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The Politics of Pain—
The controversy surrounding Chronic Pain and Opioids
By Anne-Marie Vidal
Anyone who lives with chronic pain is acutely aware of many physicians’
difficulty in coming to terms with prescribing adequate pain
medication. For us, this is more than a research or academic issue. We
know first hand that pain is debilitating and can erode our standard of
living and ability to earn an income. Inadequately treated chronic pain
patients have difficulty functioning and poor attendance records at
work. Indeed, the cost of chronic pain in the US is estimated at $40
billion annually. Yet, 50 million Americans with chronic pain are likely
to be under treated.
Events of the past year make it hard to believe that this is or an
oversight. In the spring of last year both the World Health Organization
(WHO) and the Joint Commission on Accreditation of Healthcare
organizations (JCAHO) issued statements on the far-reaching effects of
pain and the incapacity it causes. The WHO statement said in part:
“Persistent pain is a major public health problem” accounting for
“untold suffering and lost productivity around the world.” A study of
5447 individuals across 15 countries was noted. In reviewing the
relationship between pain and well-being, it was concluded “those with
persistent pain were over four times more likely to have an anxiety or
depressive disorder than those without pain. This association was
observed in all study centers, regardless of geographical location.
Other studies have suggested that pain intensity, disability, and
anxiety/depression interact to develop and maintain chronic pain
conditions.”
Within weeks, the JCAHO addressed the suffering of millions of Americans
due to chronic pain. Their June 2001 statement followed “The Leadership
Summit on Pain Management: A Multidisciplinary Approach to Good
Practices” and said in part that “excessive concerns about addiction and
the side effects of pain medicines often result in reluctance to
prescribe appropriate analgesics with the consequence that patients
suffer needlessly from pain.”
These declarations were almost immediately over shadowed as media
attention was shifted to substance abuse when a Newsweek cover story
trumpeted the new preferences of partying substance abusers,
highlighting Oxycontin and Vicodin. This story was followed within 10
days by a headline story on CNN that was carried in the press
nationally. Neither story mentioned that substance abusers doses of
Oxycontin or Vicodin are often three or four times the amount prescribed
therapeutically.
The popular conception that painkillers are addictive or the need of the
self-indulgent began. Oxycontin became an unmentionable in doctor’s
offices, pain clinics and patients found themselves under new types of
scrutiny. In support groups, the subject of pain and deteriorating
functioning was discussed. Unable to concentrate, patients related
stories of mishaps that ranged from overdrawn household accounts to
small kitchen fires. One patient told me emphatically, “Suicide
shouldn't be our only choice for pain control."
While dramatic, this remark is not over statement. Vermont stopped
paying for Oxycontin for certain welfare beneficiaries. West Virginia's
attorney general initiated legal action against Purdue Pharma LP the
maker of Oxycontin, alleging aggressive and irresponsible marketing
tactics in another state, patients were finger printed when having
their prescriptions filled.
A cyber acquaintance, a patient in Ohio, insured under a private
disability plan received notice last summer that her pain medication,
Oxycontin, would no longer be covered under her medical plan. The letter
stated the drug was addictive and implied that her use of the drug was
recreational and not rehabilitative. This patient acted quickly and
took her insurance company to court and while successful in her right to
have her pain medication as a benefit of her policy, the energy and
delay in receiving her medication was burdensome.
There is an enormous difference between using Opioid medications to be
able to function and using them to escape reality. According to
National Institute of Health (NIH) statistics, less the a tenth of one
percent of pain patients become addicts. Yet most of us will at a
minimum face severe scrutiny if not outright derision if we ask a doctor
for Opioid medications early in our treatment. There are also a variety
of opioid medications, some with much more severe side effects than
others. For instance short term acting opioids require repeated doses
during the day; where as a longer term acting drug, the patient may need
only one or two doses a day.
Gerald M. Aronoff, M.D, the medical director of the North American Pain
and Disability Group in Charlotte, N.C., made a clear distinction
between addiction and pain control. “A person's functioning improves
with successful pain relief,” he told Psychopharmacology Update.
“When the line is crossed to addiction, functioning is not enhanced; it
suffers,” he said.
An April advisory on Oxycontin from the Center for Substance Abuse
Treatment (CSAT), the government's breaking-news advisory for treatment
professionals, added illumination on the distinction. "Addiction is
characterized by the repeated, compulsive use of a substance despite
adverse social, psychological and/or physical consequences. Addiction is
often (but not always) accompanied by physical dependence, withdrawal
syndrome and tolerance."
Dr. Aronoff also strongly supports educating health care providers at
all levels as well as the public about pain management, drug use and
addiction. He believes that the ability to prescribe Oxycontin should
not be limited to pain management physicians.
