Pubdate:81797

Source:Orange County RegisterCommentary,page 1 Headline:The Politics of Pain
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Illustration by MARC MICHELON for The Orange County Register
(covers about 1/3 of front page)
WriterJohn SeilerMr. Seiler is a Register editorial writer.
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MEDICINE:Patients and physicians sometimes have to run a government
gauntlet to get effective treatment for chronic pain.
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When chronic,intense pain strikes,people need relief.

But too often, sufferers say they aren't getting adequate pain treatment
from their doctors; doctors counter that heavyhanded state and federal
regulations are intimidating and designed to steer them out of the pain
management business.

Some of the problem can be laid at the doorstep of the drug war, in which
law enforcement agencies have clamped down too hard on the prescription of
opiates, such as morphine.  

But, as courts and legislatures have grappled in recent years with the
highprofile "death with dignity" movement and the legal issue of assisted
suicide, new attention has fallen on pain management in the context of
death and dying.

Medical thinking about pain management is changing, too.  Once largely left
as an afterthought to treating the true ailment, pain management in recent
years has emerged as a parallel course of therapy, right alongside
treatment of the disease itself.

In response to this new focus on pain management and the frustrations
with legal restrictions expressed by doctors and patients alike,
across America coalitions of patients, doctors and legislators are
forming to make it easier for physicians to prescribe more powerful
pain medications.

The target is what doctors call chronic pain, generally defined as lasting
six months or more and not responsive to conventional medical treatment.
It's the back spasm that makes sitting down all but impossible.  Or it's
the aches that makes a cancer patient continually nauseated, unable to eat.

About 12 states, including California, already have passed legislation to
make it easier for patients to be given proper medication to relieve
chronic pain, and California's law has become a national model. This month,
the California Legislature is moving forward with new legislation, Senate
Bill 402, to further advance patients' rights.

But some jurisdictions are moving slowly, and physicians still run afoul of
laws that conflict with new thinking about pain management.

A case in point: William Hurwitz, M.D., an internist practicing in
Virginia.  After the Virginia Medical Board revoked his medical license for
allegedly prescribing too many pain medications, his case received national
publicity in U.S. News & World Report magazine.

On Aug. 5, the revocation was suspendedmeaning it's still in effect, but
for new he can practice medicine. He is appealing the original revocation
that would have permanently ended his ability to practice medicine. He also
expects that the federal Drug Enforcement Administration will restore his
certification to prescribe "Schedule II' drugs, which include such less
powerful painkillers as Tylenol 3.) So the ordeal he has suffered trying to
relieve his patients' suffering is far from over.

"Initially, I believed they were just shocked by the number of pills I was
prescribing to treat patients," Hurwitz told me of the reason for his
license being revoked. 'Some patients require the equivalent of three to
six doses of morphine. Or they need the equivalent in dilauldid, or
mixtures of the two. That's 100 to 200 pills per day.

"The medical literature supports the belief that some patients may require
higher doses to have a higher effect. However, from the Medical Board's
point of view and the DEA's point of view, when the number of pills used is
large, the risk of diversion [to illegal uses] increases."

For Dr. Hurwitz and many other, the national "drug war" has contributed to
what they believe is excessive scrutiny physicians must undergo when
prescribing drugs to relieve patients' pain.

"There are only about 10 doctors in this country who are willing to
help people relieve their chronic pain without sending them to Dr.
Kevorkian in Michigan," charged Harvely Rose, M.D., who practices
family medicine in Carmichael and has been active in promoting a more
compassionate pain medication policy. "Hurwitz called it a 'hidden
epidemic'" of people not treated for chronic pain. "We called it a
'hidden holocaust'."

The victims

Who can be struck with chronic painsever, nagging pain that won't go away
after months or even years?  Anybody. Chronic pain results not only from
such diseases as cancer and AIDS, but from auto accidents or even common
household accidents such as falling of a ladder.

Dr. Hurwitz described one common cause: "There are large numbers of people
with 'failed backs syndrome'. They have back pain often from a disk
problem.  The surgery makes them worse. Then they have another surgery, and
it gets worse.  Then more surgeries. At some point the surgeries and the
diagnostic work lead to the inflammation of the spinal canal, called
arachnoiditis. These patients have back pain, pain that goes down their
legs. They can't get comfortable sitting, standing, walking. I have a
number of such patients."

