Redefining Pain Management

• Drug-abuse epidemic – stimulus for change
  • Pendulum swing; WHO opiate ladder for malignant disease process 1986
    • “it is important to note that cancer pain management should be undertaken as part of comprehensive palliative care. Relieve of other symptoms, and of psychological, social, and spiritual problems is paramount. Attempting to relieve pain without addressing the patient’s non-physical concerns is likely to lead to frustration and failure.”
    • In 1986 30 mg/capita à 2009 725mg/capita *Temple University Drug Control & Access to Medicine Consortium
    • Drug-dealing charlatan doctors and well-intentioned but misguided doctors.
      • Presence of doctors trying to treat a disease by only treating its symptoms. stigmatizes even legitimate pain management; Goal of pain mgmt; find reasons for pain
      • Pain medication is means to an end
        • Difference b/t acute & chronic pain
        • Pain medication won’t heal a broken leg, just the symptoms
        • Chronic pain medications only when all other options have been exhausted. There have been many advances in controlling pain without medication.

Pain medication addictive; mustard gas
Bad clinics (pain only provide rx) & what’s wrong with that
Dispensing narcotics

Banning all pain clinics has been proposed as a solution to the prescription drug-abuse problem in Kentucky since medications used for pain treatment can also be abused. Legitimate centers that treat chronic pain, however, need to be differentiated from centers that feed addiction. While pain medications can be addictive, that is not always the case. Any medication can be harmful if not used properly. Mustard gas, for instance, is used as a weapon in battle but was also the first chemotherapy used to treat cancer. Whether it harms or cures depends on using the right amount in the right way. Banning all pain clinics would be similar to banning chemotherapy since the treatment can also be lethal if misused.

There are, indeed, a few clinics that make us weary of all pain clinics – those that ONLY provide pain medication in absence of thoughtful and appropriate attention to the injury. Imagine going to the doctor for a broken leg and just getting pain medicine along with the advise to “walk it off!” Ignoring the injury and simply treating the pain not only worsens the condition but it also promotes addiction and disability. Afterall, pain is just a messenger of injury and not the disease. Medications used for pain management, therefore, are just a single ingredient in a comprehensive approach to healing.

The goal of pain management is to restore function and return the body to its natural form that avoids pain. Physicians formally trained in pain management spend over 9 years learning how to comprehensively address pain in a safe and healthy manner that avoids addiction. Legitimate pain clinics are not simply there to give out narcotics, but rather to find the reason for patients’ pain and address the underlying causes.

Banning all pain clinics may address the pandemic of prescription drug abuse somewhat, but it comes at the sacrifice of legitimate patients who would no longer be able to receive comprehensive pain care. While the universal ban might hinder the source of illegitimate narcotic prescriptions, it does NOT deal with the greater problem of addiction community, which is really what we want to address.

We need a greater understanding of pain management. There is a substantial difference between clinics that promote addiction by simply dispensing narcotics and those that really help by treating the underlying cause of pain. As a community we need to support professional centers who want to help us live healthier lives while seeking sustainable solutions to the addiction problem that plagues the state.

Redefining Pain Management

Forty years ago, one of the greatest fears to becoming ill was not death but rather the pain of disease. From the scarcity of pain treatments arose a global initiative shedding more light on quality of life and pain control. In 1986, the World Health Organization (WHO) published its now famous protocol on pain management commonly referred to as the “Pain Control Ladder.” Whereas it was initially developed for malignant pain, such as cancer, that ladder was extended to non-malignant conditions with some dire consequences.

When the WHO ladder was published 25 years ago, the average US opiate consumption was 30 mg of Morphine Equivalents per person per year; in 2009 it exceeded 725 mg, over a 20-fold increase. The rates of prescription drug addiction have rapidly risen and now exceed the abuse rates of illegal substances such as cocaine and heroin. In the first decade of the millennium, opiate-related fatalities tripled and have continued to rise.

Greater accessibility to medications is a blessing to the patient with intractable pain or a terminal condition, but the pendulum may have swung too far in the direction of opiates. All too often, patients with treatable causes of pain such as joint, back, or neck pain are sustained for years on escalating doses of opiates while ignoring other more sustainable treatments. In doing so, the injury progressively evolves and the pain medication loses its effect. Among those with pain conditions are also patients who have inadvertently become tolerant of or even dependent on opiates. Unfortunately, there has been a national scourge of “pill-mills” and healthcare providers masquerading as pain specialists. Whether unethical or simply poorly trained, these individuals have misrepresented and stigmatized the noble purpose of controlling and rehabilitating pain.

