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 Home : Professionals : Pain Reports : Pain Report No. 3
Dannemiller Memorial Educational Foundation
An Update on Issues, Research and Treatment Trends
Volume 1, Number 3

Editorial Board
Neil M. Ellison, MD
Rebecca Finley, PharmD
Judy Paice, PhD, RN

Supported by an unrestricted educational grant from Purdue Pharma L.P.
Pain is Under-treated in Minority Patients
"Many studies have shown that black Americans are less likely than whites to receive a wide range of medical services," according to a recent editorial in The New England Journal of Medicine. The authors, Arnold M. Epstein, M.D., and John Z. Ayanian, M.D., describe "a widely documented pattern of racial differences in health care" that affects a number of minority groups in the United States.1

In another New England Journal editorial, "Racial Injustice in Health Care," Harold P. Freeman, M.D. and Richard Payne, M.D. write that "a growing body of compelling and disturbing evidence points to inferior medical care for black Americans, even if they are on an equal economic footing with whites."2 Black Americans have an overall incidence of cancer and rate of death from cancer that is higher than any other racial or ethnic group in the United States. Black Americans are also inadequately treated for cancer pain, which is not surprising to the authors in light of other studies noting undertreatment in emergency room departments of postoperative pain and pain associated with fractures of long bones.2

The undertreatment of pain in minorities is well documented throughout the medical literature:
  • A report in The New England Journal of Medicine on pain treatments received by 1308 outpatients with metastatic cancer concludes that patients seen at centers that predominantly treated minorities were "three times more likely than those treated elsewhere to have inadequate pain management."3 Pain relief was most likely to be inadequate when doctor and patient disagreed about how severe the pain was. A discrepancy between patient and physician in evaluating severity of pain predicted inadequate analgesic therapy. The researchers suggest that "accurate appraisal of the severity of pain may be more difficult for patients who are not of the same age, sex or racial or ethnic background as the treating physician."3
  • In a follow-up study, Cleeland and colleagues reported on 281 Hispanic and nonwhite outpatients with recurrent or metastatic cancer and found that 65% of minority patients with pain did not receive analgesic medications as recommended by World Health Organization guidelines. Hispanic patients achieved less pain relief and received less adequate analgesia than black patients. Patients who received their care in university settings and settings concerned primarily with the health care of minorities were more likely to report unrelieved pain when compared to those treated in community-based settings. Noting that differences exist between the expressed concerns of Hispanic and black patients, the authors recommend the initiation of patient education programs responsive to the attitudes and beliefs of persons of specific ethnic minority groups.4, 5
  • Cleeland and colleagues next studied 108 African-American and Hispanic patients with metastatic or recurrent cancer and pain. The researchers determined that 28% of the Hispanics and 31% of the African-Americans "received analgesics of insuffi- cient strength to manage their pain." In addition, the researchers asked 55 physicians and nurses who were treating these patients to complete a questionnaire on the management of cancer pain. "Physicians underestimated pain severity for 64% of the Hispanic and 74% of the African-American patients." 4
  • Hispanic patients (n = 31) treated in an emergency department for long-bone fractures were only half as likely to be prescribed analgesic medications as nonminority patients (n = 108), according to a study conducted by Todd and colleagues. 6
  • A study of patients who underwent uncomplicated adult appendectomy found minority patients suffer from ethnic stereotyping. Each of the 40 minority patients studied by McDonald et al., received significantly less postoperative opioid analgesics, on average, than the 140 white patients. "The ethnic difference suggests that irrelevant cues may be used in nurses' medication decisions," McDonald et al., concluded. 7
  • Neighborhood differences in the stocking of opioid analgesics surfaced when Morrison et al., surveyed a randomly selected sample of 30% of New York City pharmacies. Of the 347 participating pharmacies, 51% did not have sufficient amounts of opioid analgesics to treat patients with severe pain. In predominantly Caucasian neighborhoods, 72% of pharmacies were adequately stocked with opioids; in predominantly non-Caucasian neighborhoods, 25% were.8
Memorial Sloan-Kettering Cancer Center's Kathleen M. Foley, M.D., summarizes the literature on pain and cancer by saying that while large segments of patients receiving therapy for cancer and advanced malignancies receive "inadequate palliative therapy," the problem is more severe for minorities than for the average patient.9

