Dilemma can cause ‘opiophobia’ in MDs, but don’t miss window to prevent chronic pain
By Susannah Benady
MONTREAL â The treatment of pain has improved in the past decade and patients’ pain, be it acute or chronic, is now taken more seriously than it ever was, say specialists.
But improvement in the treatment of pain is hampered, both by a lack of resources to build multi-disciplinary teams and by the fact that for many physicians, prescribing opioidsâby some measures the most effective treatment with the fewest side-effectsâis a medical no-go area.
The fear that patients might either abuse the drugs themselves or that the medications might end up on the black market are possibilities that physicians have to confront, or risk depriving patients of treatment they should receive.
There is no question that the multidisciplinary approach to the treatment of pain is the ideal, said Dr. Gilbert Blaise, professor of anesthesiology at the UniversitÃ© de MontrÃ©al, who runs pain clinics at both the McGill University Health Centre and the Centre Hospitalier de l’UniversitÃ© de MontrÃ©al.
“Pain is a complex condition, frequently not well-understood by physicians, and has many dimensions to it.
“We are beginning to understand the neuroscience behind it, but its complexity requires input from physio- and occupational therapists and psychologists, as well as from physicians.”
According to a 2001 Canadian survey, 29% of the adult population experiences chronic pain, lasting more than six months, from conditions such as spinal pain, low back pain, fibromyalgia, postoperative pain and complex regional pain syndrome.
“As patients age, the more pain they get. Spinal pain, for example, will eventually affect 100% of patients,” said Dr. Blaise, who has set up a patient pain association in Montreal called ABC Douleur.
But even among children, at least 20% experience long-term pain, noted anesthesiologist Dr. Allen Finley, who treats children and adolescents at the IWK Health Centre in Halifax.
Problem of major proportions
Specialists who work in the field agree that pain, particularly chronic pain, constitutes an unsolved health problem of major proportions that undermines quality of life and imposes an enormous financial burden on society.
Four years ago the Canadian Pain Society launched a “patients’ charter” informing the public that they were entitled to expect and receive appropriate pain killing medications and have their pain treated in a timely manner.
“Not treating pain adequately not only slows recovery, but if left untreated can become chronic, at which point it is no longer simply a symptom of disease but becomes a medical problem in its own right,” said Dr. Roman Jovey, incoming president of the Canadian Pain Society.
“The trouble is that waiting lists for pain clinics are at least one year and there is a window of opportunity of two to three months for injured patients (for the best chance) to prevent them developing chronic pain.”
But in addition to the lack of resources problem that dogs all chronic conditions in Canada, is the public relations minefield that physicians enter, whether they like it or not, as soon as they consider prescribing opioids.
The prospect is so nerve-wracking that it has led to its own pathology, dubbed “opiophobia.”
‘Worst way to administer’
“It is because of institutional opiophobia that doctors and nurses are trained to give the lowest dose of opioid for the longest time intervalâjust about the worst way to administer it,” said Dr. Jovey a GP whose practice is now 60% to 70% pain management and 30% to 40% addiction medicine.
“A common fallacy is that you should ‘only take it when you absolutely have to because it is addictive.’
“This results in a situation where people under-dose themselves because they are scared, or have to take too much to deal with the acute pain.
“There is a rule of thumb in pain management that it takes less medication to prevent the return of pain than it takes to treat it once it is out of control.”
The principles of trying to minimize the addictive potential of opioids are first to use long-acting opioids, and second to keep to a strict time schedule, he advises.
“The amount of opioids you take today should not necessarily depend on how much pain you are experiencing today. This helps avoid the psychological mindset that can occur if you only take the painkiller when you have pain.
“If a person waits for the pain to become severe they will overshoot the amount ideally required, leading to excessive side-effects. This is then followed by a ‘trough’ effect on blood levels, leading to a yo-yo cycle that can exacerbate the risk of addiction in a susceptible person.”
It can even lead to an iatrogenic condition known as “pseudo-addiction,” which can be misinterpreted by the physician as drug-seeking behaviour but is in fact caused by under-treatment of pain that resolves when the appropriate level of pain relief is provided.