to prescribe narcotics to addicts.   

In the early 20th century, the prosecutions of doctors were highly publicized by the media and turned public opinion against physicians, painting them not as healers of the sick but as suppliers of narcotics to degenerate addicts and threats to the health and security of the nation.”

Source: Libby, Ronald T., “Treating Doctors as Drug Dealers The DEA’s War on Prescription Painkillers,” CATO Institute (Washington, DC: June 2005), p. 21.
http://www.csdp.org/research/cato_libby_pain_analysis.pdf

It’s hard to believe they are talking about events of 100 years ago, but this is how far backward our medical system has taken us.


(AMA on Controlled Substances and Pain) – what they said in 2010:

“The AMA [American Medical Association] supports the position that:

“1. physicians who appropriately prescribe and/or administer controlled substances to relieve intractable pain should not be subject to the burdens of excessive regulatory scrutiny, inappropriate disciplinary action, or criminal prosecution.

It is the policy of the AMA that state medical societies and boards of medicine develop or adopt mutually acceptable guidelines protecting physicians who appropriately prescribe and/or administer controlled substances to relieve intractable pain before seeking the implementation of legislation to provide that protection;

“2. education of medical students and physicians to recognize addictive disorders in patients, minimize diversion of opioid preparations, and appropriately treat or refer patients with such disorders; and

“3. the prevention and treatment of pain disorders through aggressive and appropriate means, including the continued education of physicians in the use of opioid preparations.”

Source: American Medical Association, “About the AMA Position on Pain Management Using Opioid Analgesics,” 2010.
http://www.ama-assn.org/go/painpolicy

(Factors in the Transition from Prescription Opiate Use to Heroin Use)

“Multiple studies that have examined why some persons who abuse prescription opioids initiate heroin use indicate that the cost and availability of heroin were primary factors in this process. These reasons were generally consistent across time periods from the late 1990s through 2013.

Source: Wilson M. Compton, M.D., M.P.E., Christopher M. Jones, Pharm.D., M.P.H., and Grant T. Baldwin, Ph.D., M.P.H. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med 2016; 374:154-163. January 14, 2016. DOI: 10.1056/NEJMra1508490
http://www.nejm.org/doi/full/10.1056/NEJMra1508490
http://www.nejm.org/doi/pdf/10.1056/NEJMra1508490

(Unrelieved Pain A Serious Health Problem In The US)

“It is well-documented that unrelieved pain continues to be a serious public health problem for the general population in the United States.1-8

This issue is particularly salient for

  • children,9-14
  • the elderly,15-19
  • people of racial and ethnic subgroups,20-24
  • people with developmental disabilities,25;26
  • people in the military or military veterans27-30

as well as for those with diseases such as

  • cancer,31-36
  • HIV/AIDS,37-40 or
  • sickle-cell disease.41-43

Clinical experience has demonstrated that adequate pain management leads to enhanced functioning and quality of life, while uncontrolled severe pain contributes to disability and despair.

Source: Pain & Policy Studies Group, “Achieving Balance in State Pain Policy: A Progress Report Card (CY 2013)” (Madison, WI: University of Wisconsin Carbone Cancer Center, July 2014), p. 10.
http://www.painpolicy.wisc.edu/achieving-balance-state-pain-policy-progr…
http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/prc20…

(Balancing Control And Availability Of Opioid Painkillers In Pain Management)

“Because opioid analgesics have both a medical indication and an abuse liability, their prescribing, dispensing, and administration, indeed their very availability in commerce, is governed by a combination of policies, including international treaties and U.S. federal and state laws and regulations.

This is completely inappropriate for an essential medicine, but this medicine happens to also be a drug of abuse.

The main purpose of these policies is drug control: to prevent diversion and abuse of prescription medications. However, international and federal policies also express clearly a second purpose of drug control, that being availability: recognizing that many opioids (referred to in law as narcotic drugs or controlled substances) are necessary for pain relief and that governments must ensure their adequate availability for medical and scientific purposes.

