Pain - The Killer
The need to adequately treat pain is more than a moral issue. Extensive research over the past 20 years has established that untreated pain is a medical emergency, not a matter of convenience. Inadequately treated pain causes extended recovery times from surgery. It also causes extended reactions of the immune system with elevations of stress-related hormones, which has many effects, including delayed healing; cardiac stress with elevated blood pressure and pulse rate; increased clotting times; and major depressions. Most importantly, inadequately treated pain is accompanied by a high rate of suicide.
Recognition of these facts was a major impetus for the recent JCAHO changes in accreditation requirements. These standards now require that pain be evaluated consistently as the "fifth vital sign" (Heart rate, blood pressure, respiration rate, body temperature). They also require the pain level to be tracked with a standard record form and that the evaluation of the patient and the patient's family be consistent with the evaluation of nursing and the physician. The JCAHO is quite serious about this new standard and it has created considerable turmoil in the nation's hospitals and other health care organizations.
Why the situation ever developed is less than clear. Historians point out that following both World Wars I and II there was no surge in abuse of narcotics by returning wounded and disabled. Heroin addiction rates have been largely stable for the last 75 years. Contemporary increases in heroin addiction have been transitory. The cocaine epidemic of the 80's has abated to consistent rates of use. Designer drugs, such as "Ecstasy", the darling drug of "Raves", is also relatively stable over the last decade. Alcohol and tobacco use are still substantial and consistent. It appears that "narcophobia" is more of a social phenomenon and fad, rather than an evidence-based issue of public health.
It is clear that a major driving factor behind this "narcophobia" is the media. The contemporary media has become a giant black hole that must be filled. 500 television channels on the cable, 90 million internet users, and a flood of magazines and newspapers now vie for audience. Advertising revenues are based upon audience statistics and the entire media has become infested with "Tabloid mentality".
The ethics of journalism have faded into oblivion as tabloid imperatives have taken over. "Report first and research later" (if at all) have become the operative directives. The Cleveland Free Press, for example, recently ran an article excoriating the media for fostering the pseudo-epidemic of Oxycontin "abuse". Instead of 59 deaths in Kentucky, more objective research revealed that the actual figure was 2. That did not prevent Newsweek, 48 Hours, the New York Times and even the Wall Street Journal from jumping on an hysterical bandwagon.
Sadly, even the availability of a medication as unarguably useful and safe as Oxycontin became threatened by this same media-generated hysteria. The media must fill it's own void. Drug-bashing is a convenient readership enhancing device.
Another factor appears to be the prison-industrial complex. Prison building, probation-parole, court expansion and lawyer employment are at an all-time high. Approximately 1 out of every 40 people in the United States is now on Federal probation or parole!! If state probation and parole are added, the ratio drops to 1 out of 30!! The United States has the highest per capita rate of incarceration in the world (China, our current totalitarian whipping-boy, is far below our rate, as is North Korea!) The political cash cow for the last two decades has been the "War on Drugs", which has turned out to be a war on the Constitution, including civil rights, property rights and due process. It has also become a war on doctors and patients in pain.
Equally important is the cash-hungry appetite of law enforcement bureaucracies. Whenever a public agency wants to protect its budget, or increase it at legislative budget-making time, the oldest trick in the book is to create a public "crisis" that only it can relieve. So as regularly as clockwork, when budget making time comes around each year, there is a flood of media new items, usually unattributed, announcing various crises which demand additional money, personnel, facilities and equipment for the agencies which create these news items and surreptitiously disseminate them through the "news" hungry media.
A third factor appears to be the hysterical nature of the naïve public. Unfortunately, public education does not seem to place much emphasis or priority on critical thinking. The ability to analyze the logic and thinking behind conclusions is not something with which we are necessarily born. And most school systems place little emphasis on teaching us how to analyze logic and conclusions. So, too often these days it seems that the conclusions that are touted the most, or screamed at us most loudly, or communicated most seductively, are accepted as the truth. A perfect example is the most recent hysteria about Oxycontin.
Suddenly the media was full of headlines such as, "the newest drug craze", and "deadly drug hits the streets", "59 dead in Kentucky". Within days every publication and television news program breathlessly announced impending doom from Oxycontin. Not until a month later did the Cleveland Plain Dealer print an article dissecting the dramatic claims ("The Oxyconjob").
When the facts were carefully reviewed it turned out that the hysteria of a month earlier was just that. Of the 59 deaths reported earlier, only 2 involved Oxycontin alone. All the others involved multiple substances, most notably alcohol. Although there have been some overdose deaths from the illicit use of Oxycontin, they are statistically insignificant when compared to the millions who are able to have a life through the use of this drug. A few people sniff gasoline and destroy their brains. Millions use it to drive to work. Do we ban gasoline or limit its production?
Recently a civil jury in California awarded a family $1.5 million for the needless suffering imposed upon their dying father by an opiophobic physician. Unfortunately, when this family complained to the California Board of Medicine, no action was taken. They then turned to the courts for relief.
Several months earlier the State Medical Board in Oregon fined a physician and placed him on five years of supervised probation for inadequately treating pain.
These two events signal, I believe, a sea change in attitudes and practices in medicine. Doctors will either have to become expert in the treatment of pain or become expert in referring to physicians who are. The previous use of "addiction" as an excuse to abuse and neglect patient suffering will no longer hold water. Hopefully the impending federal Patients Bill of Rights will address this issue as well.
Meanwhile, State Boards of Medicine continue to harass and persecute physicians for the legitimate practice of pain relief. Most recently, the New Mexico Board of Medicine brought an action against Joan Lewis, MD, a specialist in Albuquerque, alleging injudicious prescription. Dr. Lewis, whose work is well known to me, is an outstanding doctor. Ironically, in 1996 and 1997 she was asked by that same Medical Board to serve on the committee that drafted the policies on pain treatment that became the standard in New Mexico. Now they are prosecuting her. No one knows or understands why. Adding further mystery to the picture is the fact that the state legislature in New Mexico passed an intractable pain act in 1998, protecting the right of doctors to treat intractable pain!
This same board persecuted my treatment of intractable pain from 1991 until I gave up trying to practice there in 1997. I currently am suing them in the Federal District Court in Northern Virginia. We are to go to trial in October of this year. Ignorance is one matter, viciousness and vindictiveness is another. In my personal opinion, this Board leads the nation in stupidity on the subject of the treatment of intractable pain. Hopefully a jury will soon have the opportunity to strike respect for human beings and the law into their hearts. Dr. Lewis will certainly also benefit from this objective review by a jury of our peers. I am going to ask for $25 million in punitive damages. Perhaps that will get their attention.
The treatment of intractable pain remains one of the most important problems in American medicine. Despite widespread efforts to bring pain treatment into the 21st century, pain patients continue to be abused, stereotyped, slandered, abandoned and ignored thousands of times every day.
The Email received by the National Foundation is a litany of desperate cries for help. The NFTP responds to at least 25 patients a day. With adequate support that number could be a 1000. Outcome studies done by the Foundation reveal that is is a rare circumstance when a patient cannot be helped back to significant personal function with adequate pain relief. Instead, millions of people remain bed-ridden, and terminally depressed, by what is essentially an iatrogenic illness. Doctors refusing to adequately treat their pain ("you might get addicted"!) force millions into total disability and uselessness and then slander them as "drug-seekers".
J.S. Hochman, MD