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The Politics of Pain: The Controversy Surrounding Chronic Pain and Opioids

  [ 407 votes ]   [ 1 Comment ] • November 15, 2002

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 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, M.D., Gerard Malanga M.D., Scott Nadler DO, James P Mclean and Scott Millis, Ph.D. 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.

(c) Anne-Marie Vidal. Source:

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Article Comments Post a Comment

Joe Citizen
Posted by: JoeCitizen
Sep 13, 2012
Notwithstanding the ramifications and debates concerning euthanasia and whether it should be a liberty of personal choice or an issue of societal intrusion, I am convinced that we have another example of alleged social concern that is baseless in a society that purports itself a democracy with freedom of choice for its citizens. Have we not been bureaucratized enough? People these issues are the very reasons (or so we are told) that we fought World Wars. The freedom to drink, smoke, and eat ourselves to an addictive state that fosters all types of negative outcomes is at risk if citizens do nothing. Anybody who has suffered withdrawal from narcotic drugs understands that it is equally debilitating, dare I say horrific, as the pain of the malady that required taking the drug itself. So, when you are in a state of withdrawal and suffering additional distress, remember who put you there – your government agencies that want to protect you from yourself among other agendas, which include “pain and suffering”. That’s a legal term for any of the pain population that practice law. The fallout from this so-called “War on drugs” is that the warriors who dress up like terrorist (masks, etc.) and call their boss a Czar, has failed. Consequently, because of incompetence or failure (?), the Czar’s army is passing the buck to pharmacists, who are trained to know chemistry and its effects on biology, and trying to make pseudo-cops of them. Only in America could such a “keystone cops” approach to enforcement and/or method of operation be tolerated by its citizenry. Pain patients who are being denied a medication that was invented for severe pain need to contact their local Congressmen and get this issue on the ballot(s) so that the voters can exercise their alleged freedom(s). Also, it is more than alleged that laws (Federal, etc.) have been broken by the pharmacies who deny filling a prescription that meets legal criteria. Pharmacists need to get back to business and stop playing cop(s). The Pharmacies’ lobbyists are not fighting hard enough to prevent this tasking of mind reading and profiling customers, (following ambiguous rules & regs and other arbitrary and capricious policies ), i.e., having law enforcement responsibilities thrust upon them. In fact, the last time I remembered, profiling and discrimination (selective Rx filling) was illegal. As luck would have it, I understand that 2 stores in FL of a national or regional chain of pharmacies are losing the right to sell certain, if not all, pain meds. Now, understand what I just said, 2 stores that are legally in business to sell drugs (pharmaceuticals) of which pain meds (oxycodone, etc.) qualify are not allowed to sell what they are in business to do … . The problem was that the stores sold too much of the aforementioned pain medication; however, there was no mention whether the prescriptions met the legal dispensing criterion. I thought selling was the point in a free enterprise market (?) … .
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