Recommendations have been made on how to improve pain management for minority patients. For example, Juarez discusses strategies that might be used with a 62-year-old Hispanic patient who feels it would be unmanly and demeaning to have his children witness him taking pain medicine. Acknowledge the patient's cultural beliefs and incorporate them into his treatment regimen, she recommends. But first "be sure that you and your patient have an explicit agreement to treat each other as equals." Then use his traditional masculine values and strong family ties to lead him to an understanding that his pain may reduce his mobility, interfere with his ability to provide for his children, and hamper his involvement in their upbringing.10

Pain relief for minorities can also be improved by tailoring interventions and patient education materials specifically to the concerns of each minority group.4-5

In their NEJM editorial, Epstein and Ayanian suggest system-level improvements to ensure adequate pain relief for minority patients, including:
  • Quality improvement programs modified so that they address disparities in the provision of pain treatment;
  • Systemic change in information systems "redesigned to provide medical groups with timely feedback about treatment decisions, referral rates, and patients' ratings of their care according to race, ethnic background, and socioeconomic status."
  • Designation of nurses and social workers as advocates for underserved chronically ill patients;
  • Recruitment of "charismatic public figures or physicians" into campaigns to improve medical care for minorities.1
Inadequate treatment of pain is widely considered to be unethical.11 Those who manage patients and those who manage and supervise medical systems are being challenged to be aware of deficits in pain management of minority patients and to take positive steps to improve the quality of pain relief for these patients.1-11

References
  1. Epstein AM, Ayanian JZ. Racial disparities in medical care. N Engl J Med 2001;344:1471-1473.
  2. Freeman HP, Payne R. Racial injustice in health care. N Engl J Med 2000;342:1045-1047.
  3. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994; 330: 592-596.
  4. Anderson KO, Mendoza TR, Valero V, et al. Minority cancer patients and their providers: pain management attitudes and practice. Cancer 2000;88:1929-38.
  5. Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ. Pain and treatment of pain in minority patients with cancer: The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med 1997;127: 813-816.
  6. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993; 269:1537-1539.
  7. McDonald DD. Gender and ethnic stereotyping and narcotic analgesic administration. Res Nurs Health 1994;17:45-49.
  8. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. "We don't carry that" — failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342:1023-1026.
  9. Foley KM. Controlling cancer pain. Hosp Pract. 2000; 35:101-108, 111-112.
  10. Juarez G. When culture clashes with pain control. Nursing 1995;25:90.
  11. Kodish E, Singer PA, Siegler M. Ethical Issues In: DeVita V, Hellman S, Rosenberg SA, Cancer: Principles and Practice of Oncology 5th ed. Philadelphia, Lippincott-Raven, 1997:2973-2981.

Prudent Opioid Prescribing: Clinical and Legal Issues
"The public health problem represented by misuse of prescription opioids is miniscule in comparison with that of untreated and unrelenting pain," according to an official statement of the American Academy of Pain Medicine (AAPM). However, because of the potential for abuse of opioids, clinicians must be knowledgeable about the parameters established by legal authorities. For these medications to be used effectively, both clinical and legal issues must be considered. Yet, the consequences of inadequate treatment of patients with serious pain are, the AAPM statement makes clear, "of greater importance to public health" than issues of spanersion and abuse.1

