The under-treatment of pain – a worldwide phenomenon

Under-treatment of pain is common in all societies including industrialised countries such as ours. It is argued that a principle role for medicine is the relief of pain and that it is essential to review the use of narcotic medications as one essential approach to the treatment of chronic pain. The use of opioid medications for pain relief is a controversial issue, and there is vigorous debate within the various speciality groups (including pain medicine and general practice) about their role. Severe, chronic non-malignant pain is common, and is increasing in incidence and severity as our population ages and medicine becomes skilled at keeping patients alive who have major pathology. Many of these patients will require opioid analgesia. Modern formulations of narcotic analgesics make satisfactory pain relief both more effective and safe to administer on a long term basis. Long acting opioid medications are less likely to be abused, but abuse is still possible. This article aims to provide some basic data for practitioners to review to clarify thinking of aspects of the prescribing of opioid medication, and in particular, prescribers are asked to review their attitudes to the opioid medications and to have regard to the significant consequences of either not prescribing or under-prescribing where there is a clinical need for such medications.

1. Introduction.A principal role for all health care providers is the relief of pain and suffering. This is a noble aim, but even today, there is widespread under-treatment of pain. This is a worldwide phenomenon, noted as much in Australia as in any other country. A study in the United States has shown that approximately 50-70 million people are either under-treated or untreated for their pain. It is believed that similar pro rata figures would be found in Australia, but this author is not aware of any similar study for this country. The aim of this paper is to explore the issue of treatment and under treatment of pain and to review some of the factors leading to it. In addition, later articles will discuss practicalities of treatment and put forward some suggestions as to how the problem may be overcome by more relevant pain management in persons requiring opioid medication.Many issues within the discipline of pain medicine can arouse debate; few arouse such passion as the prescribing of opioid or narcotic drugs. To the phenomenon of fear of the use of such medications, the term opiophobia is applied.Many medical practitioners are concerned about overdosing or over medicating their patients who have either acute or chronic pain. In fact under treatment of pain is a very much more frequent phenomenon than over treatment and the problem is seen throughout the world, in both industrial and pre-industrial societies. There are many reasons for the under treatment of pain and some of these include: — Fear of overdosing the patient,- Fear of regulation, including medical boards, the law and the penalties that these bodies may impose,- Fear of the legal system, and the penalties which that may imply,- Personal anxiety about the use of opioid medications,- Anxiety about what our colleagues will think,- Concerns about addiction.- Insufficient resources – either financial or drug availability.2. The Role of Opiophobia.Opiophobia is to the term given to the fear of opioid drugs. This is common in our community, both amongst individual persons who may also be patients and medical practitioners who can be the prescribers of such medications. The phenomenon is very common throughout society, and it explains attitudes to drug use it a number of ways including medical prescription for pain, which is coloured by attitudes to those people labelled “drug addicts”.How much then, does opiophobia interfere with daily prescribing of opioid medications for pain? The answer appears to be – a great deal. Reasons for this include may of the factors set out above.Some of these issues are explored below in the hope that discussion may assist the confidence of practitioners in their daily prescribing of these medications for the many patients who would benefit from any reduction in fear of opioid prescribing. As an analogy, if the medications used for pain relief had a similar public perception to those for infectious disease, diabetes or hypertension, then pain, acute and chronic, malignant and non- malignant would be much better managed than it is now.3. Issues of AddictionMost medical practitioners and almost all members of the public are concerned that if opioid drugs are used even for a short period of time for pain relief, then those persons taking them will become addicted. Medical practitioners are also concerned that if they prescribe drugs of dependence they will be either causing addiction or adding to the medications already available to drug misusers.What then is addiction, and how does that relate to the treatment of pain?There are a number of definitions of drug addiction, but these all include the compulsive use of opioid medications usually obtained illegally and administered, often inappropriately and in a dangerous manner, for personal pleasure, even though the use of such medication will cause harm to the user and those close to them. Some writers choose to think of addiction as a “brain disease” in which the