Writing in The Rx Consultant [December 2009] and the Journal of Pain & Palliative Care Pharmacotherapy [2009], Kathryn Hahn, PharmD, CPE, DAAPM, says the issues are reaching crisis proportions: “We’re in the middle of a storm here and have to figure out some way to navigate through it.” Hahn is associated with the College of Pharmacy at Oregon State University, Chair of the Oregon Pain Management Commission, a State Action Leader for the American Pain Foundation, and a practicing pharmacist specializing in pain management.
“We have more sophisticated pain management techniques available now than ever before,” she says in a news release [2010], “but many doctors are not fully informed about all the options available, and also turn patients away because they’re very concerned about the problems with prescription drug abuse. Because of this, many people suffer needlessly with pain that could be treated, and almost 80% of visits to community pharmacies involve pain issues.” Adequate pain treatment has always been a concern, she continues, in part because it’s not a major part of most physician’s medical training.
Concerns about analgesic abuse are so great that many physicians prefer not to even work with patients who have ongoing pain issues. “I see patients every week who have lost their doctors and don’t know what to do, and these people are scared. It’s particularly bad with elderly and Medicare patients,” Hahn notes. “Prescription drug abuse is a very real problem, we do have to take necessary steps to address it, but right now the pendulum has swung too far and legitimate pain problems are not being managed.”
Long-term solutions will take education and responsibility by all parties involved, Hahn believes, including consumers, physicians, nurses, and pharmacists. Among the steps that may help, she recommends…
- Physicians and nurses should accept that patients are the final arbiter in determining that something is painful — believe them and work with them on their concerns.
- Patients should cooperate with their healthcare providers on pain relief plans that may include a range of options, including prescription drugs but also alternative approaches such as chiropractic care, exercise, acupuncture, meditation, implantable devices, massage, or physical and occupational therapy.
- Looking at medications, there is a range of opioids, over-the-counter pain relievers, antidepressants, and other medications to carefully consider for specific problems.
- All involved parties should understand that psychological addiction to analgesics is rarely a major concern with proper prescribing as part of an appropriate pain management program.
- Physicians must stay up to date on the latest approaches and the full spectrum of pain management options, and recognize than pain management is a key part of overall healthcare.
- Consumers must acknowledge the seriousness of prescription drug abuse problems and safeguard their medications. The unlocked medicine cabinet is the foundation of a cottage industry of drug abuse in America today.
References:
> Hahn K. Chronic pain management Rx Consult. 2009;18(11):1-7.
> Hahn K, Colon Y. The roles of pharmacists in pain management. J Pain Pall Care Pharmacother. 2009;23(4):414-415.
> OSU (Oregon State University). Pain management failing as fears of prescription drug abuse rise [news release]. January 4, 2010 [available here].
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7 comments:
Excellent article but what is the basis for the fear? Given that the percentage of pain patients who actually become addicted to their medications is extremely low, I think that doctors' concerns about abuse problems arise from intimidation from federal agencies and fear of sanctions and/or legal liability should a patient screw up. The end result is we are paying dearly for the sins of a few. I am in a pain management program and still cannot achieve a comfort level of acceptable pain because doctors fear that doing the right thing will have adverse consequences. Never thought that my health problems would make me feel like such a criminal.
If it is true that concerns about prescribing opioids are a major reason for poor management of pain then chronic pain conditions that respond better to non-opioids such as neuropathic pain and fibromyalgia should be much better managed than those that respond best to opioids. This is not so. Has anyone heard of physicians expressing concern about prescribing medications such as Lyrica, Cymbalta, Neurontin, or other anticonvulsants or antidepressants?
The reason why physicians do such a poor job managing pain is that they receive inadequate training on this in medical school and post-graduate training. To continue to repeat the red herring about concerns about opioid prescribing only serves to impair addressing the real issue.
Steven A. King, M.D.
Dr. King makes some very good points. Pain management doesn't begin and end with opioid analgesics; I think Dr. Hahn's message made that point as well. Yet, patients can and do misuse other agents used in pain management, so this is an ongoing concern. Certainly, more and better education for practitioners (as well as patients) is necessary. -- SBL
I've lived with chronic widespread pain throughout my body and chronic tension headaches for years. I've just been diagnosed with fibromyalgia.
Over the years I've seen all kinds of doctors, and tried all kind of treatments. I've tried massage therapy and acupuncture, physical therapy and aromatherapy.
I've tried all kind of medications for the various pain and symptoms I suffer from; Tramadol, Trazadone, Lyrica, Cymbalta, Soma, Ambien, Zanaflex, Prednisone, Lunesta, Zoloft, Botox...to name a few.
The ONLY time I have had sufficient relief from my symptoms is when I have had to go in for surgery. I've had 3 operations in the past 2 years, and have been prescribed Percocet, Vicodin and Oxycontin afterwards. There was a period where a pain management clinic prescribed me Methadone for my headache, and that really helped.
I'm now in another state, and have had no pain relief from the medicine I've been prescribed so far, Doctors here seem reluctant to prescribe painkillers.
Why am I being penalized for other peoples drug abuse? Why do I deal with ignorance on the Doctors part who think I'm only there for the drugs, and who refuse to prescribe something that will help me? Why don't they give me the credit for knowing my own body, and knowing about the very real pain I'm in?