Many physicians are so concerned with preventing spanersion that they risk impacting the best care for their patients. A recent court case in California found an internist to have been recklessly negligent — a higher standard than simple negligence — for providing inadequate pain relief to an 85-year-old terminal patient suffering from bone fractures and probably lung cancer. 2 Meanwhile, the California State Legislature has before it a bill that would require the investigation of complaints concerning the "undertreatment, undermedication, and medication of pain." The legislation would require physicians and surgeons, with the exceptions of pathologists, radiologists, and doctors not providing direct care, to "complete a mandatory continuing education course" on pain management. 3

American Pain Society president Michael Ashburn, M.D., recognizes the current climate: "We are concerned that the increasing problem of spanersion and abuse of opioid medications could be decreasing access to them for valid medical purposes." Some physicians are reluctant to prescribe opioids to patients with legitimate requirements for these agents, he stated. 4

Concerns about the spanersion of legitimate opioids for criminal purposes are reasonable. "We as providers … must understand that opioids are subject to spanersion, and that society is justified in regulating the administration of them to decrease potential for abuse," Dr. Ashburn said. 4

Most specialists in pain management agree — new addictions are reported to be rare when opioids are used for treatment of acute or chronic cancer-related pain in patients without a prior history of substance abuse. In definitions recently developed by the APS, the AAPM, and the American Society of Addiction Medicine (ASAM), addiction is defined as "a primary, chronic, neurobiologic disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm and craving." 5

The APS and AAPM recommend that the initial evaluation of a patient should include "a pain history and assessment of the impact of pain on the patient, a directed physical examination, a review of previous diagnostic studies, a review of previous interventions, a drug history, and an assessment of coexisting diseases or conditions."6 The information gathered should be documented. Such documentation may be the most important thing a physician can do in the event of a subsequent investigation of his or her prescribing patterns.6

"Experience and investigation have shown that when opioids are prescribed and used appropriately in the treatment of pain there is minimal danger of creating an addictive disorder. Evidence to date indicates that substance abuse problems have not increased as a result of the increased availability of therapeutic opioids," according to the AAPM.1 However, there is some data suggesting that those with previous history of abuse may have a significantly higher incidence of recurring abuse when treated for chronic pain. 7

The APS has recommended, "Urge your colleagues to take their patients' complaints of pain seriously. Remind them not to put patients in the position of asking for a favor when they want pain relief," the APS recommends. "Inform patients that they deserve to have their pain evaluated and treated."8

"Millions of people have suffered unnecessarily because of barriers to effective pain treatment. Exaggerated and unrealistic fears of addiction are paramount among these barriers, which should not be re-erected in response to publicity regarding drug abuse. Physicians should not be afraid to provide adequate analgesia when able to do so, and patients with acute pain or pain from cancer, AIDS, and other serious diseases should not fear the use of opioids, which are safe when used appropriately," according to the AAPM.1

Pharmacists too are being urged to adhere to accepted pain relief practices. Joranson et al., writing in the Journal of the American Pharmaceutical Association, report on a mail survey of pharmacists from urban and rural pharmacies, long-term care facilities, hospitals, and outpatient clinics in Wisconsin. Many respondents were uninformed as to what is considered lawful and acceptable medical practice. For example, many did not view the chronic prescribing or dispensing of opioids for more than several months to some patients with chronic cancer or non-cancer pain as a recommended or lawful medical practice. "Not all pharmacists knew what constitutes legitimate dispensing practices for controlled substances under federal or state policy in emergencies or for patients with terminal illnesses," the researchers state. "The incorrect knowledge and inappropriate attitudes of some pharmacists could contribute to a failure to dispense valid prescriptions for opioid analgesics to patients in pain," Joranson et al., conclude.9

