Perspectives in Intractable Pain Management:
An analysis of current divering viewpoints
Kristin Bundy
For the National Foundation for the Treatment of Pain

 

Introduction

 

Across America, two opposing attitudes or paradigms of thinking currently exist in regards to the medical management of intractable pain. Empirical, long-range medical research has brought new light into the darkness of the Old Paradigm. However, despite the studies that support the New Paradigm, millions of people in our country continue to suffer needlessly because safe, medical treatment is denied to them by regulatory agencies and healthcare professionals. The Old Paradigm ignores three decades of international studies that support opioid pain treatment in cancer pain patients and severe intractable pain patients. An important goal of the National Foundation for the Treatment of Pain is to make public this new information that will bring the Old Paradigm thinking into the New Paradigm.

The Old Paradigm believes:

• It is not safe or prudent to prescribe pain medication on a continual basis.
• Opioid pain medicine is addictive and can cause long-term damage to internal organs.
• Pain patients should be tough and learn to live with pain.
• When pain patients continue to ask for increased pain medication, they are exhibiting addictive behavior.
• Physicians who prescribe pain medicine are no different than illicit drug dealers and should be treated as such.

The New Paradigm knows (supported by three decades of empirical medical research):

• Opioid pain treatment is safe and effective when monitored by licensed physicians.
• Less than 1% of chronic pain patients become addicted or experience long-term physiological damage as a result of prolonged, controlled opioid pain treatment.
• When pain patients receive adequate pain treatment that relieves their chronic pain and associated depression, patients can lead relatively normal, productive lives. Their friends and families frequently give positive reports of an increased "quality of life," previously thought impossible.
• When pain patients continue to ask for increased pain medication, they are not addicted but experiencing increased pain. Once patients receive adequate doses of appropriate pain treatment, patients stop asking for increased levels of medication.
• There is a world of difference between licensed medical professionals who prescribe pharmaceutical drugs for legitimate pain patients in a medically controlled environment and illicit drug dealers who sell drugs in an uncontrolled, nonmedical environment.

"Perspectives in Intractable Pain Management" will show you how the Old Paradigm continues to influence many healthcare perspectives despite overwhelming evidence and medical association endorsements that support the New Paradigm. Also, we will present you with documentation and clinical studies that support adequate pain management and the steps that are being taken to move the thought processes from the Old Paradigm to the New.

 

 

Definitions and Background Information

 

What is intractable pain?

Intractable pain is a pain state in which the cause of the pain cannot be removed or otherwise treated and which, in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible, or none has been found after reasonable efforts including, but not limited to, evaluation by the attending physicians and surgeon and one or more physicians and surgeons specializing in the treatment of the area, system, or organ of the body perceived as the source of pain

What are the ailments often associated with intractable pain?

The following is a list of ailments that may result in intractable pain:

• Lower back pain
• Cancer
• Severe burns
• Tension and migraine headaches
• Arthritis
• Myocardial ischemia
• Renal colic
• Gout

What is the recommended treatment for severe intractable pain?

The recommended treatment for severe intractable pain is opioid therapy. Opioids are classified as drugs that are either natural derivatives or synthetic forms of opium.

Examples of opioids are:

• Morphine
• Hydromorphone
• Oxycodone
• Codeine
• Meperidine
• Methadone
• Levorphanol
• Fentanyl
• Propoxyphene

Who is effected by intractable pain?

Thirty-four million Americans suffer from intractable pain every year. What’s even sadder is that there are medications available that can relieve their pain, but certain barriers created by societal stigmas and taboos continue to block pain patients from receiving the relief they need.

What’s the problem?

Although opioids have been recommended for moderate to severe pain by pain researchers over the past three decades, five audiences—governments, state medical boards, physicians, patients, and insurance companies—have perpetuated the old paradigm in thinking that opioids taken for intractable pain treatment are unsuitable at high dosage levels and for an extended period of time.

The new paradigm in thought advocates for the use of opioids for intractable pain by gearing dosage levels and treatment durations specific to the levels of pain experienced by each individual patient. By allowing physicians to work with their patients to determine the appropriate pain treatment for each case, more patients will be adequately treated. Once adequately treated, most patients regain a healthy quality of life.

Review each audiences’ perspective of pain management and the updates in pain management to understand why the old paradigm continues to persist and to discover what measures are being taken to advance into the new paradigm of accepted opioid treatment for intractable pain.

 

 

 

Governments' and State Medical Boards' Perspectives

 

Three layers of governmental authority prepare laws and guidelines that supervise availability of prescription drugs:

1. International treaties
2. Federal laws and regulations
3. State laws and regulations

Regarding opioid use for intractable pain, international treaties and federal laws recognize the necessity of balance between providing adequate amounts of opioids for intractable pain and controlling drug abuse.

