Misunderstood Opioids and Needless Pain NY Times today
From: DMG (quinn@snet.net)
Wed Jan 23 05:47:03 2002
PERSONAL HEALTH; Misunderstood Opioids and Needless Pain
JANE E. BRODY
New York Times, Tuesday January 22 2002
Word Count: 1241
Chronic pain suffered by 30 million Americans robs people of their
dignity, personality, productivity and ability to enjoy life. It is the
single most common reason people go to doctors, contributing to an
overall
cost to the economy of billions of dollars a year.
Yet chronic pain, whether caused by cancer or a host of nonmalignant
conditions, is seriously undertreated, largely because doctors are
reluctant to prescribe -- and patients are reluctant to take -- the
drugs
that are best able to relieve persistent, debilitating, disabling pain
that
fails to respond to the usual treatments.
These drugs are called opioids, which are natural and synthetic
compounds related to morphine, generally known as narcotics. Many
studies
have indicated that ignorance and misunderstanding seriously impede
their
appropriate use.
Studies suggest that about half of patients with cancer-related pain
and 80 percent of those with chronic noncancer pain are undertreated as
a
result. These patients suffer needlessly, as do their loved ones.
"Some patients who experience sustained unrelieved pain suffer because
pain changes who they are," say Dr. C. Richard Chapman of the
University of
Utah School of Medicine and Dr. Jonathan Gavrin of the University of
Washington School of Medicine.
Chronic pain, they wrote in The Lancet medical journal, results in "an
extended and destructive stress response" characterized by brain hormone
abnormalities, fatigue, mood disorders, muscle pain and impaired mental
and
physical performance.
Neurochemical changes caused by persistent pain perpetuate the pain
cycle by increasing a person's sensitivity to pain and by causing pain
in
areas of the body that would not ordinarily hurt.
"This constellation of discomforts and functional limitations can
foster negative thinking and create a vicious cycle of stress and
disability," the researchers wrote. "The idea that one's pain is
uncontrollable in itself leads to stress. Patients suffer when this
cycle
renders them incapable of sustaining productive work, a normal family
life
and supportive social interactions."
Dr. Jennifer P. Schneider, a specialist in addiction medicine and pain
management in Tucson, Ariz., agrees. "When patients feel hopeless and
think
they will never get relief, it makes chronic pain and its effects that
much
worse," she said in an interview.
Abundance of Misinformation
Far too little has been done to correct the misunderstandings of both
patients and doctors that stand in the way of using opioids to control
chronic pain. Nowadays, doctors are more inclined to use narcotics for
pain
relief in patients with advanced cancer, assuming erroneously that
"since
they're dying anyway, it won't matter if they become addicts." But the
reluctance to use opioids for noncancer-pain patients persists, and
patients are equally likely to resist taking them should they be
prescribed.
"Like most doctors, most patients are relatively uninformed about the
safety of using narcotics for pain, thinking they're dangerous drugs
that
will do bad things to them," Dr. Schneider explained. "They don't
understand the difference between physical dependence and addiction, and
as
a result they're afraid they'll become addicts."
As Dr. Henry McQuay, a pain specialist at the University of Oxford in
England, put it: "Opioids are our most powerful analgesics, but
politics,
prejudice and our continuing ignorance still impede optimum prescribing.
What happens when opioids are given to someone in pain is different from
what happens when they are given to someone not in pain. The medical
use of
opioids does not create drug addicts, and restrictions on this medical
use
hurt patients."
In three studies involving nearly 25,000 patients treated with opioids
who had no history of drug abuse, only seven cases of addiction resulted
from the treatment.
Dr. Schneider was distressed last month by a segment of "48 Hours" on
CBS depicting a woman who had been taking the sustained-release opioid
OxyContin. The woman said that although the drug had relieved her
chronic
pain, she stopped taking it because she feared becoming an addict. But
instead of tapering off gradually, she quit cold turkey. As any pain
expert
would predict, she suffered withdrawal symptoms typical of physical
dependence on a narcotic: aches all over, tearing eyes, runny nose,
abdominal cramps and diarrhea.
Physical dependence, whether to an opioid or to an immune-suppressing
drug like prednisone, involves reversible changes in body tissues. To
avert
withdrawal symptoms, the medication must be stopped gradually. Addiction
is
mainly a psychological and behavioral disorder.
Dr. Schneider described the hallmarks of addiction, whether to alcohol
or narcotics, as loss of control over use, continuing use despite
adverse
consequences, and obsession or preoccupation with obtaining and using
the
substance.
The Benefits of Relief
Unlike an addict, whose life becomes increasingly constricted by an
obsession with drug use, a patient using the drug for pain experiences
an
expansion of life when relief comes from this life-inhibiting disorder,
Dr.
Schneider said. An addict gets high by taking the drug in a way that
rapidly increases the dose reaching the brain. But opioids properly used
for pain do not result in a "rush" or euphoria. When given for chronic
pain, opioids are typically given in a form that provides a steady
amount
throughout the day.
Nor do pain patients require ever-increasing amounts of opioids to
achieve pain control, because patients in pain do not become "tolerant"
to
properly prescribed opioids. Higher doses are needed only if an
inadequate
amount of the drug is given in the first place or if the pain itself
worsens with time.
Tolerance does develop to some of the common side effects of opioids,
including sedation, respiratory depression and nausea, although
constipation tends to persist as long as the drug is taken. But an
opioid
taken to relieve chronic pain does not block acute pain sensations that
might result, for example, from surgery or an injury. A broken arm or
gallbladder surgery will hurt just as if no opioid were being taken and
will require additional treatment with some other analgesic, Dr.
Schneider
said.
Of course, round-the-clock narcotics are only one aspect of proper
treatment for chronic pain that fails to respond adequately to lesser
drugs. As Dr. Schneider explained, chronic pain is "a primary disorder"
that can itself cause disabling complications, including difficulty
sleeping, muscle spasms and depression.
Thus, pain specialists commonly prescribe a low-dose antidepressant
like Elavil to promote sounder sleep, muscle relaxants and
anticonvulsants
to relieve spasms, anti-inflammatory drugs, full-dose antidepressants to
counter depression and an increase in physical activity to improve mood
and
reduce feelings of incapacity.
Patients may also be referred to psychologists for cognitive-behavioral
therapy, physiatrists (for exercises and pain-relieving injections),
physical therapists, hypnotists, biofeedback specialists and even
acupuncturists, Dr. Schneider said.
To help reduce the risk of drug abuse, Dr. Schneider and many other
pain specialists insist that before receiving opioids for chronic pain,
patients sign a "contract" that, among other things, insists that only
one
doctor and one pharmacy be used to provide opioids and that no change in
dose be made without prior consultation with the prescribing physician.
The contract also states that there will be "no early refills," no
matter what the excuse, and that patients must agree to undergo random
urine drug tests if the doctor suspects the drug is being abused.
CAPTIONS: Photo: Dr. Jennifer P. Schneider, a pain specialist in more
than
one way (she recently broke a leg), says pain is often undertreated.
(Norma
Jean Gargasz for The New York Times)
Copyright (c) 2002 The New York Times. All rights reserved.
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