References
  1. American Academy of Pain Medicine (AAPM). AAPM releases statement on the spanersion and abuse of controlled substances. February 16, 2001. (Available September 14, 2001 at: www.ampainsoc.org/advocacy/opioids.htm): 1-5.
  2. Hendricks T. Judge cuts big award in pain case; Family of dead man argued elder abuse. San Francisco Chronicle. Tuesday August 21, 2001. Available at www.sfgate.com/cgibin/article.cgi?file=/chronicle/archive/2001/08/21/MNW215830.D/.
  3. Legislative Counsel's Digest of February 21, 2001: AB 487 Assembly Bill. Available on October 19, 2001 at www.leginfo.ca.gov/pub/bill/asm/
  4. American Pain Society. American Pain Society: Curb abuse of pain medications, but don't deprive patients who need them. (Press Release). Available March 28, 2001. at www.ampainsoc.org/advocacy/opioids.htm.)
  5. American Academy of Pain Medicine and American Pain Society. "The Use of opioids for the treatment of chronic pain," available September 6, 2001 at www.ampainsoc.org/advocacy/opioids.htm.
  6. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. Available September 14, 2001 at www.ampainsoc.org/advocacy/opioids2.htm.
  7. Dunbar SA, Katz, NP. Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: a report of 20 cases. J Pain Symptom Manage, 1996;11:163-171.
  8. American Pain Society. Pain: The Fifth Vital Sign. Available September 14, 2001 at www.ampainsoc.org/advocacy/fith.htm.
  9. Joranson DE, Gilson AM. Pharmacists' knowledge of and attitudes towards opioid pain medications in relation to federal and state policies. J Am Pharm Assoc. 2001:41:213-20

Multidisciplinary Pain Centers Integrate the Activities of Healthcare Professionals
"I first began to appreciate the need for a multidisciplinary approach to chronic pain during World War II after several months' experience in treating military personnel with a variety of pain problems," noted John J. Bonica, M.D., a pioneer of pain medicine, writing on the subject of multidisciplinary and interdisciplinary pain programs. The complex nature of pain syndromes "requires a multidisciplinary/ interdisciplinary approach in evaluating patients and developing and carrying out the most effective therapeutic strategy."1

Employing the skills of a range of medical specialists and health professionals, the multidisciplinary approach integrates what each contributes into a cohesive, multipronged effort.2 Such an integrative approach is necessary because pain is a multidimensional problem with biological, psychosocial, spiritual, economic and forensic ramifications.2 Working together, health professionals can provide greater pain relief than working inspanidually.

Institutions that offer an integrative approach to pain complaints are called multidisciplinary pain centers. The International Association for the Study of Pain recognizes four levels of pain centers — multidisciplinary pain centers, multidisciplinary pain clinics, pain clinics, and modality-oriented clinics. The multidisciplinary pain center and the multidisciplinary pain clinic both make use of the skills of a wide variety of physicians and allied health professionals. Both provide patients with the potential to access multiple therapeutic modalities. The multidisciplinary pain center has the support of teaching and research as a primary goal, however, and the multidisciplinary pain clinic does not.3 Pain clinics and modality-oriented clinics may or may not employ a multidisciplinary approach.3

Because of the nature and extent of resources at their disposal, multidisciplinary pain centers often take the lead in research and treatment trends. An examination of how a center is typically created and developed provides insights into its unique role and value in the study of pain and its treatment. One or two physicians, each either an active researcher in pain medicine or a clinician devoted to the care of patients with pain complaints, assume leadership. They may organize an ad hoc committee to determine the feasibility of forming a pain center at a particular institution.2 The ad hoc committee addresses the following issues: (1) The scope of the pain center, and (2) Documentation of the existence of a pool of appropriate patients. The committee reports to the executive body of the institution.2

The endorsement of the recommendations of the chairs of the various departments and of the top administrators of the institution, as they comprise the executive decision-making body, is secured. Once this has been accomplished, a pain center director is appointed and an advisory committee established to provide the director with support. The committee includes three or four members each from such subspecialties as anesthesiology, neurosurgery, neurology, psychiatry, and psychology, as well as appropriate nurse administrators.2, 4

At this point staff is assembled and facilities secured. It's important for the medical staff to be balanced among subspecialties. Bias in favor of one or another subspecialty can defeat the program by limiting the ability of those who run it to effectively address the multiple dimensions of patients' complaints.5

