If the World War II generation was more likely to tough out intractable pain, baby boomers who come to doctors for pain relief expect results. Until recently, they may have been disappointed. However well-intentioned, the medical community has often failed to bring relief to suffering patients. This discomforting reality can be traced to at least four factors: inadequate training, limited treatment options, fears about drug abuse and addiction, and the lack of a foolproof way to adequately test for pain.

Doctors don't always receive extensive training in treating chronic pain in medical school, and even the general pain information they learned may be outmoded, says Russell Portenoy, chair of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York City and past president of the American Pain Society.

That has begun to change, as the American Academy of Family Physicians, the American Academy of Pain Management, and other groups offer seminars and special sessions in pain management. In addition, at least five states now include pain management as part of their continuing education requirements for renewal of medical licenses and even more states encourage it. On another positive note, 72 percent of chronic pain patients in a nationwide survey described their doctors as "supportive and friendly," and nearly 60 percent had experienced some relief.

Where drug options are concerned, however, doctors have long selected from a discouragingly short list. Most research on drugs to relieve pain has focused where aches originate: the skin and other tissues outside the central nervous system, known collectively as the periphery. "Today's most popular remedies -- aspirin and other NSAIDs -- largely work their magic in the periphery," wrote Allan I. Basbaum and David Julius in a 2006 issue of Scientific American. "Stubbing a toe or leaning against a hot stove activates neurons (nerve cells) called nociceptors that respond specifically to hurtful stimuli. When a tissue is injured, a variety of cells in the area pump out chemicals called prostagladins, which act on the pain-sensing branches" of those nerve cells. Aspirin and NSAIDs, the authors explain, cut back on the activity of a family of enzymes that cells use to pump out the prostaglandins that lead to pain.

The problem, Basbaum and Julius point out, is that NSAIDs can keep cells from pumping out prostaglandin in other parts of the body, sometimes leading to side effects such as stomach pain, diarrhea, and ulcers. This can interfere with their long-term use and force doctors to limit their dosages as well. (Also, in many cases, prostaglandins are not the cause of the pain. In those cases, NSAIDs will be ineffective.)

Doctors may prescribe acetaminophen, commonly known as Tylenol, in combination with opioid drugs like hydrocodone (Vicodin) or oxycodone (Percocet). Acetaminophen is effective against many types of pain and is gentler on the stomach than anti-inflammatory drugs. The main concern with acetaminophen is that in large doses the medication may stress or damage the liver.

Clincians may also turn to anesthetics such as lidocaine, which dentists use to numb gums while repairing teeth, to treat pain; a patch that slowly releases lidocaine is now commonly used for pain stemming from certain types of nerve damage. Some antidepressants are also prescribed off-label to treat certain kinds of chronic pain, especially pain caused by nerve injury.

But when these drugs fail to relieve pain, physicians often are left with what feels like an unpalatable choice: narcotics.

Opiates have fallen in and out of favor since antiquity, and the controversy continues. Morphine (and its younger opioid cousins like methadone and fentanyl) controls the more common types of pain very well, but those drugs are still perceived in some quarters as an undesirable option for non-terminal pain, partly due to concerns about addiction and tolerance. Just ask Thomas Greenly (see Part I of this story). The kind of hesitation his doctors voiced about the wisdom of prescribing opiates was hardly unheard of.

The reasons are deeply ingrained in American culture. Some experts argue that America's often puritanical attitude toward narcotics -- and some states' strict regulations that affect physicians who prescribe pain drugs -- have led to "opiate phobia" in medicine. In a study published in the Journal of Law, Medicine, & Ethics, Washington and Lee University law and health professor Tim S. Jost reported that doctors are likely intimidated by notices from state Medicaid Drug Use Review programs. Screening for drug abuse and fraud, the DUR program sends letters or other notices to doctors who seem to be prescribing large amounts of morphine or opioids. The letters are often routine, and state prosecutors told Jost they are not interested in prosecuting physicians who are legitimately prescribing these drugs for pain.

But in at least one case, a Kansas doctor prescribing narcotics for cancer pain was wrongly prosecuted and served time in prison before being exonerated. Physicians become nervous when they receive a DUR inquiry, and it tends to make them cautious about aggressive pain treatment, Jost says. Fortunately, over the past five years many states are seeking to balance the need to treat patients with efforts to reduce misuse and diversion of drugs. Recently, the Federation of State Medical Boards drafted model regulations for the medical use of controlled substances and almost half of the states have adopted them, at least in part. In addition, 40 states have adopted policies that deal with practitioners' concerns about being investigated.

Even patients afflicted with severe pain often fear opioids and addiction. A "significant number" of chronic pain sufferers surveyed in one 2004 study, for example, were hesitant to take narcotics -- even though nearly half of them reported that their pain was not under control.

Some of the worries are valid. The drugs often have unpleasant side-effects, such as severe constipation, and they may also cause confusion and other problems in brain function in some patients. They can also lead to physical dependency. As the use of opioids has skyrocketed over the past decade, so have rates of dependency and diversion of the drugs for non-medical purposes. Numerous studies have shown drug abuse among 18 to 41 percent of patients receiving opioids for chronic pain. Between 1997 and 2006, sales of methadone increased 1177 percent and sales of oxycodone increased 732 percent. During the same period, the number of people aged 12 or older who admitted to non-medical use of psychotherapeutic drugs and pain relievers increased 167 percent and 92 percent, respectively. These statistics point to the importance of close monitoring of patients on prescription opioids to ensure their proper use.

