Pain Killers (Analgesics): Panacea, Poison or Somewhere in Between
Richard B. Patt, M.D.
He helped establish the Pain and Symptom Management section at the University of Texas M.D. Anderson Cancer Center where, from 1993-1998, he served as its Deputy Chief, Fellowship Director and Associate Professor of Anesthesiology and Neuro-Oncology. Prior to this he helped establish the University of Rochester School of Medicine and Dentistry's pain program and fellowship where he served for seven years as Medical Director and Associate Professor of Anesthesiology, Psychiatry and Oncology in Medicine. While in Rochester he was named the 1992 Visiting Nurse Association Physician of the Year.
An active participant in many professional societies, Dr. Patt is co-chair of the International Association for the Study of Pain's Task Force on Pain and AIDS, and recently completed a three year position on the Board of Directors of the American Pain Society. A prolific writer, he edited the first comprehensive text on cancer pain, Cancer Pain (Lippincott, 1993) and coauthored the first self help book for patients with cancer pain and their families, You Don't Have to Suffer (Oxford, 1994), which has been translated into Chinese and Japanese. He has served on the editorial boards of 15 journals, has written over 60 textbook chapters and over 70 articles in peer reviewed journals. An advocate for the more liberal treatment of pain, he is a well-respected lecturer and teacher, and has lectured extensively abroad, especially in Asia and Latin America.
There are at least two important ways to answer this question. Unfortunately, the most scientific definition, while straightforward, is so disarmingly simple, that it doesn't tell us nearly all of what we need to know about these medications, because it ignores the important cultural forces that influence our use of these medications: the opioids comprise a class of medications that have been employed to relieve pain for well over one hundred years. Their use is so routine in certain settings (after surgery, in the Emergency Room, for labor and delivery, for cancer and in the laboratory) that they are regarded as the standard against which all other pain-killing drugs (analgesics) are compared. These drugs, previously referred to as "narcotics" are derived from or are chemically related to opium, the main constituent of the poppy plant (papaver somniferum), which has been used as a pain killer since biblical times. Science has only recently demonstrated that the human body makes substances that possess a similar structure and function. These endorphins, enkephalins and other molecules, referred to as "endogenous opioids," are thought to be responsible for the so-called "runner's high."
While the above explanation is accurate, it does not even begin to portray the raging controversy that exists surrounding the contemporary use of opioids. While the term "opioid" is awkward at first, it is preferred to the term "narcotic." Contemporary authorities including the authors of our most important pharmacology textbook, Goodman and Gillman's The Pharmacologic Basis of Therapeutics have advised that we abandon the term narcotic. It is so culturally and socially laden with references to drug abuse that its use has a chilling effect on prescribers and patients alike, interfering with appropriate treatment of pain. The lurid images of back alley abuse conjured by the term narcotic eclipse its scientific meaning, and as a result, the term opioid is strongly preferred
In the midst of the tremendous progress that has been made generally in medicine and specifically in our understanding of pain and its treatment it is practically unthinkable that the individual who has done the most to advance our thinking about this issue is Jack Kevorkian. It has taken, arguably a fanatic, if not a lunatic (this author's thoughts) to bring to our attention that despite the most sophisticated health care delivery system in the world, many Americans inappropriately are led to seek an early death because their pain is not adequately addressed. Since medical science is by no means perfect, those who suffer are not necessarily entitled to relief of their pain, but they are certainly at least entitled to our best efforts to achieve improvement, and by no means should they be subjected to humiliation or derision for seeking the relief of suffering. Although when ignored, unrelieved pain like any other chronic illness leads to depression, pain is almost always fundamentally a medical problem, so we should no more coerce the sufferer to "tough it out" than we would encourage a diabetic to withhold taking their insulin as a means to "build their character." While we don't readily admit it, modern medicine actually cures very little of today's maladies: diabetes and hypertension are not eradicated, but are managed, and thus the mandate to manage chronic pain over a patient's lifetime should not be a surprise or a dilemma that we, as a culture, should shrink away from. These unfortunate individuals should certainly not be discarded as having "failed" our current treatments, rather we should acknowledge the shortcomings of current therapies. It is only recently that pain in patients with life threatening cancer has been treated more effectively, and although legislation exists to protect the rights of those with chronic pain (and the prescribing physician), in reality, one practically needs to be dying in this country in order to be assured of getting adequate pain relief.
Can opioids (narcotics) be used effectively to treat chronic pain?