Larger medical centers and hospitals may include a broad range of medical subspecialities in the core pain management team: neurologists, anesthesiologists, neurosurgeons, psychiatrists and psychologists. Mid-size and smaller hospitals may include fewer physicians. Other key professionals on the team are nurse administrators, nurses, pharmacists, physical therapists, occupational therapists, vocational counselors, and social workers. Some variation in configuration of professional staff will, of course, characterize each inspanidual team.2-5

Consultants may be invited to affiliate with the pain center or work on a part-time basis, and these may include: radiologists, orthopedists, and oncologists. Family physicians and internists with a particular interest in pain medicine may be brought in. In addition, non-physician consultants may contribute significantly, for example: chaplains capable of addressing the concerns of terminal patients and their families, registered dietitians, pharmacologists, dentists or oral surgeons experienced in addressing pain of the jaw and surrounding areas, and neurophysiologists. If compensation claims must be addressed, lawyers should be offered affiliation.2, 3

The pain center may wish to establish a relationship with some or all of the following institutions: a rehabilitation facility; a facility capable of providing relaxation strategies, such as biofeedback, progressive muscle relaxation, operant conditioning, imagery, and autogenic training; and a drug detoxification center (for patients who have been self-medicating or have prior addictions).2

It is ideal if a secure financial basis for the pain center is established early, although in the current healthcare environment this may not be possible. Patient fees are insufficient to support research initiatives. Federal, state, and private funds can be pursued, but should not be counted upon to fully support a center.2 A statement by the American Pain Society (APS) notes that the managed care industry, which is no longer achieving consistent profits, faces a high prevalence of chronic pain conditions in the population it services. Many plans "may find that the cost impact of chronic pain problems is greater than that for all other typically diagnosed chronic conditions," according to the APS. The APS encourages MCOs to "generate their own internally derived clinical pathways for chronic pain treatment." Such factors suggest that securing adequate financing for a pain center may present a challenge.6 By providing cost-effective care, the center will facilitate its acceptance by third-party payers.2

"Attracting patients to the pain center is a key task, one easily underestimated. As soon as the director has been appointed, the pain management activities of all health professionals associated with the center are publicized. Referrals can be encouraged through such avenues as informal conversations with physicians affiliated with the medical center, formal presentations at various professional events, and mailings sent to the staffs of various specialty clinics. It is ethical for health professionals to cultivate and make use of opportunities to publicize the pain center via television, radio, and the press, as well as public presentations. The center should also be registered in the APS Pain Directory and at responsible internet sites.2

During the first years of the center's existence it may be best to focus upon a few specific pain problems. Then the staff will not become overwhelmed by complaints it is not capable of addressing effectively. Not all patients should be seen at every pain center. Each may decide if there are certain types of patients it does not wish to accept, certain types of procedures it will not perform, and certain types of research it will not sponsor. Who is seen should depend upon the expertise of the participating health professionals.2

A well-conceived, well-staffed multidisciplinary center will come to be viewed by patients as providing a supportive environment in which all staff members exhibit genuine concern for the patient's well-being.2

References
  1. Bonica JJ. Multidisciplinary/interdisciplinary pain programs. In: Bonica JJ, ed. The Management of Pain 2nd ed. Philadelphia: Lea & Febiger, 1990: 197-207.
  2. Dogra S, Ghia J. Organization of pain services for chronic and cancer pain. In: Raj PP. Practical Management of Pain. 3rd ed. St. Louis, Mosby, 2000: 39-50.
  3. Turk DC, Okifuji A. Interdisciplinary approach to pain management: philosophy, operations, and efficacy. In: Ashburn MA, Rice LJ. The Management of Pain, New York, Churchill Livingstone, 1998, p. 235-248.
  4. Wilkie DJ. Nursing management: pain. In: Lewis SM, Heitkemper MM, Dirksen SR. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 5th ed. St. Louis, Mosby, 1999:126-152.
  5. Johnson WL, Abram SE, Lynch NT. Pain clinic organization and staffing. In: Abram SE, Haddox JD, The Pain Clinic Manual, 2nd ed., Philadelphia, Williams & Wilkins, 2000: 3-11.
  6. American Pain Society. Pain assessment and treatment in the managed care environment: a position statement from the American Pain Society. Available on October 19, 2001 at www.ampainsoc.org/managedcare/position.htm/.

