Monday, February 21, 2011

Pain often under-treated due to fears of drug abuse

From The San Francisco Chronicle:

Freud Reia (pictured) needs two narcotics, a muscle relaxer and anti-anxiety medications to get through the day. In fact, he needs them just to get out of bed in the morning.

But he's thrilled to be able to live as well as he does.

It took three years with a San Francisco pain specialist to figure out the right drug combination to help him manage his chronic pain, brought on by dozens of accidents in his wild youth. But his mom, who lives halfway across the country and also suffers from chronic pain, is having a much more difficult time.

"She says her doctors are scared to death to prescribe anything stronger than ibuprofen 800 (mg)," said Reia, 37. "She's a teacher, she's a professional like me, she has no history of abusive behavior, and they won't help her. It just kills me."

Their dissimilar experiences are at the core of the pain management field in the United States.

It can be immensely challenging to find just the right combination of drugs and other pain therapy tools to give someone with chronic pain, like Reia, a decent quality of life. At the same time, doctors walk a thin line: By keeping dangerous narcotics out of the hands of addicts, or taking care to avoid creating addicts by doling out drugs to patients who misuse them, they risk undertreating someone like Reia's mother.

"I have colleagues who are board certified in pain who will not write significant pain medication for treatment. Many of them are feeling overwhelmed and scared," said Dr. Moshe Lewis, a pain management specialist with California Pacific Medical Center who has treated Reia. "Most of the patients I see, probably 90 percent, have legitimate pain. The challenge is figuring out who's who."

A 2009 national survey found that an estimated 2.8 percent of Americans had used a prescription medication - including drugs to treat pain, depression and conditions like attention deficit disorder - for nonmedical purposes in the month prior to the survey. Pain medications accounted for more than two-thirds of that prescription drug abuse.

A decade ago, 1.7 percent of Americans had abused prescription drugs in the month prior to the national survey. Public health officials agree that the jump is due almost entirely to a huge increase in drug prescriptions.

Prescriptions for narcotic pain relievers - opioids like OxyContin, Percocet and Vicodin - increased tenfold from 1990 to 2000, according to multiple studies. The increase is driven primarily by two factors: New prescription drugs are being heavily marketed to doctors and patients, and Baby Boomers are getting older and suffering more chronic pain.

But with the increase in use has come a rise in the instances of drug abuse and deaths from overdoses. Nearly 12,000 people died from narcotic pain medicine overdoses in 2007 - up from roughly 3,000 deaths in 1999, and more than the number of deaths from cocaine and heroin combined, according to the U.S. Centers for Disease Control and Prevention.

"Someone is going to suffer either way," said Keith Humphreys, a professor of psychiatry at Stanford University School of Medicine and a researcher at the Veterans Administration in Palo Alto who specializes in addiction. "There is no way to get around this basic problem that the looser we are (with pain meds), the more pain reduction we get, but the more addiction we get. And the tighter we are, the less addiction but the more pain."

The challenge to find a solution has drawn an increasing number of specialists to the field of pain management. The idea is for these doctors, who have studied the vast and complicated options for treating pain, to take over when primary care physicians can't help their patients or are wary of prescribing medications that could be addictive.

The first thing most pain specialists will do is look at nondrug treatments - things like physical therapy, acupuncture, yoga and even cognitive therapy to help patients learn ways to deal with their pain first and reach for a pill only if they have to.

It's possible, pain specialists said, that a combination of nondrug therapies and over-the-counter drugs - such as ibuprofen or acetaminophen - will help many people avoid narcotics.

"We are talking about something for which there is no magic wand, no quick fix," said Dr. Darshan Patel, a pain specialist at Kaiser San Jose Medical Center. "Medications are reserved only for a last option, when all other things fail to provide some kind of relief."

But for many types of chronic pain, medication will end up being the best option, and drugs like OxyContin are going to play a big role in how doctors fight pain in the United States for the foreseeable future.

To a large degree, the heaviest burden falls on doctors to make sure that patients get the pain relief they need and avoid addiction or overdose. But it's up to patients, too, to take care of themselves and avoid addiction and overdose, doctors said.

"As much as any area of medicine, probably more, pain management is about trust. It's trust between the doctor and the patient, and it has to be both ways," said Dr. Robert Brody, medical director of the pain clinic at San Francisco General Hospital.

Freud Reia had to learn to trust himself and his doctor when it came to developing a pain management regimen. He was terrified of taking narcotics, but as his chronic pain worsened, and physical therapy and other nondrug alternatives weren't working, he'd reached a point where he could barely function.

"It's a scary thing, being on these meds. But I wouldn't be at the level of medication I'm at if it wasn't the most effective thing for me," Reia said. "I can't imagine my life without it. I'd have to go back to being a crippled young man."