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Pain treatment creating pain.

As the 50-year anniversary of my graduation from medical school approaches, I have witnessed many advances in medical care and management. However, my recent practice has brought me face-to-face with gross distortions of medical practice as it relates to pain management.

As a State tuberculosis consultant I have been to communities where half of the residents are addicted to opiates and the other half are dealing in drugs. I have seen an instance where identical twins, one of each, are being cared for by their two grandmothers because both parents are engaged in drug-seeking behavior. In a pre-employment exam that I conducted, a coal miner had been receiving Oxycontin for nine months because of a bump on the head that could have easily been handled with two aspirins. I would not approve this miner's pre-employment physical until his treating physician stated in writing that the opiate treatment had been discontinued. I recently noted that an opiate prescribed for post dental extractions provided refills for six months when a six-day course of treatment would have been adequate.

In the 1990's, when legislation was passed requiring all physicians to take a course on pain management, I remarked to a colleague that I knew how to provide opiates for pain, having been trained in the 1960's: that is -to provide one week of opiate for post-surgical care, twenty-five days for post-trauma, and as much opiate as necessary to relieve symptoms and pain in those with advanced cancers. The deviation from this protocol has resulted in not the alleviation of disease but the creation of a new disease where individuals, by misguided treatment of pain, become dysfunctional, dependent and larcenous.

I am unsure of the extent practicing physicians contribute to this epidemic of substance abuse, however, I believe it is time we reassess concepts of pain management and I would like to offer three items for consideration.

1. Pain does not have to be completely eliminated in our lives. Pain represents life and is something that does not need to be eliminated at all costs. I wake up each morning with low back pain to the degree that I am unable to bend to dress and to easily conduct my work for several hours. Yet, as the morning wears on the pain subsides. I would not trade my morning pain for a life of drug-seeking behavior and invalidism.

2. It has been established that most pain is just as effectively treated with non-steroidal anti-inflammatory agents rather than addicting opiate drugs. Most pain that is treated by a physician due to degenerative diseases and fibromuscular disorders should be exclusively managed by the use of non-steroidal or acetaminophen drugs. The use of opiates is often prescribed inasmuch as their recipients prefer them since they provide a measure of euphoria in addition to the analgesic properties. They are provided to patients for this particular effect. I have noted that many of those dependent on opiate drugs feel this dependency is okay because a physician has prescribed it.

3. There are individuals who are marginally functioning with mental or cognitive problems. These individuals are easily tipped over into a complicating addiction when opiates are prescribed inappropriately. They are unable to handle this added distortion of their life.

It is because drug addiction and its adverse consequences have become so deep and widespread that I believe opiate prescribing should revert to the practice of a former time. For the vast majority of pain opiates should not be prescribed. Opiates should be limited to brief periods of time postoperatively and post-traumatically. Generous and liberal use of opiates should be given to those with advanced or terminal malignancies or uncommon medical conditions where intense suffering is a part of the disease, such as advanced ALS. In writing an opiate prescription a physician should ask himself "could I not relieve this person's symptoms without running the real risk of creating addiction, drug-seeking behavior, illegal activities, and the consequence of individual and family disintegration?"
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Title Annotation:Commentary
Author:Gaziano, Dominic
Publication:West Virginia Medical Journal
Article Type:Viewpoint essay
Date:Jul 1, 2012
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