Read this this morning, & seems to reflect some physicians' (opiate)
ignorance in pain tx.----
from Dallasnews.com, 3-22-05, Healthy Living section, here--(must register
first)
http://www.dallasnews.com/sharedcontent/dws/fea/healthyliving/stories/032205dnli
vbrody.9bbd.html

Doctors have much to learn about controlling pain

Writer learns lesson the hard way: Patients must be more assertive

08:31 AM CST on Tuesday, March 22, 2005

By JANE E. BRODY / The New York Times

My surgeon did a marvelous job replacing my arthritic knees and, at the same
time, straightening my terribly bowed legs when, at 63, I decided to have
knee-replacement surgery.

Although a class given at the hospital before the operation repeatedly
emphasized the importance of adequate pain control, the surgeon and his
helpers were not experts in treating prolonged, debilitating postoperative
pain.

They are hardly alone. Pain management is not generally taught as a part of
medical education, not even to residents in orthopedic surgery.

As a result, most doctors are clueless or unnecessarily cautious about
treating pain, especially chronic pain such as that caused by incurable
neurological or muscular disorders.

Opioid ignorance

They are especially ill-informed about opioids, which are synthetic versions
of morphine, the most potent painkillers that can be taken by mouth.

As Dr. Jennifer P. Schneider writes about opioids in her book Living With
Chronic Pain (Healthy Living Books, $15.95), "Fear and lack of knowledge of
these drugs prevent many doctors from prescribing them for people whose pain
is caused by anything other than cancer."

Yet, she continues, in 1995 The Journal of the American Medical Association
lamented the reluctance of physicians to prescribe needed pain medication.
The journal stated: "Bringing about significant change may depend on
empowering patients to demand adequate pain treatment. This empowerment will
not come easily, especially if opioids must be used for pain relief and if
the pain is of a nonmalignant origin."

Pay attention, current and future patients. The journal's message is really
for you: Learn what you can about pain control and insist that experts in
treating pain help you through it.

I did not know that the dose of the sustained-release opioid OxyContin
(oxycodone) that I was taking - 20 milligrams twice a day - was a low dose
until seven weeks after surgery when I learned about a high-functioning man
with incapacitating chronic pain who takes 500 milligrams daily (admittedly
a very high dose but a necessary one in his case).

I also did not know that the other pain drug I was prescribed for
breakthrough pain, Percocet, was really short-acting oxycodone plus
acetaminophen.

Because my pain was frequently intolerable despite the two doses of
OxyContin, I was taking as many as 10 Percocets a day, incorrectly using it
as a maintenance drug.

Yet, when I complained about the severity of my pain, which had me crying
for several hours a day, the surgeon added an anti-inflammatory drug and
told me to take half the OxyContin and Percocet. No surprise that my pain
remained unrelenting and occasionally worsened.

Doctor's office unhelpful

I called the surgeon's office weekly and reported my minimal progress in
pain control, but at no point was an increase in pain medication suggested,
nor was I referred to a pain management specialist on the hospital staff.

When, at seven weeks after surgery, I spoke to Dr. Schneider, a Tucson-based
specialist in pain management and addiction medicine, she chastised me for
not being more insistent about getting adequate pain relief. The trouble is,
when you're experiencing intense pain, it's hard to be proactive about
anything.

I know now from speaking with several doctors who routinely treat chronic
pain patients that my story is hardly unique. Millions of people suffer
needlessly year after year because their doctors do not know how to treat
pain properly and don't refer patients to doctors who do know.

Many doctors are afraid they will create an addiction problem, which in fact
rarely happens to chronic pain patients who don't have a history of
addiction.

When a pain patient needs increasing doses of a narcotic, it's nearly always
because the pain worsens, as often happens in patients with advanced cancer.
Patients do become tolerant to side effects, like grogginess, but rarely to
the pain-relieving properties of these drugs.

Furthermore, undertreatment of pain can actually cause a chronic problem
when the nervous system changes in response to continuing pain signals.
Nerves can become permanently hypersensitive to painful and nonpainful
stimuli, such as touch or vibration. With chronically undertreated pain, the
painful area can also spread well beyond the original injured site, as
happened to the man who now has to take 500 milligrams a day of OxyContin.

"The way to prevent this undesirable outcome is to avoid repeated pain
signals," Dr. Schneider said. "Long-acting opioids like OxyContin, which
provide many hours of consistent pain relief, are more effective than
short-acting opioids, like Percocet, at preventing pain. It takes less drug
to prevent recurring pain than it takes to treat it."

However, Dr. Schneider wrote, "Because breakthrough pain is common in
patients with chronic pain, patients being treated with long-acting opioids
often need a second prescription for an opioid with rapid onset" to treat
breakthrough pain. These second medications are "meant for transiently
increased pain, not as part of your regular pain regimen," she explained.

On the wrong track

When I read this, I realized I was on the wrong track, taking too little of
the long-acting drug and too much of the short-acting one. The latter had,
in effect, become my maintenance drug rather than the one I used now and
then when, say, I had physical therapy or spent hours riding in a car.

Surgeons may know a great deal about cutting, repairing and sewing up, but
they are not experts on pain control, though I think they should be. I know
of an orthopedic surgeon in New Jersey who won't see his knee replacement
patients for two months after surgery because he doesn't want to see them
when they're suffering.

As it turned out, my internist knew far more than my surgeon about treating
pain. He has many elderly patients with chronic pain and knows very well how
to treat it. I realize now I should have sought his help from the beginning.
Or I should have asked to be referred to a pain management specialist at the
hospital where I had my surgery.

Patients should insist

First and foremost, patients need to be proactive and insist on the help
they need. If patients are not able to do this for themselves, an advocate
should do it for them.

Second, every person with prolonged or chronic pain should become educated
about the huge range of medications, therapies and complementary remedies
available to treat pain.

"Most chronic pain patients receive more than one type of drug and end up
taking a cocktail of pills," Dr. Schneider said. The many possibilities
include anti-inflammatory drugs, muscle relaxants, drugs such as
anticonvulsants that treat nerve pain, antidepressants (in doses much lower
than those used to treat depression), topical analgesics and sleeping pills.

In addition to using combinations of drugs to control pain that does not
respond to one remedy alone, Dr. Schneider writes that patients may be
helped by physical therapy, exercise, acupuncture, electrical stimulation,
heat, massage, yoga, hypnosis (including self-hypnosis),
cognitive-behavioral therapy, biofeedback and various relaxation techniques
such as guided imagery, meditation and progressive muscle relaxation.