Can these patients be helped? "Generally, such patients will get relief
with opoid medications," he said.

As many as 34 million Americans suffer from some chronic pain each year,
according to the American Chronic Pain Association. Not all of them need
such strong painrelief medication as opiates, of course. Sources I talked
to in the pharmacy industry talked to in the pharmacy industry couldn't pin
more exact figures on the number of people who do need such heavyduty pain
killers. People are individuals who need to be treated according to their
separate conditions.

Intractable pain legislation

Hurwitz's state of Virginia has an Intractable Pain  act, which is supposed
to make it easier for doctors to relieve the chronic pain of patients. But
Hurwitz's own case shows that doctors still sometimes need the ethical
bravery of Hippocrates to help their patients.

In 1990 the California Legislature enacted Senate Bill 1802, our state's
Intractable Pain Act. It guarantees: "No physician and surgeon shall be
subject to disciplinary action by the [Medical] board for prescribing or
administering controlled substances in the course of pain." That law is so
clear that it has been adopted by the American Medical Association as a
model statute to be adopted by other states.

But as happens all too often in our society, a law making things easier on
people often is ignored. Dr. Rose is documenting the extent of the human
tragedy in aa book he is writing, "Painful Exits." It describes people who
have died in excruciating pain, committed suicide or hired Dr. Kevorkian
all because the people couldn't get adequate pain relief. There are rare
cases when patients have murdered their doctors for failing to prescribe
adequate pain relief medications.

Last month, the U.S. Supreme Court ruled that the U.S.Constitution does not
guarantee a right to doctorassisted suicide. Only one state, Oregon,
allows assisted suicides, and voters will have a chance to revoke that law
in a ballot initiative in November.

The court action protects life, but puts an exclamation point on the need
of patients to find adequate pain relief.

"Suicide is not an answer," Rose insisted. "Give people enough pain
medicine and they won't kill themselves. About a dozen states are on record
with Intractable Pain Acts. Medical boards put our directions. But
everybody's so scared,"he told me.

Fear of addiction

Much of the worry about prescribing pain medications stems from fears that
patients will become addicted. 

But, asks Rose, "Is fear of addiction a problem for cancer or AIDS
patients? No. So it's [the doctor's] fear of arrest. I call it the
Scarlet Letter of Arrest, in contrast to the Scarlet Letter of Addiction."

A study in the Nov. 6, 1996 issue of the Journal of the American Medical
Association confirmed Rose's contention: "Despite ever more sophisticated
strategies for treating human immunodeficiency virus (HIV) disease,
researchers are finding that many patients suffer needlesslly because
physicians fail to recognize and alleviate AIDSrelated pain...

"Part of the problem is what pain experts describe as overzealous concern
about the addictive potential and adverse effects of the strong opiates and
other medications that are often required for adequate pain control." 

Dr. Rose pose this question: If a patient's comfort level is 10 pills, for
relieving pain, but the doctor's comfort level is three pills, fearing that
more might provoke actions by the government, how many pills will the
patient get? The answer: just three pills.

Worries about addiction seem especially overblown in the cases of
terminally ill cancer or AIDS sufferers. 

And beyond that, medical literature also describes how severe pain "eats
up" the opoid medication in a way that prevents addiction. And unlike
addicts, who get high off the instant "rush" of the drug being injected
into their systems, pain is relieved through consistent, steady doses over
the course of time.

Addicts "take drugs to get high and are frequently lost to themselves,
their families and society," according to "The Painful Dilemma," a report
by the SacramentoEl Dorado Medical Society. "In contrast, the person with
chronic pain takes drugs to return to normal and to get on with life.
Narcotics allow individuals with pain to interact with their families and
to return to work. Pain patients overcome most of the side effects of
narcotics."

Should the pain go away and the patient give up the medication, some
physical withdrawal symptoms can occur. But patients withdrawing from pain
medication usually don't suffer the "psychological withdrawal" associated
with junkies going cold turkey.

Rose also points out that although patient addiction to painkillers is
rare, when it happens it can be cured through withdrawal therapies. "You
can get unaddicted," he said. "But you can't get undead."

