Myths Related to the treatment of pain.

Good Evening. Myths Related to the treatment of pain. My goal this evening is to give you an opportunity to understand some of the strongly held beliefs concerning pain treatment which have been shared by medical professionals and patients alike, and how these have contributed to poor pain management. I have given you a sheet with some statements about pain and pain treatment and I hope you have taken the opportunity to think about your agreement or disagreement with those statements. As I develop my presentation, you can assess your own views with those of medical professionals and patients. My interest in this policy area, developed following my appointment to the State Board of Medicine in 1995, leading to my opportunity to work on the development of national guidelines by the Federation of State Medical Boards for the use of narcotic analgesics in the treatment of pain, and later as a patient with chronic pain for about a two-year period. Through both these experiences, I have developed new insights into this problem and discovered many of my own false beliefs about chronic pain management and the use of opioid analgesics. Acute and chronic pain are public health issues. The International Association of Pain defines pain, as a sensory or emotional process, associated with tissue damage. Acute pain, such as that which we experience with trauma, alerts us to the presence of harmful or potentially harmful stimuli. Our rapid withdrawal response when we touch a hot utensil is a prime example. Such a reaction requires no conscious thought process and is protective. Chronic pain is being understood more clearly today as far more than a protracted version of acute pain. The repeated nerve stimulation, caused by chronic tissue injury, particularly when associated with inflammation, can become embedded in the nerves and spinal cord, like a memory, creating changes in the nerve pathways and creating an exaggerated response to those same pain signals. Patients who have suffered from uncontrolled pain, for months or years, often develop pain in areas well beyond the tissue or organ originally generating the pain. Physicians unfamiliar with this concept of neural memory may interpret their patient s pain complaints as psychogenic because it fails to conform to their preconceived concept of the nervous systems response to pain. 1

Instead physicians need to realize that the failure to treat chronic pain can result in physical, psychological and behavioral changes. In such situations, one can see decreased appetite, malaise, sleep disturbances and irritability, as well as, anger and depression. Pain is the most common reason that patients visit a physician. New pain complaints account for 40 million patient-visits annually. Each year, nearly 64 million people suffer from trauma-related pain. Chronic pain causes $4 billion in lost workdays, and as much as $65 million is lost as a result of diminished work productivity. The scope of the pain problem is huge. It is obvious to you that pain is also a common complication of acute and chronic diseases, or medical procedures. It has been documented that as many as 29 million people experience uncontrolled postoperative pain each year. Also, approximately 35 million people experience chronic headache and 16 million people have chronic back pain. Approximately 50% of patients with cancer report pain of at least moderate severity, and 46% of patients with cancer, report pain that cannot be managed with pain medication. Experts have come to recognize two basic types of pain, that related to tissue injury, with activation of the nervous system, called somatic pain, and that related to injury to the peripheral nervous system or brain, that may occur and continue without ongoing tissue damage, called neuropathic pain. It is important to remember that pain is a subjective experience that has both sensory and emotional components. There are several types of pain receptors found in nearly all tissues that convert noxious stimuli into an electrical impulse within the nerve that is interpreted as pain. One of the most common causes of pain is inflammation of tissues. Narcotic analgesic agents, often called opioids as a class of drugs, can have peripheral sites of action in the presence of inflammation. For instance, opioid receptors can be found on cells that respond to the tissue site of inflammation. The barriers standing between patients and effective relief of pain are largely intrinsic to the medical profession, and have been highlighted by a number of studies conducted through the 2

early to mid 1990 s. Those studies demonstrated (1)a common lack of professional knowledge about pain relief strategies, (2)a failure to make pain relief a priority and (3)an exaggerated concern about addiction, adverse side effects and regulatory scrutiny by licensing boards and the Drug Enforcement Administration. Pain treatment, or more exactly its undertreatment, regularly finds its way into the popular press. In a January 1999 New York Times Editorial, a Manhattan attorney suffering from chronic recurrent pancreatitis wrote after 23 years and close to $100,000, traditional medicine has been unable to treat or find a cause for my illness. Each time Mr. Felber has an attack of abdominal pain, he ends up in the emergency room, in acute pain for hours, before finally, he is administered morphine or another opioid for him the only class of drugs that will bring pain relief. Several times a year, Mr. Felber experiences one of the primary barriers to effective management of chronic pain physician reluctance to provide narcotic analgesics to be dispensed by a community pharmacist, and administered by the patient at home. In the past, Mr. Felber has been given fewer doses than the doctor ordered and less potent medications that have been substituted without Mr. Felber s knowledge, or a consultation with his physician. Well known pain specialists such as Dr. Russell Portenoy are beginning to get out the message to health professionals that opioid analgesics long considered taboo for the treatment of chronic pain are winning approval for use with appropriate patients. He points out to medical professionals that these medications can be given for indefinite periods; their effectiveness may never decline; the side effects may be minimal or absent altogether; and, that the risk of true addiction associated with chronic opioid use is greatly overstated. Let me tell you about Marlene. Marlene s days never seem to end. After a night of fitful sleep, the 70 year-old woman rises haltingly and makes her way to her kitchen. If her back is not hurting too terribly, she feeds the cat. Most days, however, the reaching and bending, required for this task are too strenuous, and the cat has to wait for Marlene s home health aide or daughter. Marlene s chronic back pain has not lessened in 12 years of surgical procedures, physical therapy, anti-inflammatory drugs, 3

