Hard drugs aren't a soft sell

Undertreated pain festers in our anti-opiate culture

By Katherine Addleman

Just how accurate was the Barbarian Invasions? Dr Michael Dworkin, Director of the Pain Clinic at the Jewish General Hospital in Montreal, thinks the film "may have overstated the problem, but that pain undertreatment in this country is still rampant." He observes that, "in most cases, end-of-life pain is still poorly addressed, with only about 10% of Canadian patients receiving comprehensive palliative care." He adds, "Those that are properly treated by a team that aims at medical, psychological, social and spiritual concerns, are usually being treated in large healthcare centres in urban areas where pain clinics or palliation units have been established." Dr Dworkin deplores the lack of emphasis on chronic pain in medical education. "Canadian medical schools generally grant a grand total of two hours of lecture time to chronic pain," he notes.

The waiting game
Dr Yoram Shir, Clinical Director of the Pain Clinic at the Montreal General Hospital/ McGill Health Centre, is grateful that the Canadian government recognizes the need for opiates for patients in pain. However, he's frustrated by the lack of government support for more pain facilities. "Patients with chronic pain may wait for up to two years for a first assessment at a pain clinic, although urgent cases, such as cancer patients, are seen quickly." Both Drs Dworkin and Shir are enthusiastic proponents of methadone treatment for pain, an effective approach that's not used enough. So far, neither physician is aware of any Canadian doctor who's been disciplined for undertreatment of chronic or end-of-life pain.

Paranoia about prescribing opiates has been much more intense in the US. With the highly restrictive regulatory climate, many American doctors fear that they could be arrested as pushers if they prescribe opiates. Also, the growing oxycodone abuse furor hasn't helped. US Doctors who treat pain aggressively risk investigations by state medical boards, police and agents from the Drug Enforcement Administration ? who sometimes pose as patients ? as well as loss of license and criminal prosecutions. The heavy-handed laws were born in reaction to Oregon's decision in 1997 that legalized physician-assisted suicide. In response to that initiative, the feds filed the Lethal Drug Abuse Prevention Act, a law that made any physician prescribing a controlled substance subject to prosecution, unless he or she could prove the prescription was justified. But the backlash came swiftly. Fearing that doctors would be unwilling to take on pain patients, over 50 medical and patient groups got together and stopped implementation of the bill. They were right to worry. A study later found that after the feds threatened Oregon doctors suspected of assisting in patient suicides, pain undertreatment spiked in the state.

feds ease up
But the times are changing south of the border. Earlier this year, a directive on controlled substances was passed by the American Federation of State Medical Boards, after the American Medical Association and other professional medical societies put pressure on the government to stop harassing doctors who were prescribing appropriately. The new directive clearly declares that undertreatment of pain is just as unacceptable as overtreatment. Since then, medical boards in Oregon and California have disciplined doctors for inadequate pain management. And New Mexico recently revised its medical practice act so it now identifies pain undertreatment as grounds for a citation of professional misconduct.

Reactions have been mixed. Many doctors welcome the support they feel comes from the new policy when they're prescribing controlled substances like opiates for legitimate needs. But some physicians fear they're under renewed scrutiny, now that they can be disciplined for both over- and undertreatment.