diagnosis is most often made prospectively over time by monitoring the patient’s behaviour. The issue of what is addiction is much more complicated in patients who have pain and who are taking opioid medication.”Addiction is a primary, chronic, neuro-biologic disease; with genetic, psychosocial, and environmental factors influencing is development and manifestations. It is characterised by behaviours that include one of more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.” This definition excludes such issues and tolerance and harm and focuses upon the psychological factors involved in “addiction”. In the public mind there are two views of addiction:– “Even though I am taking this medication for pain, if I can’t get the medication I need will I abuse the medication in some way or perform some criminal act to obtain my medication”?- “If I take the medication from more than a few days or weeks, will I become addicted that is will I develop the withdrawal syndrome?”In fact the first of these is uncommon among pain patients, unless they already known to have a history of substance misuse. There are no accurate figures as to the incidence of addiction in pain patients who no previous history of drug abuse because it is so difficult to define addiction when pain is present, but it is thought to be low and most likely close to 1%.The development of a withdrawal syndrome is an inevitable side-effect of the prescription of opioid medications. The abstinence syndrome can occur after only a few days of opioid therapy although the full syndrome may occur after only a week or two of therapy. The severity of the abstinence syndrome is dependent on many factors including dose, duration of the medication, and personality factors. Those with a prior history of opioid misuse will be more likely to report such a syndrome.Most medical practitioners are familiar with the types of behaviours drug abusers may utilise to obtain inappropriate medication. Such behaviours include arriving at the end of the day so there is no possibility of contacting the alleged previous prescriber, losing scripts or coming back early for medication, demanding one specific type of medications such as pethidine and having signs of injecting of oral medication, commonly at the elbows.Drug addiction is common in our society (1 to 2% or more of the population), but the drugs of abuse include alcohol, benzodiazepines as well as heroin, cocaine, amphetamine etc. There is little difference between the behaviours in all mood altering drugs, and the issues of treatment are similar. The diagnosis of “addiction” in pain patients is difficult because persons with chronic unrelieved pain will often take steps to obtain pain medication which may seem “wrong” such as doctor shopping but the behaviour ceases once the pain has been relieved. This behaviour is often referred to as “pseudo-addiction”. Pseudo addiction is “a misdiagnosis that results from under treatment of pain”. 4. Issues of pain.Pain, and especially acute and chronic non malignant pain, is much more common in our society that many of us care to think. Probably the commonest cause of chronic non-malignant pain is osteoarthritis of the knees although most practitioners would regard chronic lower back pain (also a very common cause of pain) as the most frequent.It is not the aim of this paper to discuss alternative treatments for chronic pain, (although there many of them) but to focus on those persons who have an appropriate need for opioid medication when no other techniques appear adequate.A significant key point is that under treatment of pain may well lead to significant morbidity of its own. For example the older woman patient who has osteoarthritis of the knees and who is under treated will be forced to stay chair-bound with significant reduction in quality of life and eventually developing the complications of reduced activity such as even weaker muscles than desirable and even bed sores. Even small doses of an appropriate analgesic medication (which does not necessarily mean opioid drugs) will give the patient a significantly improved quality of life with increased mobility.Chronic lower back pain is a very common cause of significant morbidity in younger people and will often lead to cessation of work and reliance on pensions, again with reduced quality of life and diminished self-esteem.As indicated above, under treatment of pain is common, almost certainly more common than “over treatment”The factors which lead to the under treatment discussed above, are complicated, but are often based on issues around concerns about prescribing opioid medication, as outlined above. The aim of this paper is to try to enhance debate about the proper use of these medications when such use is appropriate, and to assist the practitioner in having the confidence to prescribe when appropriate.5. Illicit Drug Use for Pain Relief.For those pain practitioners to work in methadone programs, most will be aware that for drug misusers, pain is common concomitant. Recent studies have shown that at least 40 to 60% of persons on methadone programs had significant chronic pain issues and a study in the Australia has shown it may be as high as 70%. If this is the case, (and the evidence suggests that it is), then there is a significant issue in need of a review. Studies in New York also had shown that a significant