The story of pain patient Marie Dabrowski that appeared at Salon.com
April 4, 2002, dramatized the dilemma of patients who are chronically in
pain. Titled “No Relief” the article by Damien Cove chronicled the
misunderstanding that occurs when the war on drugs is aimed at pain
patients. Ms. Dabrowski, who has fibromyalgia, had found long sought
release from hurting in the form of treatment with Oxycontin. However in
March of this year, her doctor, withdrew the medication. Ms. Dabrowski
stated that the change had nothing to do with callousness or lack of
concern, but with the fact that a proposed Virginia law designed to
intensify examination of physicians who prescribe the drug frightened
the doctor. In the end, she said, it was the likelihood of police
questioning that pushed her doctor over the edge. Ms. Dabrowski stated
her fears that the those chronically in pain could also be pushed beyond
their endurance, “if the pain comes back they're going to commit
suicide."
Doctors are faced with a quandary in prescribing these medications that
go far beyond the exposure of the controversy surrounding these
medications. State medical boards, professional associations and the
Drug Enforcement Agency monitor prescriptions. A doctor seemingly
dispensing too many narcotics risks possible investigation by these
agencies. This type of pressure and possible scrutiny as a drug dealer
understandably results in many doctors choosing to prescribe as few
narcotics as possible.
Purdue Pharma announced that Oxycontin would be re-constituted into a
form that could not be crushed and used recreationally, nothing has been
heard on that topic since the initial announcement. However, the
controversy over pain medication is unlikely to end there.
When women, minorities and the elderly seek treatment for enduring pain,
their needs are not received as well as the requests of white males
contended a NY Daily News editorial column by Lenore
Skenazy, “Pain and Prejudice” in February 2002. Ms. Skenazy’s column
stated that research is finding that” all too often, women, children,
the elderly and minorities are just not given enough painkillers. The
limited population receiving pain treatment, the editorial states, is
middle aged white males;” demographics that happen to reflect the
population of doctors.
Ms. Skenazy quoted Dr. Richard Payne, chief of pain and palliative care
at Memorial Sloan-Kettering Cancer Center In New York City. He stated
that "as in the rest of society, people in health care look at each
other through a lens of race and make assumptions."
While these assumptions may be unconscious, they are damaging. The
rationales run something “like black men are more likely to be addicts,
so maybe that guy's faking his tears to get a fix.” Other assumptions
are that old people whine, kids don't feel much pain and — especially —
that women are complainers the column stated "The stereotype is that
women are 'hysterical,'" says Payne's colleague, William Breitbart,
chief of psychiatry at Sloan-Kettering. "So if they say their pain is an
8 or 9 [on a scale of 1 to 10], the doctor assumes it's really a 4 or
5."
When my own request for pain medication was turned down after my
painful experience of Cox-2 inhibitors and NSAIDS, the doctor sited the
issue of substance abuse among minorities. I was acutely aware that the
doctor stopped seeing me as an intelligent, educated patient, and
suddenly saw my demographics. I am not alone in this experience. A
fellow patient-friend and advocate who happens to be African American
told me the following: “I went to the same doctor as two friends who
also had Fibromyalgia. One was Hispanic, her pain was treated with
Tylenol-3; the other was Caucasian, she received a prescription for
Oxycontin. I was told to go home and take two aspirin.”
In an era of managed care, when the cost of any health condition
immediately is assigned a “dollar value” for cost of treatment and to
the economy, is real pain management simply too expensive? Genuine pain
management requires physician vigilance, follow-up and assessment. Some
academic journals outline a comprehensive 8 step approach which while
flawless in rationale and presentation is hardly realistic for the
physician who must see 6 to 8 patients per hour.
Yet, there is evidence that chronic opioid therapy can be successful in
maintaining patient functioning. A study in the March/April 2002 issue
of Practical Pain Management “Chronic Opioid Treatments” was
authored by a team including Stephen Roman, MD, Gerard Malanga MD, Scott
Nadler DO, James P Mclean and Scott Millis, PhD. Their study reviewed
the use of opioids to treat chronic pain; keeping in mind that
employment status is often regarded as indicator of functioning. They
selected working patients under 65 with chronic non-malignant pain for
management in this program. The program was multi-disciplinary
involving, physiatrist, nurse, psychologists, acupuncturists and
physical and occupational therapists to work with the 57 participants
who were accepted for the study. These patients had not been previously
maintained on opioid medications. A variety of these were used during
the program including the transdermal fentanyl, oral codeine, oxycodone,
hyrdrocodone, meperidine, and combinations of aspirin or acetaminophen
with codeine.
The conclusion indicated that patients were able to maintain employment
or return to work and maintain family responsibility. As hypothesized,
there was no relationship between opioid use and employment status. Yet
there is a negative relationship between chronic pain and unemployment.
Perhaps the biggest challenge for patients with chronic conditions,
advocates and practitioners is pain management. We live in an era where
our right to adequate pain relief is recognized but continuously
challenged. The responsibility for demonstrating careful use of opioid
medications is ours, and the continual need to fight for our right to a
pain free life comes has accompanied it.
Copyright Anne-Marie Vidal, 2002
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