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Medical management of pain has come a long way since the days when terminal cancer patients were forced to spend their last days in tortuous agony, and postoperative patients were told to "tough it out" because physicians feared the side effects and dependency associated with the use of opioids — strong narcotic analgesic drugs synthetically derived from opium.
By the early 1990s, progressive pain management specialists had managed to convince most doctors — as well as the public and federal government — that opioids were the only way to sufficiently treat severe pain.
However, some former advocates of expanded opioid use are warning that prescribing has gotten out of hand — particularly for patients whose pain is chronic and not the result of a terminal illness or sudden, acute injury.
"The pendulum swung all the way in the other direction a few years ago," notes Steven D. Feinberg, MD, a physician and pain management specialist with the Bay Area Pain Program in Los Gatos, CA, and former president of the American Academy of Pain Medicine. "It has come to everybody and their brother writing prescriptions for opioids. This is good in some cases. But as a chronic pain doctor, I started seeing a lot of people coming into my office who were literally narcotized. I have a big problem when someone walks into my office on massive amounts of medication but they don’t seem any better."
In the 1960s and 1970s, prescribing dependency-producing drugs to treat pain was unheard of for any reason, says R. Norman Harden, MD, director of the Center for Pain Studies at the Rehabilitation Institute of Chicago and an associate professor in the department of physical medicine and rehabilitation at Northwestern University Medical School.
"There were these huge concerns, probably inappropriate concerns on behalf of the medical community, about dependency and diversion and abuse and addiction," he says.
In the 1980s, with the advent of the government’s "war" on the use of illegal drugs, many doctors became even more nervous about using opioids — most of which are Schedule I or II controlled substances. The Drug Enforcement Agency also got into the act by monitoring physicians’ prescribing practices to detect practitioners who were more "liberal" prescribers than their peers.
State medical boards suspended or revoked the licenses of physicians deemed to be prescribing too many pain medications, and subpoenas sometimes tied up a physician’s medical records for years.
By the late 1980s and early ’90s, however, pain management specialists were beginning to push for a more balanced and humane approach to treating pain. At the same time, research was helping clinicians better understand the issues of tolerance and dependency vs. abuse.
"People were really upset that we had good, strong analgesic drugs, yet people with cancer were dying in agony," Harden continues. "My first involvement with this controversy was as an advocate of patients being able to get the strong narcotics who needed it."
To Harden, the people who need the drugs are people with cancer and other life-threatening conditions who are terminally ill and in excruciating pain. Concerns about dependency and increasing tolerance are, understandably, secondary to the need to treat these patients’ pain, he says.
And, patients who have recently had major surgery are good candidates for these drugs, he adds.
"Interestingly, people who had just had operations — post-op patients — just had to tough it out because doctors were not prepared to give the appropriate analgesic medication," he explains. "These drugs certainly have some issues that surround their use, but ethically, humanitarianwise, we just have to take care of these people and not let them suffer."
Increasingly, however, some pain specialists and general practitioners are using opioids to treat all kinds of pain, including pain from chronic, ongoing, but non-life-threatening conditions.
People with chronic lower back pain or repetitive strain injuries are often given strong narcotics to manage their pain, even though they will have to live with their condition — and the medical management — for years, possibly the rest of their lives, Harden says.
"The big controversy comes in when someone says, Well, a patient came in to see me, and I put them on Motrin and it didn’t work, so the next thing I tried was OxyContin,’" he explains.
Physicians have many other options in the treatment of chronic pain, all of which should be attempted before resorting to powerful narcotics as therapy, Harden believes. "There are literally hundreds of other things we can do — we have nonopioid pharmacology, not to mention the nondrug treatments we use. We have physical therapy, occupational therapy, psychotherapy, recreational therapy, relaxation and imagery techniques, and biofeedback. Everyone knows that the most best way to treat chronic pain is interdisciplinary pain management."
At the heart of the controversy is a dispute between physicians who feel it is their responsibility to completely stop the patient’s pain by whatever means necessary, and those who feel it is their responsibility to treat the underlying condition — if possible — and help patients learn to manage their condition and their pain level so that they can comfortably continue their lives, Harden says.
"My contention is that, yes, it is our responsibility to stop the patient’s pain, but that doesn’t necessarily mean bathing them in morphine sulfate," he adds. "If you have young people who have to get on with their lives, and they have a chronic condition, it is inappropriate to use high-dose narcotics, except as a last resort."
Patients who use opioids will develop increasing tolerance to the drug, meaning that higher and higher doses will be required to achieve pain relief. That issue alone makes the use of opioids in this population, questionable, Harden claims, because it is unlikely that a patient could continue to take the drug for the rest of his or her life.
However, levels of tolerance and ability to function vary from patient to patient, and some chronic pain patients are able to use higher doses of opioids and still function, counters Feinberg.
"The problem with opioids is that many people, not all, develop tolerance — the same amount gives you less relief, and you need more," he explains. But there really are people out there on fairly decent quantities of this stuff who can function fairly well."
Tolerance issues aside, placing a patient on high doses of narcotics may essentially disable them, which violates the physician’s edict to "first, do no harm," Harden says.
In addition to the problem of increasing tolerance, narcotic use, particularly in higher doses, can cause significant side effects, such as diminished cognitive functioning, drowsiness, constipation, and impaired vision.
"If you commit to using them, you are committing your patients to a life of significantly reduced function," Harden says.
No one, including serious advocates of aggressive opioid therapy, would want someone on OxyContin to drive a school bus, he says, by way of example. "But, what about all the other cars coming down the road in the opposite direction?" he says. "Those drivers may be on OxyContin, too. What’s the deal? Are we going to say that everyone on OxyContin should surrender their driver’s license?"
Opioid medications are not a panacea, even for cancer pain, adds Harden. Studies have shown that 35% of patients do not respond to opioid drugs. And an estimated 40% cannot tolerate the drugs — meaning they reject their use because they find the side effects unacceptable, he states.
Recent research has also called into question opioids’ effectiveness in relieving certain kinds of chronic pain, says Feinberg.
"As we are doing more research, we are realizing that for nociceptive pain, which is tissue damage, opioids can be very effective," he explains. "But for neuropathic pain, they are of only questionable benefit."
Managed appropriately, people with tissue damage can be placed on opioids and do quite well, Feinberg adds. But it is important to monitor how the patient is functioning and not just whether the patient reports that the pain has gone away.
"Remember, we are looking for two things: pain relief — actually, pain reduction is a better way to put it — and increased functioning," Feinberg says. "If someone comes to me and says, I have all of these drugs, but I am in bed all day long,’ I have trouble accepting that. I ask patients to show me how the medicine is making a difference in their life, not just that they feel better."
Opioids are a powerful — and necessary — tool for pain specialists to have at their disposal, say both Feinberg and Harden. Neither physician claims that the drugs should never be used to treat chronic pain.
But, says Harden, physicians must be willing to try other options first and use opioids in these situations only as a last resort. And these patients should be closely monitored to ensure that the medications designed to ease their suffering don’t contribute to more suffering in the long term.
The following articles may be helpful in examining the issue of opioid therapy for chronic pain: