Background
According to a July 27, 1997, release from the American Medical Association, each year the lives of Americans are disrupted by 40 million headaches, 36 million back pains, 24 million muscle pains and by 20 million neck pains. Most receive inadequate care because of numerous barriers to receiving appropriate pain treatment. Another 13 million patients suffer from unrelenting, intractable, non-malignant pain. Only a small percentage receive consistent treatment and relief. Even among almost 4 million cancer patients with pain, one-half to three-quarters are inadequately treated and nearly 25% die in severe, unrelieved pain. Of those with advanced cancer, 79% have severe pain, most of which could be controlled with modern treatment.
The causes of this calamity are clear. In patients, the fear of addiction, or of being seen as an addict, is common. Their families also typically fear addiction, even in terminal cancer and AIDs cases. Further, patients tend to conceal pain, fearing that increased pain reveals increased illness, something every "good" patient is reluctant to admit or impose upon their family and physician. Among Health Care Professionals, poor pain assessment and communication with patients, fear of patient addiction, fear of medication side-effects, fear of regulatory authorities and inadequate knowledge and pain management skills, are constant barriers to proper pain care.
Even ten years later, in 2008, the situation has actually gotten worse. Not only has the population continued to age, creating more chronic disease and intractable pain, but now thousands of military veterans are returning from battle in the Middle East with injuries and pain that will never go away. They are not receiving adequate pain care from any institution, and opiophobia continues to deny them the relief that is entirely available.
Regarding the Health Care System, the principle causes of inadequate pain care are insufficient availability and access to pain treatment, inadequate third party reimbursement, indefensibly expensive long-acting pain medications, low priority for cancer and non-malignant pain, and restrictive and punitive regulation and now criminal prosecution of pain management physicians.
For the last seven years, under the current political administration, each year the Drug Enforcement Administration has annually investigated 500 physicians, forced over 400 to surrender their narcotics license (and therewith destroying their ability to practice medicine), conducted 90+ SWAT team raids on clinics (placing everyone there on the floor with guns to their heads), and removed all clinical records to seek “wrong-doing” – often keeping the records for years and causing the abandonment of thousands of legitimate patients to medical communities totally unwilling to assume responsibility for their care – out of fear and prejudice.
Whereas in 2000 there were over 35,000 physicians providing medical care for intractable pain patients, that number is now 5,000 (or less). The situation is horrific. It is now not unusual for patients to have to fly thousands of miles to find legitimate care.
The DEA argues that their activities affect only less than 1% of the 1,000,000 doctors they license. But this is a manipulation of statistics. When one realizes that they are investigating 500 out of 35,000 (or now 500 out of 5,000) the likelihood of a pain management doctor being investigated was 1 out 700 in 2000, and is now 1 out of 10!) It is no wonder that doctors are terrified of treating intractable pain.
The situation is particularly ironic as highly effective new medications have rapidly emerged, which offer great success in the management of pain. New drugs and techniques are available which provide more effective relief with fewer side effects, at lower cost. Unfortunately, the most common alternatives to pain medication, the NSAIDs (non-steroidal anti-inflammatory drugs), are pharmacologically many times more dangerous, and routinely present as gastric injuries in emergency rooms. In 1996, 76,000 hospitalizations, averaging $20,000 each, were caused by these drugs.
Equally insidious is the effect that this “chilling” has had on the medical community. “Interventional” pain management has been encouraged and approved as an alternative to the “risky” business of medical management of pain. Epidural steroid injections, nerve ablations, Botox injections, trigger point injections and a host of other highly expensive and dubiously safe invasive procedures now constitute a booming and enormously expensive industry. Aside from the fact that this industry drains away billions of increasingly scarce health care dollars for treatments with little evidence of effectiveness, these procedures often result in ineffective outcome, serious complications, adverse reactions, and, in the case of Botox, entirely unanticipated long-term problems. Out of fear of opioids, far more risky alternatives, of unproven effectiveness, have essentially been mandated by the national opiophobia.
Equally seriously, the cost to the nation of inadequate pain treatment is monumental. With contemporary medical management the morbidity of intractable pain can be very substantially reduced. Annually, 1,308 million work days are lost to back pain and 638 million days are lost to headaches. These numbers represent only a portion of the human cost, from acute pain, which is universally under treated.
The costs of chronic pain are probably greater. Intractable pain patients are inevitably disabled; most often completely. With adequate help many could recover significantly. Adequately treated non-malignant pain patients become tax-payers, assert leaders in the pain management specialties. Further, chronic pain inevitably proceeds to depression, and frequently involves alcoholism and illicit drug use, and substantially contributes to the demand for illegal narcotics such as heroin. As also noted by W.H.Stein, M.D., of the UCLA Medical Center, patients in unrelieved pain suffer increased psychiatric illness, more suicides, deteriorations in immune functions and increased metastatic cancer growth. Families are daily destroyed by the fall out of untreated pain. The status of the treatment of chronic pain is abysmal. Stein noted that in one recent study 81% of physicians and nurses felt that the most common form of narcotic abuse in the care of the dying is the under treatment of pain.
The professional costs of treating pain are staggering. According to DEA testimony, In 1995 and 1996, 900 physicians were prosecuted and lost their narcotics licenses for attempting to treat chronic pain with appropriate narcotics. This represents an incidence of almost 1 per every 300 U.S. physicians. In November of 1997, at a meeting in Phoenix, Arizona, of 125 attending pain management specialists, including orthopedic surgeons, neurologists, anesthesiologists, physiatrists, family practitioners and psychiatrists, 20 had been the object of prosecution. In at least 30 states in the union, despite overwhelming contemporary scientific acceptance of the on-going treatment of chronic, non-malignant pain, chronic use of narcotic pain medications is not permitted and is prosecuted. Despite repeated clinical studies which show that less than 1% of all chronic non-malignant pain patients ever demonstrate any symptoms of addiction, the myth of addiction, plus tabloid sensationalism about a "drug-free America", continue to drive "opiophobia".
Regarding state-level values, the Pain Research Study Group at the University of Wisconsin surveyed all the Medical Boards in the nation on their attitudes and policies regarding pain control. While 75% of the respondents approved of the use of narcotic pain medications for cancer pain patients, fully 25% of the respondents still believed that pain medications should not be regularly prescribed for cancer pain. Further, regarding the treatment of intractable pain from non-malignant causes, only 14% approved of the use of narcotic pain medications for non-malignant pain patients, and stated that they would prosecute physicians doing so! Antiquated values and attitudes, and misinformation, still dominate the state level of regulation.
Lastly, the dominant world-wide role of U.S. attitudes toward pain management has distorted and perverted international pain management. In Africa and Asia opioids are virtually totally unavailable to hundreds of millions of people, despite the AIDS epidemic and profound indigenous diseases. The failure of the United States to provide intelligent, rational and caring leadership in world-wide pain control is unspeakably shameful.
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