State laws, on the other hand, tend to place additional restrictions upon opioids to control drug diversion (using prescription drugs for recreational use); however, the restrictions usually interfere with intractable pain patients’ receiving adequate amounts of opioids for pain relief.^1,2 The factors that contribute to states' interfering with adequate opioid treatment are:

1. ambiguously defined terms for addiction
2. opioid dosage unit limitations
3. multiple copy prescription programs
4. electronic monitoring systems
5. falsely perceived illegality of opioids for intractable pain

Turning point for patients and model guidelines

 

Reference List

1. Joranson DE. Federal and State Regulation of Opioids. J Pain Symptom Manage. 1990;5(1):S12-S23. Available at: http://www.medsch.wisc.edu/painpolicy/publicat/90jpsmf.htm
2. Joranson DE, Gilson A. Controlled Substances, Medical Practice, and the Law. In: Schwartz HI, ed. Psychiatric Practice Under Fire: The Influence of Government, the Media, and Special Interests on Somatic Therapies. Washington, DC: American Psychiatric Press; 1994:173-194.
3. Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven; 1989:213-231.
4. Single Convention on Narcotic Drugs, 1961. UN Sales No. E.77.X13, 1977. Cited by: Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven; 1989:213-231.
5. Commentary on the Single Convention on Narcotic Drugs, 1961. UN Sales No. E.73.XI.1, 1973. Cited by: Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven; 1989:213-231.
6. Morgan JP, Kagan DV, eds. Opiophobia in the United States: The Undertreatment of Severe Pain In: Society and medication: conflicting signals for prescribers and patients. New York, NY: D.C. Heath and Company; 1983;chap 24.
7. Melzack R. Tragedy of Needless Pain. Sci Am. 1990 Feb;262(2):27-33.
8. Controlled Substances Act, 21 USC. §812 (1970).
9. Code of Federal Regulations (Food and Drugs), 21 USC. §1300-13161 (1987). Cited by: Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven; 1989:213-231.
10. United States Department of Justice, Drug Enforcement Administration. Physician’s Manual. Washington, DC: GPO; 1987.
11. Joranson DE, Cleeland CS, Weissman DH, Gilson AM. Opioids for chronic cancer and non-cancer pain: a survey of medical board members. Fed Bull. 1992;79(4):15-49.
12. Pain Killer [transcript]. "60 Minutes." CBS television. May 25, 1997.
13. United States Department of Justice, Drug Enforcement Administration. Multiple copy prescription programs resource guide. Washington, DC: GPO; 1987. Cited by: Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven; 1989:213-231.
14. Finkelstein KE. Deadly Morals. Playboy. 1997;44(8).
15. Sigler KA. Effect of triplicate prescription law on prescribing of Schedule II drugs. Am J Hosp Pharm. 1984;41:108-111.
16. Sullum J. No Relief in Sight. Reason. 1997;28(8). Available at: http://www.reasonmag.com/9701/fe.jacob.html
17. American Society of Addiction Medicine. Public Policy Statement on Definitions Related to the Use of Opioids in Pain Treatment. Available at: http://www.asam.org/ppol/paindef.htm
18. Spanos A. Opioids for noncancer pain: from controversy to consensus. Int J Pharm Compounding. 1998;2(2):106-108.
19. Wastila LJ, Bishop C. The influence of multiple copy prescription programs on analgesic utilization. J Pharm Care Pain Symptom Control. 1996;4(3):3-19.
20. Dunbar SA, Katz NP. Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. J Pain Symptom Manage. 1996;11(3):163-171.
21. Joranson DE, Gilson AM. State intractable pain policy: current status. APS Bull. 1997;7(2):7-9.
22. California Medical Board. A statement by the medical board: Prescribing controlled substances for pain. Fed Bull. 1994;81(3):203-205. Available at: http://www.sonic.net/daltons/melissa/calmed1.html

Healthcare Professionals' Perspective

 

The process of intractable pain relief begins with mild analgesics, such as acetaminophen, aspirin, or salicylates, and gradually proceeds to more potent analgesics, including opioids, as pain persists. Most intractable pain patients who require opioids for pain relief receive inadequate pain treatment because clinicians following the Old Paradigm:

• fear addicting their patients^1-5
• lack the knowledge of opioid pharmacological effects^1,3,4-6
• fear state medical board/Drug Enforcement Administration (DEA) investigation^2,3,7-10

For safe, effective pain management for all intractable pain patients, these three major thought patterns of the Old Paradigm need to metamorphose into the New Paradigm. This New Paradigm in pain management:

• supports opioid pain treatment without threat of addiction
• educates clinicians on the pharmacological effects of opioids
• enlightens state medical boards and the DEA on the proven advantages opioids have in managing pain

Healthcare professionals' transition into the new paradigm of pain management

 