The public needs better understanding of pain management so as to discriminate between those committed to healing and those with less-noble intentions. Legitimate pain clinics do not simply write for narcotics, but rather seek the reason for pain and address the underlying causes. Physicians formally trained in pain management spend over 5 years after medical school learning how to comprehensively address pain in a safe and healthy manner. If necessary at all, opiates are only a means to an end and not the sustaining force of therapy. Other modalities like behavioral modification, focal nerve blocks, non-invasive procedures, and rehabilitation exercise are needed to treat the source of pain and prevent its relapse.

If a broken leg was only numbed with pain medication alone and no casting or rehabilitation was provided, that leg would eventually lose its function and lead to disability. Many chronic pain conditions result from an accumulation of injury brushed under the carpet with opiates. Kentucky ranks among the top five states in disability according to Department of Health and Human Services. It also has 7^th highest rate of opiate abuse. Early treatment with proven therapies by a genuine pain specialist can prevent the deterioration to disability or a chronic pain state.

Our bodies are incredibly resilient and have an amazing capacity to heal. We need a greater understanding of pain management. There is a substantial difference between clinics that promote addiction by simply dispensing narcotics and those that really help by treating the underlying cause of pain. As a community, we need to support professional centers who want to help us live healthier lives while seeking sustainable solutions to the addiction problem that plagues the state.

The Renaissance of Pain Management

On Tuesday, April 24 House Bill 1 was signed into law by Governor Beshear creating stricter regulations on the practice of pain management. Whereas time will determine the effects of the bill, the need for public attention and re-evaluation of pain management is great. Forty years ago, one of the greatest fears to becoming ill was not death but rather the pain of disease. From the scarcity of pain treatments arose a global initiative shedding more light on quality of life and pain control. Gradually that pendulum began swinging in the opposite direction, and today it is clear the pendulum may have swung too far.

In 1986, the World Health Organization (WHO) published its now famous protocol on pain management commonly referred to as the “Pain Control Ladder.” At the time of publication, the average US opiate consumption was 30 mg of Morphine Equivalents per person per year; in 2009 it exceeded 725 mg, over a 20-fold increase. Whereas the WHO ladder was initially developed for malignant pain, such as cancer, it gradually found use in non-malignant conditions with ever-expanding indications.

All too often, patients with treatable causes of pain such as joint, back, or neck pain are sustained for years on escalating doses of opiates while ignoring other more sustainable treatments. In doing so, the injury progressively evolves and the pain medication loses its effect. Among those with pain conditions are also patients who have inadvertently become tolerant of or even dependent on opiates. Unfortunately, there has been a national scourge of “pill-mills” and healthcare providers masquerading as pain specialists. Whether unethical or simply poorly trained, these individuals have misrepresented and stigmatized the noble purpose of controlling and rehabilitating pain.

Kentucky has the 5th highest rate of opiate abuse in the nation and rates 6^th in opiate overdoses according to the CDC. The overdose rate has nearly quadrupled in the past decade and prescription drug abuse now exceeds the abuse rates of illegal substances such as cocaine and heroin. Aside from the societal costs, non-medical use of pain medication costs the national healthcare system $72.5 billion.

House Bill 1 is intended to curb this trend by targeting sham pain clinics, but the public also needs better understanding of legitimate pain management so as to discriminate between those committed to healing and those with less-noble intentions. Legitimate pain clinics do not simply write for narcotics, but rather seek the reason for pain and address the underlying causes. Ignoring the cause and solely treating the symptoms can eventually lead to further degeneration and disability. Physicians formally trained in pain management spend over 5 years in residency and fellowship after medical school learning how to comprehensively address pain in a safe and sustainable manner.

If necessary at all, opiates are only a means to an end and not the sustaining force of therapy. Pain is a symptom, not the disease. So, just as how a broken bone needs mending and rehabilitation, not just pain treatment, most injuries warrant more than just symptomatic pain control. Other modalities like behavioral modification, focal nerve blocks, non-invasive procedures, and rehabilitation exercise are needed to treat the source of pain and prevent its relapse.

Our bodies are incredibly resilient and have an amazing capacity to heal. The public needs a greater understanding of pain management. There is a substantial difference between clinics that promote addiction by simply dispensing narcotics and those that really help by treating the underlying cause of pain. As a community, we need to support professional centers who want to help us live healthier lives while seeking sustainable solutions to the opiate abuse problem that plagues the state.