Senate Bill 402

Rose and other reformers have been pushing for more sensible state laws.
The result is Senate Bill 402, sponsored by  state Sen. Leroy F. Greene of
Carmichael, which passed 273 in the Sentate and 180 in the Assembly
Health Committee. It is expected to be taken up by the full Assembly later
this month.

The bill stipulates: "Inadequate treatment of acute and chronic pain from
cancer and noncancerous origin is a significant health problem...In the
hands of knowledgeable and experienced pain practitioners, opiates
administered for severe acute and severe chronic intractable pain can be safe.

The patient suffering from severe chronic intractable pain has the option
to request or reject the use of any modality to relieve pain ... Physicians
may prescribe any dosage deemed necessary to relieve severe chronic
intractable Pain Treatment Act."

Gov. Pete Wilson's office told me the governor is still looking at the
bill. But he is aware of the issue. In 1994 he convened the Summit in
Effective Pain Management: Removing Impediments to Appropriate Prescribing.
"Many patients do not receive effective treatment," the Wilson Summit
concluded.

"Pain is undertreated in our society for many reasons: the low priority
given system; failure to diagnose pain properly; lack of awareness that
much pain can be relieved; incomplete application of existing knowledge;
exaggerated fears of addiction; and problems with government and private
sector attitudes toward controlled substances, health care, and
reimbursement..." 

Let's hope the governor has been convinced by the findings of his Summit,
and signs SB 402.

Both physicians and politicians need to adopt the principle of the great
Albert Schweitzer: "We all must die. But if I can salve [a patient] from
days of torture, that is what I feel is my great and ever new privilege.
Pain is a more terrible lord of mankind than even death itself."

RESOURCES FOR PAIN RELIEF

A concise book on pain relief, using the questionandanswer format,
is "How to Protect Your Loved Ones from Pain," by Robert L. Sassone,
a lawyer in Santa Ana. Although not a physician, he has been active
in the movement to make pain relief more available and provided some
of the research used in this article. The book contains numerous
resources and can be obtained by sending $4 to: American Life League
Inc., PO Box 1350, Stafford, VA 22555

The American Pain Society provides information on pain control: 4700 W.
Lake Ave., Glenview, IL 60025. Phone: 8473754715. Internet site:
www.ampainsoc.org

The Worldwide Congress on Pain's internet site is: www.pain.com. The
organization also lists other pain associations: www.pain.com/
associations.html

The National Hospice Organization's phone number: 8006588898. Internet
site: 
www.nho.org

The National Chronic Pain Outreach Association's phone nember: 5409975004. 
Internet site: www.win.bright.net/~davidk/ mission.htm

Alist of California pain clinics can be found on the Internet at:
www.pain.co/PainClinics/CA.htm

Resources for pain management are available from: the American Academy of
Pain Management, 13947 Mono Way #A, Sonora, CA 95370. Phone: 2095339744.
Internet site: www.aapainmanage.org

POLICLY STATEMENTS AND OTHER READING:

A statement by the Medical Board of California on "Prescribing Controlled
Substances for Pain" is on the Internet: www.calyx.net~schaffer/asap/cmb1.html

The California Board of Registered Nursing's "Pain Management Policy" is on
the Internet: www.calyx.net/~schaffer/asap/bnr.html

An article from the February 1990 "Scientific American" magazine, "The
Tragedy of Needless Pin," is on the Internet:
www.calyx.net/~scgaffer/asap/sa1.html

The report of Gov. Pete Wilson's 1994 Summet on Effective Pain Management:
Removing Impediments to Appropriate Prescribing, is on the Internet:
www.calyx.net/~schaffer/asap/psum.html

Acopy of "The Painful Dilemma: The Use of Narcotics for the Treatment of
Chronic Pain," prepared by the SacramentoEl Dorado Medical Soaciety ad hoc
committee on the treatment of pain includes the names of many California
doctors who treat pain. It's on the Internet at"
www.calyx.net/~schaffer/asap/dilemma.html

The  text of SB 402, state legislation that would protect the reights of
patients to receive adequate pain medication, can be found on the Internet:
www.leginfo.ca.gov/bilinfo.html(type in the bill nember: SB 402)

Adescription of the difficulties faced byl Virginia internist William
Hurwitz, who had his medical license revoked for allegedly prescribing too
many pain medications, can be found on the Internet at: drcnet.org/guide
1096/pain.html