acupuncture and spiritual healers. In that time, Marlene s pain has alienated her husband, who now lives elsewhere, and two of her three grown children. Her physicians doubt that her pain will ever get better. Yet they have ignored the recommendation of a local pain specialist to prescribe opioid therapy to Marlene. When will the profession recognize the role of opioids in chronic back pain? That s a question that more and more medical professionals are asking, as the media focuses new attention on the fact that back pain remains poorly controlled. We should note that: Compensation for low-back pain and injuries now costs US business and industry 60 billion dollars a year. In the United Kingdom back pain resulted in 52 million lost work days; there, statistics show that if a person takes off work for back pain for more than six weeks, he only has a 50% chance of ever returning to work. Back pain is the most common cause of disability among people over the age of 45 years. As with every other medical issue, such cases, like these of Mr. Felber and Marlene, are finding their way increasingly into courts and to the Boards of Medicine, for review. Let me tell you about Mr. Bergman. Early in 1985, 85-year old William Bergman came to the emergency room of Eden Medical Center in Castro Valley CA in severe pain. The Vicodin (a mild narcotic analgesic agent) that had been prescribed for him was clearly no longer adequate. He was promptly given morphine by the ER physician, which provided him with welcome relief. Because of a long history of smoking, advanced lung disease, and a recent history of weight loss, Mr. Bergman was admitted to the hospital under the care of Dr. Chin. Ostensibly based on concerns that Mr. Bergman could not tolerate morphine because of his lung disease and respiratory depression, Dr. Chin ordered the patient be given 25-50 mgm of Demerol, as needed for pain,[a dose which is known to be very minimal and often ineffective]. During the 5-day hospitalization, according to the charted nurse s notes, Mr. Bergman s pain ranged from 7-10 on a scale where 10 represents the most severe pain one can imagine. However, both Dr. Chin and the nurses who cared for Mr. Bergman denied that he experienced severe unrelieved pain. According to the nurses, whenever Mr. Bergman rated his pain in the 7-10 range, they administered Demerol according to Dr. Chin s standing order and Mr. Bergman was made more comfortable. The reason low pain levels never appear in the hospital record, 4

the nurses insisted, is that it was not their practice to chart pain levels when they were low. In his sworn deposition, Dr. Chin acknowledged that he pays no attention whatsoever to nursing notes that purport to chart pain levels based on a 10-point scale. His approach to pain assessment is to ask patients, in the course of making rounds, how they are feeling and to observe their demeanor. If the patient does not say he is in severe pain, and if the patient is not writhing in or otherwise physically exhibiting significant pain or discomfort, then he assumes either that the patient has no pain or that it is well controlled. Mr. Bergman s family insisted that when they visited him in the hospital, they often found him to be in severe pain and that it was often necessary to prevail upon the nurses to administer additional pain medication. Mr. Bergman, they affirmed, like many men of his generation, was not one who felt comfortable acknowledging weakness or complaining of physical pain. Mr. Bergman was convinced that he had lung cancer based on initial x-ray studies although no specific tissue diagnosis had been made. He refused further diagnostic studies and requested to be discharged home to die as his wife had done with lung cancer two years earlier. Dr. Chin indicated to Mr. Bergman, that without a tissue diagnosis he was not willing to treat him as a patient who was dying with lung cancer. Dr. Chin was prepared to discharge Mr. Bergman from the hospital with a prescription for oral Vicodin, the analgesic that had failed to relieve his pain prior to hospitalization, even though the nurses were charting his pain as 10/10 on the day of planned discharge. Dr. Chin agreed to give Mr. Bergman a shot of Demerol and sent him home on a narcotic patch, an analgesic approach that may require several days to achieve pain control. When Mr. Bergman was visited by the hospice nurse at home shortly after his discharge, she found him to be in significant pain. The nurse was unable to convince Dr. Chin to prescribe morphine for Mr. Bergman s pain, so she secured such a prescription from another physician in the community. Once he began to receive morphine, his pain was easily brought under control. Mr. Bergman died of advanced lung cancer 3 days after his discharge from the hospital. 5

