Pain Again

Pain Again
Posted by FoM on December 13, 1999 at 19:19:37 PT
Dr. Alan Eshleman  
Source: SF Gate
I've had a headache all day, a dull, poisonous ache across the top of my head that has been building for hours, triggering waves of nausea and blurring my vision. I've tried a cup of black coffee, 800 mg of ibuprofen, and a scalp massage, but nothing has worked. 
Fifteen minutes ago I took 30 mg of codeine. In another fifteen minutes or so I plan to feel a warm little glow of opiated euphoria and a big reduction in my headache symptoms.There used to be a television commercial for a certain over-the-counter pain reliever that made the statement that "you can't buy anything stronger for headache pain." "# *!," I'd say, "you sure can!" At least you can if you and your prescribing physician agree that you'd be helped by one of the many variations on the theme first expressed by the opium poppy, the group of drugs known as opiates or opioids.I've written three previous columns discussing pain, and each time the response from my readers suggests that this is a topic everyone can identify with. Pain is, after all, one of the more common reasons to see the doctor.In "Triplicates," I told of how angry and exasperated I became when the orthopedist who was treating me for a serious fracture blithely remarked that he had never bothered to apply for the necessary forms to allow him to prescribe the stronger "Schedule II" opioid drugs. He had not bothered to do this despite the fact that his chosen specialty's stock and trade is broken bones.In "The Half Life of Medical Truth" I tried to illustrate how scientific medicine can respond to research findings and ultimately overcome long held prejudices about what constitutes "good" practice. In this instance, the prejudice was that giving strong painkillers to patients with abdominal pain would somehow interfere with the ability to make an accurate diagnosis -- that the signs of the problem would be masked by the medication. It turns out this was wrong: giving the pain medicine before pressing on a patient's tender belly may actually increase diagnostic accuracy.In "A Marked Woman" I wrote about a drug- seeking patient. A woman with chronic pain who had been going from doctor to doctor requesting injections of demerol and prescriptions for tablets of hydrocodone, both controlled, opioid medications.During the last decade there has been a definite change in physicians' attitudes toward prescribing opioids for pain control. I count myself among those who have changed. Driving this change has been the realization that these drugs really can help people when all other therapies fail, and that seeking out these drugs -- even being dependent on them -- is not always the same thing as abuse or addiction.What's the difference between addiction and drug-seeking? According to experts in addiction medicine, addiction means that a person will seek increasing amounts of a particular drug despite all manner of bad consequences, including loss of job or love or friends or health. Drug-seekers, on the other hand, are usually seeking the drug they know will help eliminate their pain, and when they have enough medicine they are content. Doctors frequently confuse the two behaviors, which is not surprising since they appear much the same on the surface. Both behaviors can involve doctor-shopping, pharmacy- hopping, and even forging prescriptions. This confusion also deprives a large number of patients of effective pain relief.Until very recently, doctors had strong incentives not to prescribe opiates for chronic pain. First, there was a very real fear that if they continued to refill prescriptions for large amounts of these medications that they would attract the scrutiny of state and federal drug control agencies. Harvey Rose, MD, a family practitioner in California who was one of the pioneers in prescribing opiates for chronic pain patients, was brought up on charges of overprescribing before the State Medical Board. "I went through four years and $140,000 in legal fees" in a successful legal defense, says Dr. Rose in a recent interview in the journal Hippocrates. Dr. Rose wasn't the only practitioner to get into legal hot water while trying to help his patients.Doctors also worried that they would be creating addicts by stepping up their prescriptions for opiates. But this too does not seem to be the case. Consider this: from 1980 to 1997, annual morphine consumption has increased nine-fold to nearly 40,000 pounds, but the rate of morphine addiction has held steady.What does happen when a patient with chronic pain takes opiates for pain control is that the patient develops tolerance. Tolerance means that one becomes immune to some of the more dangerous side effects of the opiates -- the fuzzing of the thought processes and the depression of the breathing response -- without losing the pain-killing effect. Tolerance also means that stopping the drug will produce an unpleasant withdrawal syndrome. But research studies are beginning to show that an opiate-tolerant patient on a steady, regular dose of medication can remain mentally sharp, even able to operate a car or machinery, and remain happily free of the pain that may have vexed him for years.And, sad to say, too many doctors impose their own morals on patients with chronic pain. They see these patients as whiners and complainers, and think of the experience of pain as somehow "building character." These same doctors, of course, have never experienced chronic pain first-hand, for if they had, they'd realize that it is more apt to destroy than to build character.Today physicians who choose to give opiates for chronic pain control have a degree of official support. In 1998 the Federation of State Medical Boards issued a statement recognizing that opiates "may be essential in the treatment of [both] acute ... and chronic pain." The Medical Board of California issued a strong statement in favor of doctors providing better pain relief. The Board's full statement may be found at:'s an excerpt from that statement:The Board recognizes that pain, whether due to trauma, surgery, cancer and other diseases, is often undertreated. Minorities, women, children, the elderly and people with HIV/AIDS are at particular risk for undertreatment of their pain. Unrelieved pain has a harsh and sometimes disastrous impact on the quality of life of people and their families. While some progress is being made to improve pain and symptom management, the Board is concerned that a number of factors continue to interfere with effective pain management. These include the low priority of pain management in our health care system, incomplete integration of current knowledge into medical education and clinical practice, lack of knowledge among consumers about pain management, exaggerated fears of opioid side effects and addiction, and fear of legal consequences when controlled substances are used. Opiates are not a panacea, nor are they the only treatment for pain. Bodywork, low doses of antidepressants, physical therapy, and emotional therapy are also useful. But in a time when many patients are alienated by mainstream medicine and turn to alternative therapies and herbal remedies of questionable efficacy, I suggest that it makes sense for physicians to make better use of drugs based on that herbal remedy par excellence -- the fruit of the opium poppy.My head feels much better now. Newshawk: Frank S. WorldDrug Policy Forum Of Wisconsin, December 13, 1999  1999 Chronicle Publishing Company 
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