Sunday, February 19, 2012

Baby, Bathwater, and Prescribing for Chronic Pain

John Fauber, the indefatigable investigative reporter from Milwaukee, has a new article out on how the current overuse of opiate narcotics for treating chronic pain was spurred by heavy industry funding of major pain organizations, including one at University of Wisconsin:

I have blogged on this topic before: also got out a little bit ahead of it back in HOOKED when I sympathized with the pain organizations but also criticized them for taking industry money and leaving themselves open to these charges.

I agree therefore with Fauber that these organizations issued tainted statements and guidelines due to their willingness to take funding from industry--which at the time might have seemed understandable because no one else was willing to put funding into pain issues, despite the estimated 75-100 million Americans who live with undertreated chronic pain. It is important that we don't lose sight of this critical public health need for better pain management while getting on the latest bandwagon deploring the overprescription of narcotics.

Where I would take Fauber's article somewhat to task is for 20-20 hindsight. Today we have some reasonable evidence to urge caution in prescribing opiates for chronic pain, especially in higher dose ranges. This evidence was not generally available 10-15 years ago when many of the ideas about improved treatment of chronic pain were first formulated. While it is true that these pain guidelines were unfortunately influenced by money from Pharma, it is also true that there were reasons to believe in the older style of pain therapy that was willing to go to higher doses of narcotics, and the evidence then available did not clearly indicate its hazards or limits.

As a family physician I never was a pain "specialist" but cared for a number of patients with severe chronic pain before I ceased patient care in 2006. If I knew then what I now believe to be the case, I would have managed some of them differently. But at the time I could point to apparently authoritative guidelines to support what I did, and I had all too few real options available--another point ignored by Fauber's article. What do you do with chronic pain that's not responsive to lower-dose opiates? The ideal answer, so far as I now know, is to refer the patient to a multidisciplinary pain clinic with a team approach that includes pain psychology, physical and occupational therapy, and so on along side pain medicine--and that's also willing to prescribe narcotics if that's justified in any individual case. Such clinics are few and far between--and if your patient is Medicaid, which is very commonly the case, then it's even harder to find such help for treating them adequately.

I would also disagree with one rather sweeping conclusion Fauber offers, that "pseudoaddiction" is a concept promoted by industry marketing, now known to be invalid. Pseudoaddiction refers to the fact that patients with untreated severe pain will in fact be "drug seekers"--they will display behavior which health providers often interpret as that of an addict just trying to get a fix, when the underlying problem is pain and not addiction, and if you gave enough drug to eliminate the pain, all the "drug seeking" behavior would disappear. As a clinician I would argue that this concept remains valid. Fauber seems to dismiss it because it's obviously invalid if one assumes that any patient showing such behavior is not an addict but has undertreated pain. I don't know any pain expert who has ever recommended this perspective; the suggestion as I have always understood it is that pseudoaddiction should be considered as a possibility alongside other explanations for the patient's behavior.

The sad news from a public health perspective is that if high-dose opiates are not the way to properly treat chronic pain, simply saying so, and ceasing to prescibe opiates that way, does nothing to diminish the serious problem of undertreated pain in our society. One of the wisest things I ever hard about this problem came from a colleague who had training in both palliative care and addiction medicine. She said that there are three kinds of patients who suffer from serious diseases and that deserve our sympathy as well as the best treatment we can come up with. The first group has severe pain. The second group has addiction. The third group has both of the above. While all three deserve our sympathy and care, what's the right type of care depends critically on locating each patient withyin the correct category out of the three. Sadly many practitioners in the US today don't have the sort of help they ideally need to make that determination, let alone administer the correct therapy.

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