Reference List

1. Marks EM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med.  1973;78:173-181.
2. Morgan JP, Kagan DV, eds. Opiophobia in the United States: The Undertreatment of Severe Pain In: Society and medication: conflicting signals for prescribers and patients. New York, NY: D.C. Heath and Company; 1983;chap 24.
3. Joranson DE, Gilson A. Controlled Substances, Medical Practice, and the Law. In: Schwartz HI, ed. Psychiatric Practice Under Fire: The Influence of Government, the Media, and Special Interests on Somatic Therapies. Washington, DC: American Psychiatric Press; 1994,173-194.
4. Sullum J. No Relief in Sight. Reason. 1997;28(8). Available at: http://www.reasonmag.com/9701/fe.jacob.html
5. Patients Face Numerous Barriers to Receiving Appropriate Pain Treatment. American Medical Association (News Release, July 1997). Available at: http://www.ama-assn.org/sci-pubs/sci-news/1997/snr0716.htm#briden
6. Charap AD. The knowledge, attitudes and experiences of medical personnel treating pain in the terminally ill. Mt Sinai J Med (NY).  1978;45:561-579.
7. Melzack R. Tragedy of Needless Pain. Sci Am. 1990;262(2):27-33.
8. Morgan JP. American Opiophobia: Customary Underutilization of Opioid Analgesics
9. In: Hill CS Jr, Fields WS, ed. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven Press, Ltd.; 1989:181-189.
10. Pain Killer [transcript]. "60 Minutes." CBS television. May 25, 1997.
11. Finklestein KE. Deadly Morals. Playboy. 1997;44(8).
12. The painful dilemma: the use of narcotics for treatment of chronic pain. Sacramento, CA. Sacramento-El Dorado Medical Society, 1990.
13. Joranson DE, Cleeland CS, Weissman DH, Gilson AM. Opioids for chronic cancer and non-cancer pain: a survey of medical board members. Fed Bull. 1992;79(4):15-49.
14. Temin P. Taking your medicine: drug regulation in the United States. Cambridge, MA: Harvard University Press; 1980.
15. Ravenscroft PJ. Use of opioids in treating chronic pain. No longer available.
16. Brownlee S, Schrof JM. The Quality of Mercy. US News World Rep. 1997;122(10).Available at: http://www.usnews.com/usnews/issue/970317/17pain.htm
17. Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven; 1989:213-231.
18. Barnebei R, et al. Management of pain in elderly patients with cancer. JAMA. 1998;279(23):1877-1882.
19. Spanos A. Opioids for noncancer pain: from controversy to consensus. Int J Pharm Compounding. 1998;2(2):106-108.
20. Hale KL. Cancer pain treatment: overcoming the barriers. MD Anderson Oncolog. 1995;40(3). Available at: http://www.mdacc.tmc.edu/~oncolog/manage.html
21. Cops and doctors: drug busts hamper pain therapy. Wellness Web. Available at: http://www.wellweb.com/pain/cops.htm
22. The California & Arizona Medical Drug Use Initiatives, 1996: Hearings Before the Senate Committee on the Judiciary (statement of Thomas A. Constantine, administrator, DEA, US Department of Justice).
23. The Use of Opioids for the Treatment of Chronic Pain: Consensus statement. Glenview, IL, American Academy of Pain Medicine and American Pain Society, 1997. Available at: http://www.painmed.org/html/body_aapm_opioids_statement.htm

 

 

Patients' Perspective

 

One out of six households in America contains a member with severe, intractable pain.¹ Unfortunately, most of these patients go undertreated because healthcare providers do not provide adequate amounts of opioids to relieve their pain.

Ironically, some patients also perpetuate their own undertreatment of pain because they:

• don’t always report their pain to their doctor^2-4
• are reluctant to take opioids for intractable pain treatment^2,3,5

Whether patients report their pain or not, however, undertreatment of pain is usually inevitable. Eventually, unrelieved pain patients may head into a downward spiral of depression^4-8 and, perhaps, begin to consider suicide.^4,5,9,10

The New Paradigm creates a new transition in thought that educates patients about pain treatment, empowers patients to seek appropriate relief, and helps patients avoid depression and thoughts of suicide.

 