When both control and availability are appropriately recognized in public policy, and implemented in everyday practice, this is referred to as a balanced approach

Source: Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation (CY 2013). (University of Wisconsin Carbone Cancer Center: Madison, WI, July 2014), p. 17.
http://www.painpolicy.wisc.edu/achieving-balance-federal-and-state-pain-…
http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/evalg…

(Law Enforcement’s “Chilling Effect” on Pain Treatment)

“The under-treatment of pain is due in part to a kind of undesirable ‘chilling effect.’ The concept of a chilling effect, generally, is a useful law enforcement tool. When publicity surrounding a righteous prosecution ‘chills’ related criminal conduct, that chilling effect is intended, appropriate, and a public good.

A chilling effect on the appropriate use of pain medicine, however, is not a public good.

Recent research by members of the Law Enforcement Roundtable confirms that prosecutions of doctors for diversion of prescription drugs are rare.2 But, on occasion, overly-sensationalized stories of investigation of doctors have hit the nightly news. When that happens, the resulting chilling effect reaches far beyond a ‘good’ chilling effect on bad actors, and directly affects appropriate medical practice.

The consequence is extreme, and not what law enforcement would ever seek – our parents and other loved ones who are in pain simply cannot get the medicines they need.”

Source: “Balance, Uniformity and Fairness: Effective Strategies for Law Enforcement for Investigating and Prosecuting the Diversion of Prescription Pain Medications While Protecting Appropriate Medical Practice,” Center for Practical Bioethics (Kansas City, MO: February 2009), p. 3.
http://www.fsmb.org/Media/Default/PDF/Publications/pub_bbpi_policy_brief…

(Barriers to Effective Pain Care)

“A number of barriers to effective pain care involve the attitudes and training of the providers of care.

First, health professionals may hold negative attitudes toward people reporting pain and may regard pain as not worth their serious attention.

As discussed in detail in Chapter 2, patients can be at a particular disadvantage if they are members of racial or ethnic minorities, female, children, or infirm elderly. They also may have less access to care if they are perceived as drug seeking or if they have, or are perceived to have, mental health problems.

A literature review showed that people with pain, especially women, often have attitudes and goals that are different from, and sometimes opposed to, the attitudes and goals of their practitioners; patients seek to have their pain legitimized, while practitioners focus on diagnosis and therapy (Frantsve and Kerns, 2007).

Consumers testified before the committee that patients often believe practitioners trivialize pain, which makes them feel even worse.

Researchers working with patient focus groups have noted the ‘perceived failures of providers to fully respect, trust, and accept the patient, to offer positive feedback and support, and to believe the participants’ reports of the severity and adverse effects of their pain’ (Upshur et al., 2010, p. 1793).”

Source: Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” (Washington, DC: National Academy of Sciences, 2011), pp. 153-154.
http://www.nap.edu/openbook.php?record_id=13172

(Majority of Pain Patients Use Prescription Drugs Properly)

“The research findings noted above need to be set against the testimony of people with pain, many of whom derive substantial relief from opioid drugs.

This tension perhaps reflects the complex nature of pain as a lived experience, as well as the need for biopsychosocial assessments and treatment strategies that can maximize patients’ comfort and minimize risks to them and society.

Regardless, the majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others.

Source: Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” (Washington, DC: National Academy of Sciences, 2011), p. 145.
http://www.nap.edu/openbook.php?record_id=13172

(Tolerance of Opiates and Escalation of Effective Dosage)

During long-term treatment, the effective opioid dose can remain constant for prolonged periods.

Some patients need intermittent dose escalation, typically in the setting of physical changes that suggest an increase in the pain (eg, progressive neoplasm).

Fear of tolerance should not inhibit appropriate early, aggressive use of an opioid. If a previously adequate dose becomes inadequate, that dose must usually be increased by 30 to 100% to control pain.”

Source: “Treatment of Pain.” The Merck Manual for Health Professionals. Merck & Co. Inc. Last accessed April 6, 2013.
http://www.merckmanuals.com/professional/neurologic_disorders/pain/treat…

(Risk of Opioid Medication Abuse by Pain Patients)

“Opioid medications present some risk of abuse by patients as well. A structured review of 67 studies found that 3 percent of chronic noncancer pain patients regularly taking opioids developed opioid abuse or addiction, while 12 percent developed aberrant drug-related behavior (Fishbain et al., 2008).

A recent analysis revealed that half of patients who received a prescription for opioids in 2009 had filled another opioid prescription within the previous 30 days, indicating that they were seeking and obtaining more opioids than prescribed by any single physician (NIH and NIDA, 2011).”

Source: Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” (Washington, DC: National Academy of Sciences, 2011), p. 146.
http://www.nap.edu/openbook.php?record_id=13172
Source: Pain & Policy Studies Group, “Achieving Balance in State Pain Policy: A Progress Report Card (CY 2013)” (Madison, WI: University of Wisconsin Carbone Cancer Center, July 2014), p. 11.
http://www.painpolicy.wisc.edu/achieving-balance-state-pain-policy-progr…
http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/prc20…

(Barriers to Adequate Pain Care)

“Adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and the societal stigma that is applied, consciously or unconsciously, to people reporting pain, particularly if they do not respond readily to treatment.

Questions and reservations may cloud perceptions of clinicians, family, employers, and others: Is he really in pain? Is she drug seeking? Is he just malingering? Is she just trying to get disability payments?

Certainly, there is some number of patients who attempt to ‘game the system’ to obtain drugs or disability payments, but data and studies to back up these suspicions are few.

The committee members are not naïve about this possibility, but believe it is far smaller than the likelihood that someone with pain will receive inadequate care.

Religious or moral judgments may come into play: Mankind is destined to suffer; giving in to pain is a sign of weakness. Popular culture, too, is full of dismissive memes regarding pain: Suck it up; No pain, no gain.”

Source: Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” (Washington, DC: National Academy of Sciences, 2011), pp. 46-47.
http://www.nap.edu/openbook.php?record_id=13172

(Prevalence Of Persistent Pain Among Adults In The US)

Approximately 19.0% of adults in the United States reported persistent pain in 2010, but prevalence rates vary significantly by subgroup (Table 1).

Older adults are much more likely to report persistent pain than younger adults, with adults aged 60 to 69 at highest risk

This means the number of Americans in pain will increase over the next decades due to the “aging of America” as the average age of our population (and that of the developed world in general) is increasing.

Source: Jae Kennedy, John M. Roll, Taylor Schraudner, Sean Murphy, and Sterling McPherson, “Prevalence of Persistent Pain in the U.S. Adult Population: New Data From the 2010 National Health Interview Survey,” The Journal of Pain, Vol. 15, No. 10 (October), 2014, pp. 979-984.
http://dx.doi.org/10.1016/j.jpain.2014.05.009
http://www.jpain.org/article/S1526-5900%2814%2900774-3/abstract

(Significance and Growing Prevalence of Lower Back Pain)

“The potential impact of the growing prevalence of pain on the health care system is substantial. Although not all people with chronic low back pain are treated within the health care system, many are, and ‘back problems’ are one of the nation’s 15 most expensive medical conditions.

In 1987, some 3,400 Americans with back problems were treated for every 100,000 people;

by 2000, that number had grown to 5,092 per 100,000.

At the same time, health care spending for these treatments had grown from $7.9 billion to $17.5 billion.

Thorpe and colleagues (2004) estimate that low back pain alone contributed almost 3 percent to the total national increase in health care spending from 1987 to 2000. While about a quarter of the $9.5 billion increase could be attributable to increased population size, and close to a quarter was attributable to increased costs of treatment, more than half of the total (53 percent) was attributable to a rise in the prevalence of back problems.”

Source: Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” (Washington, DC: National Academy of Sciences, 2011), p. 64.
http://www.nap.edu/openbook.php?record_id=13172

(Opioid Use And Risks In Treatment Of Pain)

“Some opioids used for analgesia have both agonist and antagonist actions. Potential for abuse among those with a known history of abuse or addiction may be lower with agonist-antagonists than with pure agonists, but agonist-antagonist drugs have a ceiling effect for analgesia and induce a withdrawal syndrome in patients already physically dependent on opioids.

“In general, acute pain is best treated with short-acting pure agonist drugs, and chronic pain, when treated with opioids, should be treated with long-acting opioids

Because of the higher doses in many long-acting formulations, these drugs have a higher risk of serious adverse effects (eg, death due to respiratory depression) in opioid-naive patients.

“Opioid analgesics are useful in managing acute and chronic pain. They are sometimes underused in patients with severe acute pain or with pain and a terminal disorder such as cancer, resulting in needless pain and suffering.

