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.