Meeting the Challenge of Chronic Back Pain
Low back pain is the most common cause of work-related disability for American employees 45 years of age and younger.1,2 Whether cost is measured in terms of workers' compensation or medical expenses, low back pain consumes more healthcare dollars than any other cause of work-related disability.2 In addition, low back pain is the cause of loss of time from work for 8 out of 10 workers1 and directly affects more than half of all adults.2

A survey of physicians on low back pain treatments revealed "ignorance or rejection of existing scientific evidence, excessive commitment to a particular mode of therapy or a tendency to discount the efficacy of competing treatment."1 From the literature on the diagnosis and management of chronic low back pain, 10 key points emerge:
1) Low back pain should not be considered chronic until symptoms are present for at least several weeks. Referral to a specialist should not be made until this period has elapsed.1-3 The routine use of imaging and laboratory tests on patients who have presented recently is not recommended, although for systemic disease or trauma plain radiographs should be taken.2-3
After low back pain has persisted 4 to 6 weeks, radiography should be performed.2 CT and MRI should be reserved only for patients whose medical history and physical examination suggests the presence of underlying infection, cancer, or neurologic deficit.2 Patients who have a neurologic deficit that is progressive, a condition whose clinical features suggest serious illness, or inadequate resolution of their condition after 5 weeks may be referred to a multidisciplinary pain center.3
2) A multitude of psychosocial factors bear on the diagnosis and management of the patient suffering from low back pain.1 The physician should determine whether a particular social or psychological stressor is intensifying or prolonging the pain.2 Even if no single cause of distress exists, it is important that health professionals treat not only the disease but the whole patient.1, 2

3) The patient who understands why pain is present and who participates in designing the treatment program is more likely to comply with the program.1

4) Each patient should receive an inspanidualized strategy that may include:
  • Combinations of formal exercise and periods of rest
  • Psychosocial strategies that for some patients include family therapy or the involvement of the employer in a modification of work activities, and
  • Medications. Pharmacotherapy is well established as an effective therapy for chronic low back pain,1, 2 but medications alone do not constitute a comprehensive management plan.1, 2 "Any one medication is not 'the program,' but rather a component of it."1
5) Bed rest for more than a day or two should be discouraged, as it may delay recovery. 2 Encourage patients to resume normal activities, and explain that doing so may lead to improvements in their condition. Patients whose work involves strenuous activity, such as heavy lifting, might be instructed to modify these activities.2

6) Surgery should be reserved for patients with sciatica, pseudoclaudication, or spondylolisthesis. Multiple surgical procedures are rarely beneficial for patients with chronic low back pain.2

7) Pain is not just "an unpleasant sensation" but is, as well, "an emotional response to that sensation."4 Therefore, maintaining a healthy physician-patient relationship — as well as educating and encouraging the patient — is an essential part of disease management.1 The health professional should permit the patient to express anger and frustration, fears, and concerns, for this helps the patient address the painstress reaction. The health professional should provide an understanding, sympathetic, non-judgemental ear for such feelings.5 Some patients will benefit from supportive psychotherapy or family therapy.1

