Two recent initiatives on cancer treatment and prescription drug abuse vividly illustrate the public health and public policy cross-currents swirling around the issue of proper treatment of pain. The American Cancer Society and the National Comprehensive Cancer Network, representing the country's preeminent cancer treatment centers, early this month released its first guidelines explicitly designed to address pain as a problem in cancer treatment, "Cancer Pain Treatment Guidelines for Patients." This week, the National Institute on Drug Abuse (NIDA) issued its report on the abuse of prescription drugs, "Prescription Drugs Abuse and Addiction," and its director, Dr. Alan Leshner, used a press conference touting the research to issue a dire -- and much reported -- warning that four million Americans are abusing prescription drugs.
Not to be outdone, Newsweek leapt into the fray with a major story in its April 9th issue, "Playing With Painkillers," replete with doctor-shopping, pill-popping pain patients run amok. Overall a fairly reasonable piece, the story nonetheless helps explain the reluctance of some patients and doctors alike to adequately confront intractable pain. Both groups fear and misunderstand the use of opiates and can be reluctant to venture into the murky cultural terrain where pain patients scale into junkies and conscientious physicians morph into dope-dealing Dr. Feelgoods.
The new cancer pain treatment guidelines summarize these issues in its section on obstacles to pain relief. They list patients' fear of addiction ("but this rarely happens"), their fear of side effects, doctors' and nurses' inadequate knowledge of pain relief techniques, patients who "tough it out" instead of telling doctors of their pain, and "legal obstacles."
"Doctors' and nurses' personal beliefs interfere with adequate management of chronic cancer pain," say the guidelines. "In the past, doctors and nurses were not well trained to care for patients with chronic pain. They did not always know what medicines were used to control pain. They also were afraid of the possibility that patients would become addicted."
And in an implicit acknowledgment of the role of drug prohibition in complicating pain treatment, the guidelines note that, "When prescribing opioids, especially doses that some might consider high, doctors, pharmacists, and nurses fear actions by drug enforcement agencies. These actions may be exaggerated by professionals and should not be an obstacle to pain relief."
Arrests of doctors for prescribing pain medications may be rare, responded Skip Baker of the American Society for Action on Pain (http://www.actiononpain.org), a patients' and doctors' advocacy group, but their effect on practicing physicians is dramatic. Baker, himself an intractable pain patients taking high doses of an opioid pain reliever, can quickly reel off the names and case information of at least five doctors who have faced or are facing criminal prosecutions for their attempts to treat patients in pain.
"You've gotta treat pain more aggressively," Baker told DRCNet. "It's a shame that half of those patients are never treated for pain, but the medical profession runs scared when prosecutors come along and arrest a bunch of doctors. My own doctor is under investigation over my dosage."
"The government is at cross-purposes with itself," Baker growled. "If we're going to let drug warriors falsely arrest and indict doctors and lie about it without ever paying any price for their reprehensible actions, we'll never get anywhere. We need congressional hearings on this issue," he added.
According to the American Cancer Society spokeswoman Joann Schellenbach, about one-third of all cancer patients have the kind of pain that could be managed by opioids or other techniques, but not all of them are receiving adequate care for pain. "Almost all of them could have pain alleviated completely or managed well enough that they have reasonable quality of life," she told DRCNet, "but only about half of those are getting the treatment they need."
Schellenberg proved reluctant to finger law enforcement as a problem, pointing instead to patient and doctor attitudes, especially in regard to pain medicines also being used recreationally. "Information about drug abuse feeds into patients' and doctors' concerns about drug addiction in general," she said, "and many patients refuse management of their pain because they worry about becoming addicted."
Dr. Robert C. Young, president-elect of the American Cancer Society, elaborated in the group's press release: "Reactions to recent disturbing media coverage of drug addicts and pain killer abuse may ironically interfere with important efforts to appropriately manage cancer patients' pain," he said. "In fact, when pain medicines are given and taken appropriately, patients rarely become addicted to them."
That didn't stop NIDA's Leshner from sounding the alarm about prescription drug abuse. "No one starts out to get addicted," he told the NIDA press conference. The press conference kicked off a new NIDA campaign to combat what Leshner called "a dangerous new drug abuse trend" -- the non-medical use of prescription drugs.
Leshner apparently does not remember Marilyn Monroe, "Valley of the Dolls," or "Mother's Little Helper," but the NIDA research shows prescription drug misuse escalating, especially among women, senior citizens, and young people. Nor did Leshner make the connection between rising prescription drug abuse and the staggering increase in mood-altering medicines in the 1990s described in the NIDA report. NIDA found that from 1990 to 1998, new users of pain medications doubled and nearly doubled again, while the use of prescribed stimulants was up 165%, tranquilizers up 132%, and sedatives up 90%.
ASAP's Baker is not pleased with NIDA and Leshner. "Why is he saying all this stuff that is just going to hurt pain patients? That's all crazy," Baker fumed. "Why doesn't he look into what all this drug war nonsense is doing to pain patients?"
Pain treatment is available, says the medical profession. But as they approach the nexus where medicine meets the drug war, too many doctors and patients alike would rather suffer in silence.
The ACS guidelines can be found online
The NIDA report is online at: