Treatment of Pain

Millions of seriously ill Americans suffer from unrelieved pain. According to pain experts, most of this suffering is unnecessary and could be alleviated by the wider use of opioid analgesics.

Reasonable fears over uncontrolled use of street narcotics have produced unreasonable attitudes about the drugs that are the most effective for controlling pain in patients who are chronically, seriously, or terminally ill. Education about the mechanisms of pain and addiction has been limited. Thus patients, families, health care professionals, and policy makers often confuse three phenomena: addiction, dependence, and tolerance.

Addiction refers to compulsive drug use, the loss of control over drug use, and continued use despite harm. Patients being treated for pain with opioids-a group of drugs including codeine, morphine, methadone and fentanyl that work on specific receptors in the nervous system-typically do not become addicted to them and do not abuse the drugs.

Drug tolerance and dependence are relevant to the medical use of pain drugs. Tolerance means that the body needs more of a particular medication to maintain an effect. A cancer patient may need increasing doses of an opioid to relieve pain. Physical dependence, on the other hand, means that a person may experience symptoms of withdrawal if the drug is abruptly discontinued. Dependence is not unique to opioids. Beta-blockers prescribed to lower blood pressure, corticosteriods prescribed to control asthma, and caffeine self-administered to perk up in the morning all produce physical dependence. Opioids are among those medications that are best withdrawn gradually if they are to be replaced with another medication or discontinued.

Concern that controlled substances (narcotics) will be fraudulently obtained from legal sources and diverted to street use also restricts the legitimate prescribing of these drugs. Recent research indicates that diversion can be controlled without impeding the medical use of opioids.

Pain care can be frustrated on many levels.
A patient may suffer in silence because he thinks it is a character weakness to express pain, because he is afraid of addiction, or because he doesn't want to "bother" his doctor or distract her from other treatment.

Physicians and other health professionals may not offer relief because they don't know enough about how pain operates in the nervous system or how it can be managed. They may have moral objections to opioid treatment or erroneous beliefs about addiction. They may be afraid of being investigated by state regulators if they prescribe controlled substances. They may feel it is "too soon" in a patient's illness to prescribe opioids, and they may fear they will kill a patient if large doses are needed to control pain. Some may want to avoid treating seriously ill patients.

A patient seeking pain relief may not have insurance coverage or the money to pay for medication. Nearby pharmacies may not carry the prescribed opioids at all to avoid the risk of theft, or may have them only in short supply or inconsistently. Friends and family members may exacerbate a patient's fear of addiction or shame over taking a narcotic.

A state regulatory agency or medical board may be operating with outdated drug control laws, regulations, and medical practice standards causing physicians to fear investigation and loss of their licenses if they are regarded as prescribing opioids for too many patients, in too high doses, over too long a time.

While these barriers remain operative, they are being challenged as never before. A number of states are revising their drug-control policies to reflect the current science. In clinical settings, movements are underway to monitor pain as routinely a blood pressure. Myths that old people and children don't feel pain have been thoroughly refuted, although those populations are still widely undertreated for pain. Palliative care programs are teaching clinicians how to use drugs and other means of lessening pain. Part of that education is addressed to patients so they understand that opioids can help them to function better and live longer rather than turn them in to "dope fiends" or "zombies."

These efforts and others are described in the following profiles of palliative care specialists.

Profiles of Researchers and Projects >