Still, there is little doubt of the therapeutic value of opioids in the treatment of cancer patients, which has been confirmed by scores of studies over the past decade. Clinical trials show that other chronic pain patients can also benefit, although evidence of their long term (over six months) effectiveness is variable. The American Society of Interventional Pain Physicians gives only a weak recommendation for the long-term use of opioids in the treatment of chronic pain, which means the best therapy may depend on the circumstances of the particular patient.

Physicians face the challenge of staying on top of the latest studies and guidelines in a field that is rapidly evolving. In addition, perhaps the biggest challenge facing physicians is the fact that there is no adequate test for chronic pain, other than patient reports.

Traditionally, pain medication has been dispensed and used on an as-needed basis, giving many patients the perception that pain drugs are to be used only when discomfort reaches an unbearable level, says Dr. Portenoy. In some cases patients become so afraid they won't be given more pain medication later if they need it that they hoard pain pills and don't take the medication as directed.

In other cases patients think pain should be toughed out. "There's a streak of stoicism out there, the idea that pain is redemptive or good for people in some way," says Dr. Portenoy.

And when patients choose or are forced to bear pain, the consequences can be dire. Recent studies paint a disturbing portrait of unmanaged pain. Not only are rates of depression more prevalent, but in perhaps the most chilling statistic, one study found patients with chronic pain committed suicide at two to three times the rate of the general population, while another found that one-third of those said they, like Thomas Greenly, had seriously considered suicide.

Elderly patients may receive especially spotty pain management. A 1998 study that looked at 13,625 cancer patients in nursing homes found that 30 percent reported daily pain. Yet only 26 percent of those were receiving morphine for their pain, while more than a quarter got no analgesics at all -- not even aspirin. The authors noted that pain appears to be underreported and undertreated in the elderly, even though there is no physiologic basis for a reduction in pain as people age.

As the National Institutes of Health reported in 2005, "While advances have been made in the management of pain, these advances have not translated into standard-of-care practices in the clinical setting. A significant proportion of patients report that they are not routinely asked about their pain …and at times are not offered any treatment even when they do report problematic symptoms. Undertreatment is related to fears surrounding the use of opioids [which are] often exaggerated or unfounded….Patients continue to suffer from inadequate relief of their pain."

Even patients treated with narcotics report inadequate relief. In a 2006 American Pain Foundation survey of adults taking an opioid for chronic pain, more than half felt "little or no control" over their pain. Three-quarters reported feeling depressed, and more than half said their chronic pain had strained their relationship with family and friends. Intractable pain had cost half of them a job, 86 percent reported trouble sleeping at night, and most admitted that pain had undermined their enjoyment of life.

"People don't understand how debilitating it can be to live with chronic pain," says Andrea Cooper in response to the APF survey. Cooper, who says she has suffered from chronic pain for years, adds, "I may look okay on the outside, but I'm screaming on the inside. It prevents me from doing some of the things I love the most."

Of those surveyed, more than three-quarters were looking for new options to treat their pain. Only 14 percent were satisfied with their current medications. Equally disturbing, less than half said they were getting enough information on effective ways to manage their pain.

"Millions are suffering too much for too long and need more aggressive treatment," says Dr. Portenoy.

Michael Potter, MD, stresses that it's only a relatively small handful of pain sufferers who need daily opioids to manage their pain. An associate professor and family physician at UCSF Medical Center with an expertise in pain management, Potter says that while treating the pain itself, doctors and patients should not stop looking for ways to treat the underlying causes or accompanying illnesses, such as depression, that often make it worse. "Opioids should rarely be the first line of treatment, but they shouldn't be forgotten," he says, especially when the pain is moderate to severe.

And when pain lingers, patients can become frustrated, depressed, angry, even hostile about their doctors' inability to offer relief. Not surprisingly, primary care physicians treating these patients discover they themselves are suffering from a similar cycle of negative emotions.

"My heart sinks when I see certain patients in the waiting room again and again," says Andrew Zalski, former director of the Advocate Illinois Masonic Family Practice Center in Chicago. "The chronic pain patient who can't be helped can be your worst nightmare."

Still, attitudes seem to be changing rapidly, as physicians and pain specialists increasingly test for pain and use narcotics and other medications to relieve chronic pain -- even when people's illnesses are not terminal. And new technologies promise to one day interrupt the cascade of signals transmitting pain to the brain and deliver us from pain that now appears unrelenting.

Part III: Promising new approaches to pain treatment

-- Judith Horstmann is a northern California health reporter who has written for many health and medical publications. Jennifer Biddle is a research associate at Consumer Health Interactive. Part of this story was adapted from an article by Horstmann that was published in Hippocrates magazine.

References

First published March 2, 2007
Last updated June 26, 2008
Copyright © 2007 Consumer Health Interactive