8) Intensive exercise and rehabilitation has a place in the treatment of low back pain.2, 6-9 Van Tulder et al's systematic review of randomized controlled trials of the most common interventions for chronic nonspecific low back pain found "strong evidence" for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain.6 Deyo and Weinstein in their New England Journal of Medicine review state that although back exercises are not helpful in the acute phase, these exercises are useful later for preventing recurrences and for treating chronic low back pain. "Intensive exercise reduces pain and improves function in patients with chronic low back pain."2 A rehabilitation program tailored to the inspanidual patient's needs is, however, likely to be more successful than a generic prescription of exercise.1

Compliance is a serious problem for patients attempting rehabilitative regimens. Van Tulder concludes that the strong evidence found for exercise and associated therapies applies "especially for short-term effects."6 Deyo and Weinstein state that "maintaining adherence to the sort of exercise regimen that is required for long-term benefits is often difficult."2
9) Pharmacotherapy may provide many patients with benefit.1, 2
  • NSAIDs and muscle relaxants are useful for patients who tolerate them. Side effects of NSAIDS may be addressed by switching the patient to acetaminophen, which, however, provides no peripheral anti-inflammatory effect.1 As to muscle relaxants, a prominent side effect is sedation.2
  • Antidepressant-drug therapy is "useful for the one third of patients with low back pain who also have depression," Deyo and Weinstein conclude. Evidence regarding patients who do not have clinical depression is conflicting. Tricyclic antidepressants may be more effective than selective serotonin-reuptake inhibitors (SSRIs) for treating pain in patients without depression.2
  • Opioids may be appropriate for some patients, as accumulating studies support a wider use of opioid medications. 10, 11 A criteria-based review of the literature published in the Proceedings of the 9th World Congress on Pain, concludes: "Our literature review decreases the doubt about the efficacy of opioids for some types of chronic noncancer pain syndromes."10 As the results of more and more studies on the effectiveness of opioids for noncancer pain have become available, physician attitudes are becoming more favorable to administering opioids to these patients.1
According to a policy statement issued by the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM), entitled "The Use of Opioids for the Treatment of Chronic Pain:"

Many strategies and options exist to treat chronic noncancer pain. Since chronic pain is not a single entity but may have myriad causes and perpetuating factors, these strategies and options vary from behavioral methods and rehabilitation approaches to the use of a number of different medications, including opioids.12
10) Massage therapy has yielded promising preliminary results in studies, as has spinal manipulation. Acupuncture has yielded less encouraging results.2 However, further research on the effectiveness of these modalities for chronic back pain is needed.2
Low back pain may present a serious health problem to patients and complaints about this type of pain should not be dismissed. Patient concerns should be addressed in such a way as to nurture the formation of a therapeutic bond that supplements other therapeutic approaches. Providing reality-based encouragement to patients may be helpful. In addition to recommending therapy, health professionals should inform patients that the natural history of low back pain is favorable and that it is likely that their condition will naturally improve over time.1, 2

References
  1. Rowlingson JC, Keifer RB. Low back pain. In: Ashburn MA, Rice LJ. The Management of Pain. New York, Churchill Livingstone, 1998:261-274.
  2. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363-370.
  3. Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16:120-131.
  4. American Academy of Pain Medicine. FAQs. Available on September 6, 2001 at www.painmed.org/faqs/pain_faqs.html:1-2.
  5. Harsha W. Understanding and treating low back pain. In: Weiner RS. Pain Management: A Practical Guide for Clinicians. 5th ed. Boca Raton, Fl, St. Lucie Press, 1998: 231-238.
  6. Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine 1997;22:2128-2156.
  7. Manniche C, Hesselsoe G, Bentzen L, Christensen I, Lundberg E. Clinical trial of intensive muscle training for chronic low back pain. Lancet 1988;2:1473-1476.
  8. Manniche C, Lundberg E, Christensen I, Bentzen L, Hesselsoe G. Intensive dynamic back exercises for chronic low back pain: a clinical trial. Pain 1991;47:55-63.
  9. Frost H. Lamb SE, Klaber Moffett JA, Fairbank JCT, Moser JS. A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomized controlled trial. Pain 1998;75:273-279.
  10. Graven S, de Vet HCW, van Kleef M, Weber WEJ. Opioids in chronic nonmalignant pain: a criteria- based review of the literature. In: Devor M, Rowbotham MC, Wiesenfeld-Hallin Z, Proceedings of the 9th World Congress on Pain: Progress in Pain Research and Management. Vol. 16. Seattle, IASP Press, 2000: 965-972.
  11. Abram SE. Systemic opioid therapy for noncancer pain. In: Abram SE, Haddox JD. The Pain Clinic Manual, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2000: 135-138.
  12. American Academy of Pain Medicine and American Pain Society. "The Use of opioids for the treatment of chronic pain," available September 6, 2001 at www.ampainsoc.org/advocacy/opioids.htm.

