Vidyya Medical News Service
Volume 6 Issue 77 Published - 14:00 UTC 08:00 EST 17-Mar-2004 Next Update - 14:00 UTC 08:00 EST 18-Mar-2004
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The state of pain management

By B. Eliot Cole, M.D., M.P.A.

Over the last 25 years, there has been a growing sense in health care that pain has been under-managed and that many people have needlessly endured awful levels of pain for no purpose. I think that we got to this place because health practitioners lacked the skills needed to recognize and control pain or they refused to give adequate amounts of medications because they feared the scrutiny of regulatory bodies.

It was not that long ago that health care students were actually taught that the "first dose of morphine should be the last one" and that "no one ever died from pain, they just wished that they could." At least three generations of physicians, nurses and pharmacists were taught to fear pain-relieving medications that were derived from opium poppies (opioids).

By the late 1980s and early 1990s, Americans began to demand that more be done to relieve their unnecessary pain. Better pain management techniques were developed. These included preemptive strategies to isolate the surgical area from the central nervous system by giving epidural, spinal or regional anesthesia along with general anesthesia; more consistent use of patient-controlled analgesia (PCA) equipment; and protocols for administering pain relievers around the clock rather than "as needed" for predetermined periods. Fellowship programs were initiated to train anesthesiologists, neurologists and psychiatrists to provide real solutions for pain, regardless of its cause. Nurses and pharmacists, along with many other health care professionals, worked closely with pain management specialists.

Because of these improvements, we now hear about our friends and family members having nearly painless surgery. We know people who walk, talk and visit with loved ones only hours after major heart surgery. We have come to expect that pain of short duration (acute pain) is easily controlled. But, sadly, we know of people who suffer from pain lasting weeks, months and years after some illness or surgery. For these people, we have not yet entirely solved the puzzle that causes them to suffer. Much progress has been made in pain treatment, but there is still a failure to entirely account for the complexity of chronic pain.

Pain management programs exist in virtually every state, but many people with chronic pain never satisfactorily regain control over their pain. Some continue to be managed as though they only had acute pain, some have not been accurately diagnosed, and others never have all of their issues addressed or properly treated. Some turn in desperation and frustration to unproven treatments or submit to risky procedures hoping that something--anything--might make them feel better.

We must continue to improve education about pain treatments that have clear benefits, while also acknowledging that there are risks. For example, we don't fully understand the implications of starting people in pain on long-term therapy with opioid analgesics. There is also a need to consider the degree of pain relief relative to the cost and risk of some surgeries.

Due to issues of drug abuse and diversion of many of our medications, I am increasingly concerned that manufacturers will be reluctant to develop new release formulations or that regulatory agencies may take action against those prescribing the most potent pain-relieving medications. This will sadly lead to a chilling effect and limit access to treatment for patients in need of relief.

Additionally, there is still a lack of access to pain management services for too many of our citizens. People of color, people living in poverty, and those living in rural locations still lack the full range of pain management services. We have much work left to do and must view modern pain management as a job not yet completed.

There have been great advances in technology and pharmacology over the past 25 years. We have improved our ability to control pain and have developed well-crafted protocols for medication administration that allow people with terminal illness to die with comfort and dignity. Yet, the field of pain management is still young and evolving. It will take more time to know the best strategies for managing pain for all patients under all circumstances.

The great hope is that, in the next few years, the basic mechanisms of pain will be more completely understood, and treatments will continue to improve. In the meantime, health care practitioners of many disciplines have more opportunities than ever to learn about caring for people who experience pain. We remain committed to educating consumers that pain is often treatable and nearly always manageable.

B. Eliot Cole, M.D., M.P.A., is the director of education for the American Academy of Pain Management, located in Sonora, Calif.

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