I've already indicated that the use of opioids is controversial in essentially all settings. Debate still persists about medicating terminal patients, so you can imagine how heated the discussion becomes for treating chronic pain, a setting in which there is no end in sight and where complaints often appear to be out of proportion to accompanying physical signs or x-ray findings. Regrettably, most of today's cure-oriented physicians still do not understand chronic pain. Since it has only been recently that, stimulated by hordes of frustrated patients, a few physicians have even developed the courage to ask questions about chronic pain and opioids, it is not surprising that answers are still elusive.
This question is actually probably best regarded as two related questions: (1) are opioids effective in relieving chronic pain, and (2) if so, when (if ever) is their use appropriate? The bad news is that the ultimate answer to whether opioids are effective in the long term will only be answered with certainty with controlled clinical trials which have not even yet been proposed. Since it would be unethical to allow patients to suffer while awaiting this data, we need to be asking what is known that will help guide today's treatment safely?
The good news is that there has been increasing experience with using opioids to treat chronic pain due to a variety of causes. While still not as reliable as a controlled trial, data from this experience can be cautiously applied to many of today's patients with chronic pain. It appears that opioids effectively reduce pain over long intervals in a proportion of patients with chronic pain without intolerable side effects or problems with addiction. One key point here is that as long as the source of pain persists, pain can often be reduced but rarely if ever is it eliminated. Thus, if treatment is to even have a chance at success, patients must maintain realistic expectations, such as a 50% reduction in pain severity. Another key point relates to side effects: in fact, most patients will experience side effects when opioids are first started or their dose is changed, but when medications are started in low doses, are only gradually increased, and with reliance on long-acting formulations side effects can usually be resolved or minimized. Most patients will continue to experience low level side effects as long as opioid therapy is ongoing, but this may represent a reasonable tradeoff if pain is severe. While opioids may produce dangerous respiratory depression when used erratically, this almost never occurs with carefully supervised use. Nausea, sedation and itch are common at first, but usually resolve over time. Constipation is an ongoing difficulty that can and must be prevented with activity, diet and regular gentle laxative use. Because fatigue so commonly accompanies chronic pain, most patients cannot tolerate high doses of opioids, and thus must be satisfied with partial relief. In other words, while opioids are helpful in some cases, they don't eliminate chronic pain: patients continue to have ongoing, but lower grade symptoms, with some good and some bad days. These drugs are not a panacea, but simply represent one of the many tools at our disposal to help make chronic pain more bearable. Moreover, opioids are usually not a first line treatment, and work best when integrated with other drug treatments like antidepressants, anti-inflammatories, muscle relaxants and anticonvulsants, as well as with non-drug therapies like physical therapy, distraction and relaxation training.
Addiction Revisited
In considering the contemporary role of opioids it must be borne in mind that, although these substances are subject to abuse, the intention for which opioids exist is the treatment of pain. Far too often, the potential for abuse interferes with the appropriate use of pain medications for those in need. Although drug abuse is a compelling public health problem, allowing abuse potential to limit access to opioids for those with medical illnesses is an unjust response. A useful analogy is our system of using checks to pay for purchases which is circumvented when "bad" checks are "bounced," ---- but we don't respond by banning checks as legal tender, a policy decision that would punish everyone. If you believe in a higher power, especially one that did not put us here to suffer unnecessarily, then we can reason that God gave us the opioids and their derivatives to better cope with pain and suffering. Unfortunately, as a culture we have been tragically ineffective in distinguishing between drug abuse and the treatment of pain, and thus when it comes to pain medications, it has been a classic case of a few bad apples ruining things for the whole bunch: today's patients with pain have become the innocent victims of a war on drugs that should have nothing to do with them.
