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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12 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 have had a complex regional pain disorder for 13 years. I have been very active in the "chronic pain" community. First of all, thank you for the well written article.
It is a fact that for many people with pain syndromes such as FTD/CRPS etc. strong opioids are what keeping them functioning day by day.
I have become disabled and now have another disease that is terminal but I like others have had a tremendous struggle getting the treatment I needed for pain relief. I am not talking about total pain relief, I am talking about enough pain relief to get by day by day.
There have been great discoveries in pain research lately. Unfortunately, most doctors either don't read the research or they are afraid to treat pain patients anymore.
As someone else commented, governmental interference has caused many doctors to feel an implied threat against them and they are not treating people with chronic pain anymore.
When I think about what the DEA did, raiding doctor's offices, etc. I am still amazed that this sort of thing could happen in the U.S.A.
Granted the DEA didn't raid many physician's offices and most cases were settled out of court but there was enough publicity to scare many physicians to the point that they have stopped treating chronic pain patients.
It is only going to get worse. To see this you can look up the FDA and their proposed REMS for certain narcotics. They say these are the narcotics that are most abused. I'm sure that is true but trying to keep doctors from prescribing these drugs will not do anything to help the War on Drugs. Most people who abuse these drugs will find other sources to get them.
The media has made it sound like doctors were indiscrimately given out pain medicine to people who then went and sold it on the streets or it got into the hands of teenagers that were taking their grandparent's prescriptions.
The percentage of cases in which that actually happened is much lower than the DEA or FDA would have you think.
I finally found a practice in New York that has a wonderful physician who has worked with me for several years to manage my pain.
For the past year I've had to fly to see him as well as set up teleconferencing, etc. If you had a cardiac condtion and the only way to get your medicine was to go wherever you had to go you would do it.
Of course, there is a different issue there about certain people not being able to receive treatment because of socioeconomic status but I think you understand what I mean.
Thanks for reading my post
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.
When the sypmtoms 1st started, my doctors were dismissive of my complaints. I was in my early 20's and physically appeared to be in good health. I had back pain that really resembled the pain I had while in labor. But the symptoms that I was having was seriously disrupting my life. For the 1st coupla years I did alot of research online about my symptoms. I googled my symptoms and I kept running across this dx called fibromyalgia. My picture should be next to the disease causes I have a text book case. I actually diagnosed myself and had to educate the physicians that I was consulting with; who probably should have known since they were experts in their specialities. Anywho, after several years of taking OTC meds they no longer controlled my pain at a level where I could function throughout my workday. Plus the Motrin had caused an ulcer. I have had to screen many physicians over the years to find one who actually listened to my complaints and actually appeared to believe me. And it has not been easy to find a practitioner who believes that 1st of all that I have pain. And then was willing to write the Rx for narcotic pain killers. Since diagnostially I was negative for any disease processes that would cause me pain.
As a nurse, I was taught that the the patients' was whatever, he or she said it was. And it that pain should be considered a priority. I have not found this practice to be common among many practitioners that I have both worked with and seen as a patient. It's actually sad, that people are made to feel like addicts for trying to find relief from pain that they are experiencing. I agree that practitioners need to be reeducated in how to be empathetic and treat the pt's accordingly.
I have been psychologically scarred by the way I've been treated by Doctors in the past. Now I have PTSD from years of not being listened to, treated as if I were a junkie and suffering needlessly. It should be a crime to let a patient suffer in pain for no reason other than fear. I finally have found a compassionate Pain Doctor who I feel cares how I am feeling, a rarity these days. But I still go to Doctors regularly who tell me I shouldn't be on the medication I'm on, even though I work full time, go to school and function at a higher rate than I did pre-meds (which is the point of taking them isn't it?). They put me on anti-depressants and seizure medications that induced neuropathy and made me feel like I was going insane. Then they blamed me for those treatments not working, when all I ever needed was a low dose time release opioid and not 7 other medications that didn't help anyway and were probably more damaging than the opioid! Its all frustrating and its a fight for our lives! I've had to fight every step of the way, to get them to even do the testing to find out what is wrong with me and then to get properly treated! It's a shame really. And I feel sorry for anyone who is just starting out in this process and feels as overwhelmed, helpless and hopeless as I did for almost 10 years! I did all their expensive testing, their invasive procedures that did not help and the medication that made me feel worse. If that weren't enough, I still get lectured about my choices in pain control. Enough is enough.
The problem is that many patients do seek pain management physicians for drugs, not to control pain. You can't see pain. And everyone has a different tolerance for pain. So, prescribing drugs for pain manangement becomes an ART but a very difficult piece of art to paint. Which dose is good enough for patient A but not enough for patient B? My husband is an anesthesiologists who refused to go into pain management, although he loves the science of it and sees the need for good pain manangement doctors in our town. He is scared to practice that type of medicine b/c of the liability involved. You only need one patient's abuse to put you in jail. Is there a solution to this problem? It's very unfortunate for people living with pain who are not drug seekers...
Call it the 'war on drugs'. It is all about diversion and addiction, not about medicine. They haven't the time to count people like 'us', the millions of chronic pain patients that require opiate medications to just LIVE; oh.. and yes, some of us pay taxes that fund this hysteria.
It's time to put a stop to the assumptions, myths and ignorance surrounding opiate medications. Regarding Dr. Hahn's comment about the imparied driver and the treating physician; this is sad. How can 'they' assume that the driver was impaired when everybody metabolizes medications differently? I wonder though, if the patient were taking Lyrica for example, if the same assumption would be made. Personally, I can't function while taking Lyrica (and I wouldn't even attempt driving) but can function normally on hydrocodone or oxycodone. I wonder also if UDT were used as a tool to gauge metabolization and prescribe appropriately, rather than to screen abusers, (or both) we would get somewhere, no? There is no 'one-size- fits-all' solution for this dilemma.
I just think it's sad that criminal charges can be made (or even talked about!) based on an assumption. Where is the scientific data? What has happened to our government? our legal system? What will become of 'us'?
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