THE DECADE OF PAIN CONTROL AND RESEARCH.

At the dawn of this present millennium, last fall, Congress passed a law declaring that the next 10 years are to be designated as the "Decade of Pain Control and Research." In January of this year, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) issued new standards mandating that pain be considered as a "vital sign," in effect making it compulsory for health care professionals practicing within accredited health care facilities to enquire about, measure, and treat pain as they would temperature, blood pressure, pulse, and respiratory rate. These standards are now in effect, and JCAHO surveyors are at present assessing compliance with this standard. California made medical license renewal contingent upon completion of a pain management CME program.

The past centuries have witnessed a dramatic change in the way pain is perceived by health care professionals as well as by society. Long gone are the days when one was expected to suffer pain stoically and bear it with a stiff upper lip! In those days, pain had to be endured as an inevitable consequence of disease. Pain also was sometimes seen as a means of expiating one's sins, and several "holy people" inflicted on themselves discomfort and pain: self-flagellation, for instance, was not an uncommon practice.

It is also probable that because of the adverse effects associated with the few pain killers that were available, physicians were reluctant to use them freely. Instead, they expected the patients to suffer and be "patient." Physicians were also taught not to treat symptoms such as pain before establishing a firm diagnosis, or at least as firm a diagnosis as possible. At that time, little was known about the various "medications" used, and it is in many ways telling that Hippocrates' first dictum is "First, do no harm."

These days are now gone. Our present pharmacopeia includes several analgesics of various potencies. There are also many nonpharmacologic means of alleviating pain. The judicious use of resources at our disposal should allow us to control most types of pain effectively, with minimal adverse effects. The key word, however, is "judicious," for if improperly used, all sorts of problems may arise.

Unfortunately, until recently, not enough was being taught about pain and pain control in medical schools. Although specialized pain centers are increasingly available, most practicing physicians should be able to effectively manage most types of pain. It is important especially for physicians providing primary care to understand the proper use of narcotics, which are still the mainstay of pain management. They also need to stay abreast of changing prescribing guidelines. Most states have enacted pain management legislation or guidelines. Many also have developed regulations to protect physicians who prescribe therapeutic doses of oral narcotics for long-term, disabling pain. One should, however, be familiar with the state regulations and should keep adequate documentation.

Health care professionals have a great deal to learn about pain and pain control. Foremost, however, is the need to change our attitude toward pain. In most instances there is no longer any need to let patients suffer. One should not wait for the patient to complain about pain; instead, one should enquire about this symptom and to what extent it is interfering with the patient's daily activities and mental state.

In this respect, it is worthwhile to remember the World Health Organization's definition of "health." It is a state of complete social, mental, and physical well-being, and not merely the absence of disease. Pain interferes with the patient's well-being and should be adequately addressed.

In a way, it is regrettable that law-makers had to tell health care providers how to care for their patients. On the other hand, proper pain management is long overdue and many patients have been--and are still--suffering unnecessarily. Various surveys have shown that 37% of all men and 46% of all women with arthritis experience daily, long-standing pain; that about 50% of cancer patients report inadequate pain relief; and that 56% of adults suffering from noncancer pain experienced pain for more than 5 years and that in 41% of these cases, the pain was described as being "out of control."

Great strides have already been made. In the US, the sales of prescription analgesics tripled since 1996, reaching $1.8 billion in the year 2000. Analgesics are now more effective, have a longer duration of action, and are associated with fewer adverse effects, especially nausea and sedation.

Unfortunately, however, in many instances analgesics are not used judiciously, and the incidence of reported first-time abusers of painkillers has surged during that period. It is estimated that in 1999 about 4 million Americans over the age of 12 years used prescription analgesics for "nonmedical reasons." About half were first-time users. Oxycodone and hydrocodone are, according to the DEA, the most abused prescription drugs. Indeed, emergency room visits involving hydrocodone jumped from 6,100 incidents in 1992 to over 14,000 in 1999, and those involving oxycodone from 3,750 to 6,430. The National Institute on Drug Abuse is launching a major initiative to reduce prescription drug abuse.

Abuse of prescription analgesics is not associated with the stigmata of other nonprescription drug abuse. Abusers also may think that these compounds are "safe." There does not appear to be a typical profile of a medication drug abuser: teenagers, stay-at-home mothers, executives, or even health care professionals may succumb to the habit. It is indeed sobering that in Cincinnati, which tracks prescription drug abuse, about 30% of cases of prescription drug abuse involve health care employees.

The potential of drug abuse, however, should not be a baffler to effective pain control. It is time we moved from Hippocrates' first dictum, "First, do no harm," to his next one: "Second, do good!"

Ronald C. Hamdy, MD, FRCP, FACP 

Editor