A JOINT STATEMENT FROM 21 HEALTH ORGANIZATIONS AND THE DRUG ENFORCEMENT ADMINISTRATION
Promoting Pain Relief and Preventing Abuse of Pain Medications: A Critical Balancing Act
As representatives of the health care community and law enforcement, we are working together to prevent abuse of prescription pain medications while ensuring that they remain available for patients in need.

Both healthcare professionals, and law enforcement and regulatory personnel, share a responsibility for ensuring that prescription pain medications are available to the patients who need them and for preventing these drugs from becoming a source of harm or abuse. We all must ensure that accurate information about both the legitimate use and the abuse of prescription pain medications is made available. The roles of both health professionals and law enforcement personnel in maintaining this essential balance between patient care and spanersion prevention are critical.

Preventing drug abuse is an important societal goal, but there is consensus, by law enforcement agencies, health care practitioners, and patient advocates alike, that it should not hinder patients' ability to receive the care they need and deserve.

This consensus statement is necessary based on the following facts:
  • Undertreatment of pain is a serious problem in the United States, including pain among patients with chronic conditions and those who are critically ill or near death. Effective pain management is an integral and important aspect of quality medical care, and pain should be treated aggressively.
  • For many patients, opioid analgesics — when used as recommended by established pain management guidelines — are the most effective way to treat their pain, and often the only treatment option that provides significant relief.
  • Because opioids are one of several types of controlled substances that have potential for abuse, they are carefully regulated by the Drug Enforcement Administration and other state agencies. For example, a physician must be licensed by State medical authorities and registered with the DEA before prescribing a controlled substance.
  • In spite of regulatory controls, drug abusers obtain these and other prescription medications by spanerting them from legitimate channels in several ways, including fraud, theft, forged prescriptions, and via unscrupulous health professionals.
  • Drug abuse is a serious problem. Those who legally manufacture, distribute, prescribe and dispense controlled substances must be mindful of and have respect for their inherent abuse potential. Focusing only on the abuse potential of a drug, however, could erroneously lead to the conclusion that these medications should be avoided when medically indicated — generating a sense of fear rather than respect for their legitimate properties.
  • Helping doctors, nurses, pharmacists, other healthcare professionals, law enforcement personnel and the general public become more aware of both the use and abuse of pain medications will enable all of us to make proper and wise decisions regarding the treatment of pain.
American Academy of Family Physicians

American Academy of Hospice and Palliative Medicine

American Academy of Pain Medicine

American Alliance of Cancer Pain Initiatives

American Cancer Society

American Medical Association

American Pain Foundation

American Pain Society

American Pharmaceutical Association

American Society of Anesthesiologists

American Society of Law, Medicine &Ethics

American Society of Pain Management Nurses

American Society of Regional Anesthesia and Pain Medicine

Community-State Partnerships to Improve End-of-Life Care

Drug Enforcement Administration

Last Acts

Midwest Bioethics Center

National Academy of Elder Law Attorneys

National Hospice and Palliative Care Organization

Oncology Nursing Society

Partnership or Caring,Inc.

University of Wisconsin Pain &Policy Studies Group
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