minority of patients on methadone programs are there having misstated that they have been using heroin, to obtain appropriate pain medication for their medically untreated pain.It is known that illicit drugs are freely available in the community and it is much easier to obtain drugs like heroin or illegal morphine than morphine from a practitioner for appropriate pain relief. Thus the well meaning doctor who declines to provide appropriate pain relief because he or she is concerned that the patient may become addicted, may well be forcing the patient onto the street to obtain these illegal and often dangerous medications.6. Doctor Shopping.In many countries it has been difficult to obtain data about Doctor shopping, although it is thought to be common in almost all societies. In Australia the study of doctor shopping is simpler because of centralised funding of medications on the NHS and the Federal government has made a determined effort to understand the problem in part because of cost to government, and concern for the well-being of the individuals involved. Commonwealth government figures have shown that 70% of doctor shoppers have one or more illnesses, and that less than half are seeking to obtain medications for their drug habit. Patients identified so far in this category in Australia appear to be inappropriately treated for physical or psychological pain or both. Such doctor shopping habits are dangerous for the individual and have repercussions for the individuals concerned as well as society.Thus the proven doctor shopper presenting to a medical practitioner for extra medication, needs to be reviewed to ensure that there is no underlying illness. Conversely, only one third of patients who are Doctor shopping appear to be doing it to obtain drugs for a “high”.7. Use of Non-Narcotic Drugs where possible.There are now medications available which are non-narcotic and may well be satisfactory for a number of patients who suffer from pain. For a patient who is not well known to the practitioner and who presents with an emergency pain problem, drugs such as tramadol are preferred as it may well prevent the practitioner from receiving continued visits from such a patient looking for drugs. In case of illnesses such as migraine tramadol is usually satisfactory and may well stop the patient from developing a drug habit via for inappropriate medications such as pethidine.8. Role of Narcotic Medications.The narcotic medications are appropriate under the following conditions: displays: — When all other treatment modalities have been eliminated,- For the reduction of pain,- For improvement in the quality of life,- To enhance the capacity to return to work, including of course functioning in a domestic situation.The issue of prescribing narcotic medications is both controversial and an emotional issue even within the pain community. There are positive indications for the use of narcotic medication as outlined above. When practitioners are concerned about whether to use narcotic medication or not, the disadvantages of not using them should be taken into account as well as the benefits.Although this will be discussed in a later paper, the principle of treatment for patients with chronic pain is to prescribe long acting medications. Short acting opioid drugs may well be necessary to adequately relieve break-though pain.9. Safety and Dosage.Narcotic medications are remarkably safe for long term use and contrary to common opinion, the efficacy of the drug does not change, so dosage dose not have to increase unless the underlying disease worsens. Some patients can stay on the same doses for many years, and some will use the medication to mobilise and over time, the dose will fall, or the medication will cease altogether.The issue of dosage is both controversial and can be a very emotional issue among prescribers. In most patients, small doses will give a major change in the pain problem, allowing greater mobilisation and quality of life. A few may require larger doses. The determinant is not the dose, but the improvement in function. If increasing the dose does not give improvement in pain or function, then the dose should be reduced or the drug ceases as not all pains (especially muscular disorders) are opioid sensitive. In these cases alternative therapies need to be tried.References.1) Krames ES, Olson K. Clinical Realities and Economic Considerations: Patient Selection in Intrathecal Therapy. Journal of Pain and Symptom Management 1997; 14 (3 suppl): S3-13. 2) Portenoy R K, Payne R and Passik SD. Acute and Chronic Pain in Lowinson JH, Ruiz P, Millman RB and Langrod JG. Substance Abuse – A Comprehensive Textbook. Fourth ed New York: Lippincott, Williams and Wilkins 2004, Chapter 55:863-904.3) Gourlay D, Heit H, Almahrezi A. Pain Medicine 2005;6(2): 107-112.4) Savage SR, Joranson DE, Covington EC et al. Definitions related to the medical use of opioids: evolution towards universal agreement. Journal of Pain and Symptom Management 2003; 26 (1): 655-657.5) Fisher F. Journal of the American Physicians and Surgeons 2004;9 (1): 25-28.(Kindly contributed by Dr Ian Buttfield, Specialist Physician MB,BS, MD, FRACP, FRACMA.)The statements or opinions that are expressed in Pulse News and the website are the views of the authors and do not represent the official policy of the Virtual Medical Centre unless declared.