All I want is something to help me get through the day. Doctors need to realize that the are some genuine cases where there is a need for adequate pain relief. We're not all out to get high.
The following was sent in by Kathryn Hahn, PharmD, CPE, DAAPM, author of the articles referenced in our posting above.
As I sit here pondering all the excellent comments to the original blog about my writings, I am drawn to a recent email from a colleague who treats pain. A patient of his had a car accident while on appropriately prescribed opioids that had caused no sedative effects for the past 5 years. Others were injured, and because the driver was on opioids, it is assumed he was driving impaired. The physician may now be implicated, though office exams showed no impairment and the patient signed a "contract" agreeing to not drive impaired. It is possible the physician may be charged with a civil or even a criminal suit. Medical malpractice insurance does not cover expenses nor defense for criminal or civil charges, only for medical malpractice.
The physician writes: "herein lies the real and basic reason doctors are so reluctant to prescribe any medications for patients with painful conditions. If prosecuted and convicted of civil or criminal behavior, you can lose your life savings, your home, and your retirement savings including your 401K and your IRA. You can go to prison, and several well meaning doctors have. Neither your assets nor your freedom are protected."
In fact, another colleague of mine, Jennifer Bolen, JD maintains a website, "The Legal Side of Pain" to help physicians navigate the legal landmines associated with the practice of pain medicine.
The physician further observes: "without a change in the laws regarding civil and criminal liability for doctors who prescribe medications for painful conditions it is unlikely things will change much. Patients in pain will still find it difficult to find a physician willing to treat them. And who can blame physicians for being reluctant to prescribe, given the liability issues that go beyond medical malpractice."
And so, apparently I have added another step to the list of long term solutions necessary for real change in access to appropriate pain management: legislation addressing the liability born by the attending physician of a person with persistent pain being treated with opioids. Don't hold your breath for that one.
Respectfully,
Kathy Hahn
I have dealt with severe chronic low back pain since 1997 while working as a nurse. I am now a nurse practitioner. Most of my experience is in cancer nursing. That being said it feels like docs have no problem treating cancer pain.
Because I have chronic back pain I have had issues getting adequte pain management. I do not expect complete relief but enough relief to function without wanting cry/scream when I move. Right now I have a primary care doc who is wonderful and will prescribe what I need, but sometimes when I ask for an increase in dosage I feel like she is reluctant. Right now I take morphine and vicodin for pain along with antdepressents sleep aids etc etc.
I will also say that pain management has improved over the past 25 yrs. I say that because 28 yrs ago I injured my ankle and it was misdiagnosed and untreated (long story). Turns out I walked on a broken ankle for 4-6 months. Ten yrs later I had my ankle fused. During that 10 yrs I went from doc to doc trying to find someone to lisen to me. I had horrible pain. When I did find a doc who listened to me he did a CT scan on my ankle and I had no cartliage in my ankle, hence the fusion. During that time I was treated as a drug seeker...in a way I was seeking drugs...for pain relief. I think maybe I had such a hard time because of my age (20-30's), and because I still worked. How could someone still work with that much pain????Pure determination and that is it. I did not want to go on disability, I loved my job, it actually helped me to cope.
I think that one of the biggest reasons there is poor pain management is that practitioners (docs, nurse practitioners etc) make judgements without listening to their patients and then witout using their brain to figure out the problem instead of relying on tests, x-rays. Medicine is an ART as well as a science . Alot of practitioners have forgotten the art part. IMHO.
I think tht the article is excellent but only addresses part of the problem. I think pain and its mangement needs to be taught in medical schools and nursing schools. I also think people need to start listening to and being empathetic with their patients. I also think patients need to be honest and truthful wth their practitioners....and work with their practitioners to find a treatment plan. I have seen alot of docs with egos as big as all get out who get angry if if something else is suggested. That has to go.
Unfortunately, very few humans have the ability to handle power. Doctors have enormous power. They control whether or now we are allowed to go back to work or remain home, whether or not we are allowed to go on Disability or Social Security; they are the ONLY people permitted to prescribe our medications. They have our lives in their hands - in ALL respects. Not only do they have our health in their hands, but also our financial well-being, for those of us who are on short-term, long-term or permanent disability, as well as those who are on Workers Comp.
When we give anyone this much power, abuse is inherent. The abuse I have experienced and seen as a permanently disabled person with continual severe pain (CRPS - Complex Regional Pain Syndrome), is horrific and has provided me with a glimpse of the medical atrocities which occurred under Hitler's Regime. I am not exagerating. I have had many doctors make me undergo expensive (because I have insurance) procedures in order to get my pain medication. I need these medications in order to exist on a day to day basis, due to my pain being so very severe and debilitating.
By the way, in all the time I have taken these narcotics, I have never experienced the so-called "high" that people refer to. My pain is so extreme that when I take the medication, it simply acts as an agent to reduce the pain to a more manageable level, however, all I feel is the reduction - no "high." Imagine that, someone who gets some benefit from these horrible drugs that are spoken of with such disdain. Enough said - I just needed to get that off my mind.
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