Reasons for undertreatment include

  • Underestimation of the effective dose
  • Overestimation of the risk of adverse effects

“Generally, opioids should not be withheld when treating acute, severe pain; however, simultaneous treatment of the condition causing the pain usually limits the duration of severe pain and the need for opioids to a few days or less.

Also, opioids should generally not be withheld when treating cancer pain; in such cases, adverse effects can be prevented or managed, and addiction is less of a concern.

“In patients with chronic noncancer pain, nonopioid therapy should be tried first 

Opioids should be used when the benefit of pain reduction outweighs the risk of adverse effects and of drug misuse.

If nonopioid therapy has been unsuccessful, opioid therapy should be considered.

In such cases, obtaining informed consent may help clarify the goals, expectations, and risks of treatment and facilitate education and counseling about misuse.

Patients receiving chronic (> 3 mo) opioid therapy should be regularly assessed for pain control, adverse effects, and signs of misuse.

If patients have persistent severe pain despite increasing opioid doses, do not adhere to the terms of treatment, or have deteriorating physical or mental function, opioid therapy should be tapered and stopped.

Physical dependence (development of withdrawal symptoms when a drug is stopped) should be assumed to exist in all patients treated with opioids for more than a few days.

Thus, opioids should be used as briefly as possible, and in dependent patients, the dose should be tapered to control withdrawal symptoms when opioids are no longer necessary.

Patients with pain due to an acute, transient disorder (eg, fracture, burn, surgical procedure) should be switched to a nonopioid drug as soon as possible.

Dependence is distinct from addiction, which, although it does not have a universally accepted definition, typically involves compulsive use and overwhelming involvement with the drug including craving, loss of control over use, and use despite harm.”

Source: “Treatment of Pain.” The Merck Manual for Health Professionals. Merck & Co. Inc. Last accessed September 24, 2014.
http://www.merckmanuals.com/professional/neurologic_disorders/pain/treat…

(Unrelieved Pain Continues To Burden Americans)

“Pain remains one of the most common physical complaints upon a person’s admission into the healthcare system

insufficient treatment attention often is given to appropriate pain relief, especially when pain is severe or prolonged.

In extreme circumstances, pain can impair all aspects of life and sometimes contribute to a person’s wish for death (Fishman & Rathmell, 2010; Ilgen et al., 2013; Institute of Medicine Committee on Advancing Pain Research, 2011; Institute of Medicine National Cancer Policy Board, 2001; Wasan, Sullivan, & Clark, 2010).

When pain relief is achieved, it can result in improved quality of living for people with prolonged pain and can decrease suffering for people at the end of life (Higginson & Evans, 2010).”

Source: Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation (CY 2013). (University of Wisconsin Carbone Cancer Center: Madison, WI, July 2014), p. 13.
http://www.painpolicy.wisc.edu/achieving-balance-federal-and-state-pain-…
http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/evalg…

(American Medical Association on the Undertreatment of Pain, 2004)

Unbalanced and misleading media coverage on the abuse of opioid analgesics not only perpetuates misconceptions about pain management; it also compromises the access to adequate pain relief sought by over 75 million Americans living with pain.

“In the past several years, there has been growing recognition on the part of health care providers, government regulators, and the public that the undertreatment of pain is a major societal problem.

This has clearly been reversed from 13 years ago

.”Pain of all types is undertreated in our society. The pediatric and geriatric populations are especially at risk for undertreatment.

Physicians’ fears of using opioid therapy, and the fears of other health professionals, contribute to the barriers to effective pain management.”

Source: American Medical Association, “About the AMA Position on Pain Management Using Opioid Analgesics,” 2004.
Note: This report no longer available on the AMA’s website, however its content is discussed in “California law eases threat to pain medication prescribers,” American Medical News, Sept. 13, 2004.
http://www.amednews.com/article/20040913/profession/309139960/1/

 

Related DWF Chapters for More Information:

Pain Management Chapter Subsections:

Source: American Medical Association, “About the AMA Position on Pain Management Using Opioid Analgesics,” 2010.
http://www.ama-assn.org/go/painpolicy
Source:  American Medical Association, “About the AMA Position on Pain Management Using Opioid Analgesics,” 2010.
http://www.ama-assn.org/go/painpolicy
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