Reference List

1. The Mayday Fund. New survey finds broad support among Americans of physicians prescribing high doses of pain medication, such as morphine, for severe pain. Available at: http://www.pain.com/news/Mayday.cfm
2. Barnebei R, et el. Management of pain in elderly patients with cancer. JAMA. 1998;279(23):1877-1882.
3. Patients Face Numerous Barriers to Receiving Appropriate Pain Treatment. American Medical Association (News Release, July 1997). Available at: http://www.ama-assn.org/sci-pubs/sci-news/1997/ snr0716.htm#briden
4. Brownlee S, Schrof JM. The Quality of Mercy. US News & World Report. 1997;122(10). Available at: http://www.usnews.com/usnews/issue/970317/17pain.htm
5. Sullum J. No Relief in Sight. Reason. 1997;28(8). Available at: http://www.reasonmag.com/9701/fe.jacob.html
6. Marks EM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med.  1973;78:173-181.
7. The painful dilemma: the use of narcotics for treatment of chronic pain. Sacramento, CA, Sacramento-El Dorado Medical Society, 1990.
8. Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds. Advances in Pain Research and Therapy. Vol 11. New York, NY: Raven; 1989:213-231.
9. Pain Killer [transcript]. "60 Minutes." CBS television. May 25, 1997.
10. Gorman C. The case for morphine. Time. 1997;149(17). Available at: http://www.pathfinder.com/time/magazine/1997/dom/970428/ medicine.the_case_for.html
11. Wells N, Johnson RL, Wujcik D. Development of a Short Version of the Barriers Questionnaire. J Pain Symptom Manage. 1998;15(5):294-298.
12. Thomason TE, McCune JS, Bernard SA, et al. Cancer Pain Survey: Patients-Centered Issues in Control. J Pain Symptom Manage. 1998;15(5):275-284.
13. Bostrom M. Summary of the Mayday Fund Survey: Public Attitudes About Pain and Analgesics. J Pain Symptom Manage. 1997;13(3):166-168.
14. Hale KL. Cancer pain treatment: overcoming the barriers. MD Anderson Oncolog. 1995;40(3). Available at: http://www.mdacc.tmc.edu/~oncolog/manage.html
15. Melzack R. Tragedy of Needless Pain. Sci Am. 1990;262(2):27-33.
16. Ravenscroft PJ. Use of opioids in treating chronic pain. Available at: http://www.win.bright.net/~davidk/opioduse698.htm
17. Gianelli DM. Controlling chronic pain: groups release guidelines for opioid use. American Medical Association (News Release, March 1997). Available at: http://www.ama-assn.org/special/hiv/newsline/special/ amnews/amn0317.htm

 

 

Healthcare Reimbursement System's Perspective

 

As intractable pain management remains a low priority in healthcare, so does it remain a low priority in healthcare reimbursement.^1,2 In the United States, many intractable pain patients are not able to comply with their intractable pain treatment because they don’t have the appropriate healthcare coverage to pay for their medication or equipment.

The United States is one of few developed countries that does not provide healthcare coverage for its citizens³; therefore, economic status ultimately determines the quality of care that patients receive.⁴ The following pattern has developed between patients’ economic status and the quality healthcare that is readily available to them:

• patients’ economic status reflects the amount of insurance affordable to them
• the type of insurance patients have determines the amount of healthcare coverage they will receive
• the amount of healthcare coverage patients receive determines how well they will comply with their prescribed treatment

Steps to overcome healthcare reimbursement limitations

 

Reference List

1. Joranson DE, Gilson A. Controlled Substances, Medical Practice, and the Law. In: Schwartz HI, ed. Psychiatric Practice Under Fire: The Influence of Government, the Media, and Special Interests on Somatic Therapies. Washington, DC: American Psychiatric Press; 1994:173-194.
2. Joranson DE, Cleeland CS, Weissman DH, Gilson AM. Opioids for chronic cancer and non-cancer pain: a survey of medical board members. Fed Bull. 1992;79(4):15-49.
3. Joranson DE. Are health-care reimbursement policies a barrier to acute and cancer pain management? J Pain Symptom Manage. 1994;9(4):244-253.
4. Saper J. Bills Would Help Manage Pain. 1997. Available at: http://www.ring.com/nprofit/lifespan/saper.htm
5. Angarola RT, Joranson DE. Healthcare reimbursement policies: do they block acute and cancer pain management? APS Bulletin. 1994;4(5):7-9. Available at: http://www.biostat.wisc.edu/painpolicy/publicat/94apshr.htm
6. Brand FN, Smith RT, Brand PA. Effect of economic barriers to medical care on patients’ noncompliance. Public Health Reports. 1997;92(1):72-78.
7. Ferrell BR, Griffith H. Cost issues related to pain management: report from the cancer pain panel of the agency for health care policy and research. J Pain Symptom Manage. 1994;9(4):221-234.
8. Wastila LJ, Bishop C. The influence of multiple copy prescription programs on analgesic utilization. J Pharm Care Pain Symptom Control. 1996;4(3):3-19.

 

 

Updates in Intractable Pain Management

 

Below you will find links to weekly news and medical and legislative advancements in intractable pain management. Please refer to this section often to review updates in pain management.

Weekly Pain Management News

Federation of State Medical Boards of the United States Model Guidelines for the Use of Controlled Substances for the Treatment of Pain
Adopted May 2, 1998

"Unprecedented Changes in State Pain Policy"
David Joranson, et al describes the trends states are making to address intractable pain policy.

 

E-mail your pain management updates to NFTP