Research consistently demonstrates that exposure to pain medications does not foster addiction. In fact, under-prescribing is more likely to fuel addictive behavior, because pain is never relieved, and patients are left feeling abandoned, left to continually seek help that becomes increasingly elusive. With chronic treatment, patients may become tolerant or accustomed to the effects of opioids (thus requiring higher doses over time), and physical dependence (the onset of withdrawal or an abstinence syndrome when treatment is abruptly stopped) may arise, but addiction, a reversible complication, is extremely rare, occurring in no more than a few per cent of patients exposed to analgesics in the course of treatment. Tolerance and physical dependence are inevitable biologic consequences of chronic opioid use, that are independent of the patient's background, values and circumstances. The onset of tolerance and physical dependence are expected, are unrelated to addiction and are not problematic since they can be overcome by simply adjusting doses of medications gradually. Addiction, which is the same as psychological dependence, is an infrequent outcome that is highly dependent on the patient's prior history, experiences and values. Addiction involves compulsive, nonmedical use of drugs that persists despite the presence or threat of physiologic or psychological harm, and indeed is a highly disruptive phenomena. Rare in otherwise well-adjusted individuals, exaggerated perceptions of its dangers causes a great many patients with legitimate pain to be mistrusted and undertreated. Unfortunately, when pain is ignored, most other aspects of healing (rest, mood, nutrition, energy and rehabilitation) also falter. Too often, we operate from the mistaken belief that simple exposure to painkillers produces addiction, while in fact addiction appears to be much more person- and style-specific than substance-specific. Predisposition to addiction has much more to do with an individual's style of coping with adversity, stress and illness. Addicts are less functional as a result of their drug use and become more isolated from the mainstream of life, family and work, while patients using drugs appropriately are consequently more functional, less isolated, and more prone to resuming activities they once avoided because of pain.
In the course of twenty years of educating physicians and nurses, patients and their families, administrators and policymakers and other interested parties about pain management, the topic of addiction never fails to elicit great interest. As a means to convey my thinking about this complex issue and especially the thorny distinction between addiction and the treatment of painful medical disorders with drugs, I created and have come to rely on a vignette that, by employing an analogy focuses our attention in a way that may help us think more clearly about issues that appear bewilderingly complex but are perhaps more simple than they appear to be.
So..heaven forbid, your teenage child or grandchild "borrows" the key to the family car, say a Ford Taurus, goes on to drink a six pack of beer and then wraps said car around a tree. Fortunate enough to walk away from the event, employing another example of adolescent logic, he/she draws the following conclusion: "Ford Taurus* are bad cars."
The obvious corollary is that drugs, in and of themselves are neither "good" nor "bad," although their use can produce dramatically opposed good or bad outcomes depending on how they are prescribed, dispensed and taken ("driven," if you will). Our culture strives to ascribe pat answers to complex phenomenon, and thus arises the oversimplistic temptation to denounce a substance as being responsible for a behavioral problem, because it is often easier than looking honestly at our own maladaptive behaviors. As we have come to recognize the dangers of alcohol and tobacco, it becomes clear that the problem of addiction transcends the domain of illicit drugs, and viewed from an even broader perspective we have come to recognize the hazards of addictions to activities as diverse as gambling, risk-taking and sex.
The recent media feeding frenzy condemning a newer opioid compound, Oxycontin is a prototypic example of how unless such hysteria can be curbed many of the advances that have been made on the behalf of patients with chronic pain can be summarily annihilated. Oxycontin is simply a preparation of an opioid drug that is slowly released over twelve hours to promote even relief without the roller coaster effects and the clock-watching associated with short-acting painkillers. The recognition by abusers that this when crushed, chewed, sniffed or injected, the safety of this miraculous "tiny time pill" could be bypassed led major news organs to irresponsibly capitalize on the sensationalist aspects of this criminal misuse of a product that used properly has helped countless sufferers. This irresponsible journalism has not only disseminated an otherwise obscure strategy of abuse in the minds of susceptible addicts, but has terrified patients who have been benefitting from an otherwise appropriate treatment for years, and has frightened prescribing physicians and pharmacist who are now reluctant to dispense an otherwise very helpful drug. Just like a truly resourceful burglar will find a way to circumvent even the most stringent security system, an addict who is truly intent on abusing drugs will find a mechanism to abuse almost anything. The bottom line message is not to throw out the baby with the bathwater: the answer to curbing addiction to prescription drugs is not to limit their availability, but to teach doctors, patients and pharmacists to communicate more effectively about a problem that is distressing to all of us.
Patients should be aware that while the risk of addiction is exaggerated by even (well meaning) experts, it still exists. Addiction may arise in between 0.1-10% of patients, but it is a treatable disorder, and shouldn't interfere with the consideration of trials of opioids in patients with lower risk profiles. Individuals who have had difficulties with drugs, alcohol and tobacco in the past are at high risk for addiction and are generally considered poor candidates for treatment. Patients in denial who expect a "quick fix" and wish to eliminate rather than manage pain are also likely to encounter difficulties with treatment.
Medical Use of Opioids Appears not to Promote Drug Diversion
A recent article in the Journal of the American Medical Association (Joranson DE, Ryan KM, Gilson AM, Dahl JL: Trends in medical use and abuse of opioid analgesics. JAMA 2000 Apr 5;283(13):1710-4) sheds some light on the use versus abuse issue. These investigators reviewed multiple databases between about 1990-1996. They found that the prescribing of strong opioids increased by 59%, 1168%, 23%, and 19% for morphine, fentanyl, oxycodone and hydromorphone, respectively. Only the medical use of meperidine (Demerol fell (by 35%), which is a good thing, since of all the opioids, Demerol is probably the least safe for chronic use because it occasionally produces seizures. Despite this massive increase in prescribing (that has probably increased exponentially in the last four years), "drug abuse mentions" for these opioids rose by only drug (6.6%), and even more impressively, the proportion of mentions for opioid abuse relative to total drug abuse mentions decreased from 5.1% to 3.8%. This article supports the view that, like almost anything, opioids are abusable, but that with expert medical help, this is a very rare occurrence, and for years we've probably let a few rotten apples ruin things for the whole bushel.
Special Prescriptions: A "Chilling" Effect on Doctor, Pharmacist and Patient
The potent opioids are commonly used (like "mother's milk") to treat cancer pain, and we now understand that they can often be used safely and effectively for chronic pain. Unfortunately, at least in Texas, their use requires a special "triplicate" prescription that must be filled within seven days and that cannot be renewed or called in. Also, pharmacies are often reluctant to stock these medications because of extra paperwork and the fear of robbery, although this situation has improved dramatically in recent years. Most pharmacists now will happily order what patients need if given sufficient notice. Nevertheless, these multiple copy prescriptions have a chilling effect on doctors' prescribing habits, because of the sense that "big brother is watching."
Some good news: due to the work of the Texas Pain Society, Dr. C. Stratton Hill, Jr. and other forward-thinking "activists," the situation in Texas is very reasonable. We were the first state to pass an "Intractable Pain Act" that states that these medications are, in some cases, indispensable for the treatment of chronic pain and that neither patients nor their doctors should be fearful of punishment for their use, as long as that use follows the guidelines of good medical care. There has even been a legislative decision to abolish triplicate prescriptions in Texas, although it is uncertain how and when this will be accomplished.
Route of Administration (Pills and Patches preferred to "Shots")
One of the biggest hurdles we've had to get over is the lurid media depiction of back alley injections and mainlining of drugs, which is a reflection of abuse, not appropriate medical treatment. The good news is that we have come to learn that injections are almost never necessary. Even the strong medications given by mouth or by a skin patch are just as effective as injections. Injections are still used around the time of surgery, in emergency rooms, hospice and when nausea prevents using pills, but almost never for the treatment of chronic pain. They simply are not needed: chronic pain, however unpleasant and distressing, is not an emergency, especially when treated proactively.
Pain "Contracts"
Increasingly, pain clinics are dealing with some of these issues more openly, and one approach includes a pain contract. While not necessarily a true legal document, this approach simply spells out what's expected of both parties, the patient and the doctor. The "contract" can be implied, verbal or written and often includes expectations like you will get all of your pain medications from a single doctor, will not "swap" them with others and will take them only as directed, but on the other hand, that if you hold up your end, your doctor will take your pain seriously and provide sufficient medications to get from visit-to-visit.
The Bottom Line: Summing Up
While opioids are helpful in some cases, they don't reverse the cardinal features of chronic pain: patients continue to have daily pain with some good and some bad days. These drugs are not a panacea, but simply represent one of the many tools at our disposal to help make this dreadful disorder more tolerable. Moreover, opioids are usually not a first line treatment, and work best when integrated with other drug treatments like antidepressants, anti-inflammatories, muscle relaxants and anticonvulsants.
Physicians considering trials of opioids for the chronic pain should not view this therapy as a lifelong commitment: discussions with the patient and family members should identify functional treatment goals which will help determine whether treatment is successful and should be continued or whether medications should be tapered and stopped. While most patients want pain relief, often at nearly any cost, most experts agree that a mature and consistent approach to maintaining an active lifestyle is the most important answer for chronic pain. Thus, opioid therapy is best conducted based on whether patients are able to maintain increases in their functional status. Rather than relying on reports of more or less pain which cannot be substantiated, it is optimal to base treatment on objective outcomes around which the patient, family members and physician can agree on. Thus improved mood, nighttime sleep, daytime arousal, socialization, exercise tolerance, range of motion as documented in a regularly kept diary are the most useful goals for treatment.