While Mr. Bergman s case may be an extreme example, it is not rare, and, increasingly complaints are being filed with State Licensing Boards claiming medical negligence for failure to appropriately treat patients pain. Mr. Bergman s family did complain to the CA State Board of Medicine who heard conflicting testimony from several experts. For whatever reason, the Board chose not to take disciplinary action against Dr. Chin. One observer felt that the Board did not feel that one isolated instance of poor pain management constituted a basis for disciplinary action. It should be noted that other medical boards have take action in similar circumstances. Mr. Bergman s family subsequently filed a civil action against Dr. Chin and the hospital. The hospital settled with the family out of court but a judgement of 1.5 million dollars was assessed against Dr. Chin for gross negligence leading to elder abuse. While the treatment of cancer pain is a problem, there may be even greater problems with other forms of non-cancer chronic pain as demonstrated by Mr. Felber s and Marlene s case histories. In a survey of 2000 nursing home patients, ¾ had chronic pain and nearly ½ of these had had no assessment of the pain within the previous 3 months. Most of these were receiving no therapy, medication or otherwise, for their pain. Of those receiving pain medication, 2/3 were receiving short acting drugs administered on an as needed basis, a therapeutic approach that is well recognized as ineffective treatment of chronic pain. Demerol, which may be very effective for the treatment of acute pain, is frequently prescribed for the treatment of chronic pain. This is inappropriate, because one of its metabolites builds up over time and is very toxic. In an opinion survey of physicians conducted in the year 2000, 1/3 physicians felt that narcotics should be limited to the treatment of severe intractable pain. One-third felt that the use of narcotics for non-cancer pain of any type was illadvised. Two-thirds of those surveyed felt there was a legal limit to the number of narcotic tablets that could be prescribed to a patient. One-fourth of the physicians noted that it was their practice to limit the number of pills they list on a prescription to avoid investigation by their licensing board or DEA. 6

Patient s attitudes also effect the ability to treat chronic pain. Many patients desire to be seen as non-complaining by their physician and therefore do not bring up or adequately describe their pain symptoms. Some patients have concerns about taking strong pain killers, even for a limited time. Some patients feel that if they focus on their pain concerns, that this will take their doctor s focus away from their primary disease process or problem. Many patients express concerns about becoming hooked or addicted to narcotic analgesics. Health care professionals and patients alike often lack an accurate understanding of drug tolerance, physical dependence and addiction. Confusion about these conditions results in unfounded fears in both patient and physician regarding the use of opioids. This, in turn, leads to suboptimal use of opioids, particularly in the treatment of chronic pain. Addiction is a chronic, neurobiological disease manifested by behaviors including impaired control over drug use, compulsive use, continued use despite harm and craving. There is no substantive data that the treatment of chronic pain with opioids leads to addiction. Physical dependence and tolerance are physiologic outcomes that should be expected in patients receiving long-term therapy with opioids and should not be confused with addiction. Physical dependence is a state of adaptation that can be manifested as a withdrawal syndrome. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug s effects over time (i.e., a desired effect such as pain control or a side effect such as sedation). So enough bad news, what is happening to change this and what remains to be done? With a significant push from government standard setting groups and private accrediting agencies, the profession has begun a multidisciplinary effort to provide better care. My own assessment is that we are doing a better job of asking patients about pain during most acute care encounters [the concept of pain assessment as the fifth vital sign of the VA] and a better job of treating acute pain with appropriate use of patient controlled analgesia and follow-up assessments to gauge the effectiveness of pain control efforts. Medical Schools and residency training programs are including these issues in their 7

curricula and board examinations are including assessment of this cognitive area in their testing designs. Where we clearly still have much work to do is to get the word out to all practicing physicians, particularly those that potentially can improve the care of patients in nursing homes and those with chronic pain. In 1998, The Federation of State Medical Boards adopted guidelines for effective pain management that were developed on the basis of quality standards from governmental agencies and national pain professional organizations. These guidelines or a variation on them have been accepted by most of the 70 state medical boards. I would say that based on my experience with our own State Medical Board, that only the most egregious of actions are brought to the Board for disciplinary action and I have seen no complaints of undertreatment presented to the board. A nationally published consensus statement on the use of opioids for the treatment of chronic pain lists eight key points that are a reasonable roadmap of ongoing and for continued action. (1) In the US pain management is becoming a higher priority (2) Opioid pain management is in a critical phase of assessment (3) Non-cancer pain is often inadequately managed; opioids should be included in the list of potential treatment strategies (4) Commonly held assumptions about addiction, respiratory depression and side effects, tolerance and drug diversion need to be modified so that misconceptions do not impede effective opioid use (5) Evolving public policy on opioid use indicate a growing recognition that the use of opioids for the relief of chronic pain is a legitimate medical practice (6) There is a continuing need to promulgate accepted practice principles to physicians and regulators (7) Opioid prescribing requires good medical practice, no more and no less, to include proper patient evaluation, an 8

individualized treatment plan, consultation with pain specialists as needed, periodic review of treatment efficacy, and proper medical record documentation I have focused my presentation on myths related to the medicinal use of opioid agents because, as a therapeutic strategy, they can be very effective in the management of chronic pain and allow the patient to function normally. Effective pain management may require a multimodality approach that should not be solely limited to medications. I would be pleased to entertain comments or questions at this point. 9