Let's get serious about treating pain...good read

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Tuesday, January 17, 2006

Let's get serious about relieving chronic pain

The Roanoke Times

Patients with debilitating pain from chronic illness, accidents, surgery or

advanced cancer have long had problems getting adequate medication to

control their pain and make life worth living.

Now the federal government, and especially the Drug Enforcement

Administration, is working overtime to make it even harder for doctors to

manage serious pain, including that of dying patients trying to exit this

world gracefully.

In an article in the current New England Journal of Medicine titled " The Big

Chill: Inserting the D.E.A. into End-of-Life Care, " two specialists in

palliative care, Dr. Quill and Dr. Diane Meier, state that despite

some physicians' commitment to treat pain and despite the effectiveness of

opioid drugs such as OxyContin and morphine, " abundant evidence suggests

that patients' fears of undertreatment of distressing symptoms are

justified. "

They continue, " Although a lack of proper training and overblown fears of

addiction contribute to such undertreatment, physicians' fears of regulatory

oversight and disciplinary action remain a central stumbling block. "

Obstacles to relief

In addition to a case before the U.S. Supreme Court, v. Oregon,

that threatens to undermine Oregon's Death With Dignity Act, the DEA has

recently increased raids on doctors' offices, confiscating files and

arresting doctors on charges of overprescribing narcotics to patients who

are addicts or drug dealers.

Most of these physicians are compassionate people trying to help suffering

patients but are sometimes fooled by clever addicts, drug dealers or

undercover agents who fake their pain.

Should the court rule against Oregon, the DEA could turn to all physicians

whose patients die while getting prescribed opioids or barbiturates, even if

the drugs were administered only to relieve intractable pain, not to hasten

death.

Yes, there are bad apples among members of the medical profession. There are

some doctors who charge for medical exams they never perform and provide

phony patients with prescriptions for narcotics to feed their habits or sell

on the street.

But should all physicians be subject to intense scrutiny by the DEA and risk

arrest and prosecution, leaving legitimate patients to suffer intensely or

scramble to find other doctors willing to risk taking them on?

Doctors have no certain way to measure patients' pain other than to ask

them. Patients should be asked to rate their pain, say, on a scale of 1 to

10, with 10 being the most intense they can imagine. " Model Guidelines for

the Use of Controlled Substances for the Treatment of Pain " were established

in 1998, and every physician who prescribes narcotics should know them by

now. These guidelines emphasize that documentation is critical to proper

pain management.

Prescriptions for controlled substances such as narcotics cannot be refilled

automatically. When a patient asks for a new one, a well-documented

follow-up visit is necessary. The doctor should ask about the kinds and

amounts of painkillers being taking, side effects, performance of daily

activities and aberrant drug-related behaviors.

Dr. Schneider, a pain management and addiction medicine specialist

in Tucson, Ariz., gives this example: " Back pain today is 4 [on a scale of]

10, walks the dog 15 minutes daily, constipation is controlled with

Senokot-S, patient is on schedule with his meds. " She advises physicians,

" If a patient lies about his medical problems and turns out to be a drug

abuser, at least you've documented that you were acting in good faith. "

A fear of prosecution

The growing number of arrests of pain management specialists is exacting

high costs for patients, physicians and medical insurers. Some doctors order

costly but unnecessary diagnostic tests so they can show the DEA a reason

for prescribing strong pain medication.

Many doctors are simply unwilling to prescribe narcotics, no matter how much

a patient suffers. Ignorance, as well as a fear of the DEA, plays a role.

An addict uses a drug to get high, becomes tolerant and needs

ever-increasing amounts to maintain that high. Patients taking narcotics for

pain don't get high; they get relief from their pain, and when larger doses

are needed, it is usually because their pain has become more intense, as

often happens in patients with advanced cancer or degenerative diseases.

Physical dependence occurs in almost everyone who takes a narcotic for two

weeks or more. The body becomes adapted to the presence of narcotics (that

is, becomes physically dependent on them). A patient cannot go off them

abruptly without suffering serious withdrawal.

A gentle weaning process

I asked Schneider how to go off narcotics safely. She suggested cutting back

10 milligrams every three days (the exact amount would depend on the dose a

patient is on).

If at any point in the weaning process my pain became more intense, I was to

go back to the last dose, wait a week, then try to resume the weaning.

As I neared the end, the cutback was five milligrams every three days. Then

the dose was down to nothing, and no withdrawal symptoms, either.

Having heard only about those who, like Betty Ford, got hooked on

painkillers, many patients are afraid of becoming addicted if narcotics are

prescribed. But it is the rare patient who becomes addicted, and it is

nearly always someone with a history of addiction, typically to alcohol.

Proper pain management for dying patients can facilitate important

communication between patients and their loved ones and provide what most

people would call " a good death. "

" Pain is a common symptom in patients nearing the end of life, " with up to

" 77 percent of patients suffering unrelieved, pronounced pain during the

last year of life, " Dr. Moynihan wrote in The Mayo Clinic

Proceedings in 2003.

http://www.roanoke.com/extra/wb/wb/xp-48666

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