Successful Treatment of Intractable Pain
The most recent letter posted to the National Foundation for the Treatment of Pain (NFTP) website by RL in Florida (May 21, 2002) is a typical example of the results of effective treatment of intractable pain. In fact, positive results are now so common that I herewith propose entirely discontinuing the use of the term intractable. Henceforth I will only use the term chronic. Intractable means unmovable. In my experience, chronic pain is anything but unmovable. Effectively treated, chronic pain is entirely controllable and patients commonly are able to regain a quality of life that it profound and often dramatic. RL literally went from a wheelchair to a college classroom, on her own two feet, in one year. Her story is far from atypical. To the contrary, with effective care, it is entirely commonplace.
Ironically, if the term intractable is to be used at all, it should be in describing the rigidity of physician attitudes. Not a day passes without encountering the mindless prejudices of doctors toward the use of pain medications and ignorance of their own science. To make this point clear, consider the following definitions from the Medical Quality Assurance Commission Guidelines for Management of Pain from the State of Washington:
1. Addiction. A disease process involving use of psychoactive substances wherein there is loss of control, compulsive use, and continued use despite adverse social, physical, psychological, or spiritual consequences.
2. Physical Dependence. A physiologic state of adaptation to a specific psychoactive substance characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by re-administration of the substance. Physical dependence is not necessarily associated with full-blown addiction, and the condition does not always equate with addiction.
3. Psychological Dependence. A subjective sense of need for a specific substance, either for its positive effects or to avoid negative effects associated with its abstinence.
Virtually all doctors fail to understand and apply these distinctions. Instead, every patient using opioids is an addict in their minds and they can think of nothing but “detoxifying” them. In countless cases, patients are forced into detoxifications—often costing $10,000 to $30,000—and end up drug-free and in agony. The sum result is that they have to again undergo titration to effective pain control and nothing has been accomplished except the waste of enormous amounts of money and precious medical resources. Further, the offending physicians also place an enormous emotional burden on the patients. Already suffering from low self-esteem and depression from their inability to work and be productive, the patients are also saddled with the guilt of being “addicts” when, in fact, they are not.
Having kept careful records on almost 4,000 chronic pain patients in the last 19 years, I can state unequivocally that over 90% of all pain patients go through an initial period in which the medications are titrated up to effectiveness after which they are stable in dosage and schedule. Tolerance, dose escalation, increased schedule, overdose, addiction, diversion, etc., rarely occur. The patients are typically completely stable in their treatment regimen and uniformly report enormous improvements in their quality of life, with only rare complications or adverse effects.
As I have written previously, the “drug-seeking” that many doctors experience with their patients is an iatrogenic phenomenon. Because they do not titrate to effectiveness, patients, having obtained some relief from inadequate doses or inappropriate medications (typically short-acting hydrocodone combinations), press their doctors for more medication. The doctors misinterpret this as addictive behavior, panic professionally, mislabel the patient a “drug-seeking addict,” and try to dump the patient on pain specialists or into a detox program. The results are always calamitous, wasteful, and destructive. They can avoid this physician-induced situation by treating pain medication as they would any other medication. Pick the right medication, titrate the dose to effectiveness, and be consistent in the on-going treatment regimen.
As a last note, we should not be naïve about the risks to the physician of pain treatment. Based on data provided by the National Practitioners Data Bank, over last 10 years, every year, an average of 25 physicians have lost their licenses related to the prescription of opioids. It is not comforting to note that that these physicians were, on the whole, not prescription-mill doctors. Many were not expert enough to meet the requisites of state board pain treatment guidelines. Because of this, they were successfully attacked by regulators and, as a consequence, lost their license. Remarkably, many medical board prosecutors retain the now ancient mythology about doctors prescribing opioids. They see all opioid prescriptions as suspect and are prepared to destroy a doctor’s career if they can prove any breach of procedure. They have what I call “hardening of the categories”: if a doctor prescribes opioids, he is a “pusher” and must be eliminated.
As I have previously discussed, doctors have been at a significant disadvantage in this arena. Every doctor accused of injudicious prescription has had to face this accusation alone. Further, even with legal representation, the doctor as had to pay to educate their attorney in this area of the law and administrative regulation. Few attorneys in the United States have any expertise in these matters. Consequently, every accused physician has had to pay from $25,000 to $250,000 to defend themselves. If they are charged with a criminal offense, it will cost approximately $1,000,000 to successfully prove their innocence. The playing field has been deeply inclined against them, as all expense of defense could only come out of their own pocket.
That situation has been resolved with the availability of membership in the Pain Practice Liability Association (www.pplaonline.com). Doctors who want to provide pain management can receive a wide variety of help in safely doing so, through membership in PPLA. Not the least of the benefits is up to $1,000,000 in legal defense.
Skillful pain management provides such extraordinary benefits with so few risks to the patient, that the wanton, uncaring, scientifically indefensible denial of relief to patients is clearly immoral and, in the view of the National Foundation for the Treatment of Pain, criminal. Condemning any human being to bed-ridden suffering, when alternatives are readily available, is monstrous. When one acknowledges that the only reason for doing so is out of ignorance and prejudice—so-called “Opiophobia”—this behavior deserves condemnation as it is a specific betrayal of the sworn duties of every physician. It is not simply malpractice, it is criminal malpractice.