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Barriers to Pain
Control
Last updated:January 22, 2008 |
Numerous clinical studies document that many American
adults and children receive inadequate pain control. Understanding the
obstacles that exist, both on a personal and systematic level, is a
fundamental step in correcting this problem.
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u“
the most pervasive and difficult (barriers) to overcome relate to the
fears among patients, families, and health professionals of opioid
analgesics, which are the cornerstone of drug therapy for moderate to
severe pain.
u
These fears include an exaggerated estimation of opioid
addiction and tolerance, fear
of opioid side effects -- most notably respiratory depression -- and
ethical and regulatory concerns about using opioids.”u
uWeissman, David E. Home Health Care Consultant Vol.
2, No. 5, Sept. 1995
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Fundamental Philosophy
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Narcotic Addiction
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"Today, the use of opioids in cancer patients is
generally accepted, but there are still some concerns over the risks of
addiction and adverse reactions, and opioids are sometimes withheld from
patients who would otherwise benefit from them. However, it has been
shown that such concerns are misplaced: the risks of severe adverse
reactions and addiction are low when opioids are used correctly in
patients with chronic pain."
Sorge, J. Eur J Pain. 2000;4 Suppl A:3-7. |
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The Truth About Pain Management: An Addictionologist's Perspective -
CME available
 | Howard A. Heit, MD, FACP, FASAM |
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| Substance Use Disorders
In the Palliative Care Patient |
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Pseudoaddiction |
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Ethical perspectives: opioid treatment of chronic pain in the context of
addiction.
| Cohen MJ, Jasser S, Herron PD, Margolis CG. Clin J
Pain 2002 Jul-Aug;18(4 Suppl):S99-107
Pain Medicine Program, Department of Psychiatry and Human Behavior,
Jefferson Medical College, Philadelphia, Pennsylvania 19107-4414, USA.
Mitchell.J.Cohen@mail.tju.edu |
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Narcotic Adverse Effects
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TThe
Legal Liability of Undertreatment of Pain - Definitely
worth a look
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| “The
respiratory depressant effect of opioid agonists can be demonstrated
easily in volunteer studies. When the dose of morphine is titrated
against a patient’s pain, however, clinically important respiratory
depression does not occur. This appears to be because
pain
acts as a physiological antagonist to the central depression effects
of morphine.”
-- Wall, R.D., ed. Textbook of Pain. Churchill
Livingstone |
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Many physicians have an exaggerated
view of the risk of respiratory depression when using opioids to
relieve pain. The inappropriate application of animal and human
models from acute pain research is in part responsible for this
fear. Pain is a potent stimulus to breathe, and pharmacologic
tolerance to respiratory depression develops quickly. Opioid effects
are quite different from those experienced by a patient who is not
in pain and receives similar doses. As doses increase, respiratory
depression does not occur suddenly in the absence of overdose.
Somnolence always precedes respiratory depression. Adequate ongoing
assessment and appropriate titration of opioids based on
pharmacologic principles will prevent misadventures. --EPEC Pain
Module |
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Pain and the Law
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Working
Together: DEA and the Medical Community
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DEA Issues Policy Statement on Dispensing and Prescribing Controlled
Substances for Pain Treatment |
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The DEA proposed a formal rule that enables doctors to write
multiple prescriptions in a single office visit for patients
requiring a steady supply of morphine-based painkillers. The new
policy allows physicians to write three 30-day prescriptions at a
time, two of them future-dated, to be filled on a monthly basis. |
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Drug Scheduling |
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U.S. Pain Policy Resources |
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Articles on U.S. Pain Policy |
| Fear of prescribing
narcotics |
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Pain meds: A balancing act
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A government effort to
crack down on prescription drug abuse must not exacerbate the
undertreatment of chronic pain.
Amednews.com editorial. April 12, 2004 |
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| "Two sets of observations have been the strongest
impetus for a critical reexamination of the evidence supporting the
traditional view of opioid therapy. First, experience gained during the
management of cancer pain has demonstrated the potential for highly
favorable outcomes from long-term opioid therapy. Second, evidence has
accumulated that the laws and regulations intended to reduce illicit use
and misuse may have unintended adverse effects on legitimate
prescribing. These observations provide a context for further analysis
of the controversy surrounding the use of opioids for nonmalignant
pain."
Opioid Therapy for Chronic
Nonmalignant Pain: Clinicians' Perspective 24(4) J. L., MED.
& ETHICS 286 (1996) [HTML]
[PDF]
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| "Health care professionals offer many reasons for the
undertreatment of pain, and an effective response to the problem
requires an effort on several fronts. Health care professionals require
much more effective education and training in the treatment of pain.
Institutions must remove unnecessary institutional barriers to pain
relief and should ensure that effective pain management is an
institutional priority. Payment systems should realize the costs of pain
and adequately support pain control. Patients and caregivers must also
be informed and assured that pain relief is to be expected and that
fears of addiction are unfounded.
One source of the problem, according to physicians, is the threat of
legal sanctions for treating patients in pain, especially when that
treatment must rely on the use of controlled substances. Doctors have
reported that they undertreat for pain, in part, from fear of legal
penalties, especially disciplinary action.…"
, Disciplinary Actions
and Pain Relief: Analysis of the Pain Relief Act, 24 J. L., MED.
& ETHICS 319 (1996). [HTML]
[PDF]
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Drug Diversion: An Investigator’s Perspective - CME available
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David B. Brushwood, RPh, JD:
The reluctance to prescribe effective opioid medication has often been
influenced by exaggerated fears of addictive behavior from patients and
regulatory scrutiny from medical boards. Accordingly, this activity will
address considerations associated with avoiding regulatory problems.
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| EPEC Legal
Issues Review |
| Pain
Management and Prescription Monitoring (pdf) |
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Physicians told not to fear discipline for pain treatment
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New studies
have a message for doctors who prescribe pain medication: Don't fear
discipline from medical boards or criminal prosecution if you follow
pain guidelines and appropriately prescribe medications. |
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| Pain Management Standards
Clearly, there is now a national movement, in both the
medical and lay sectors, to improve the quality of pain control provided
to both adults and children. Fundamentally, upholding a philosophy that
demands that people need not suffer is becoming a mandate of our society.
Fortunately, regulatory bodies are supporting this concept and physician's
efforts to provide this care.
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