Pain Specialist Calls for Physician-Regulator Dialogue on Opioid Therapy

WASHINGTON, Nov. 17, 1996 -- In a presentation at the 15th Annual Scientific Meeting of the American Pain Society, Russell K. Portenoy, MD, Co- Chief of the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York, called for spreading the word among both physicians and state regulatory boards that pain specialists now consider opioid therapy appropriate, safe, and effective on a long-term basis for selected patients with chronic nonmalignant pain, provided that patients are carefully monitored.

Reluctant to stir up images of opium dens and morphine addicts or to invite sanctions by suspicious state regulatory boards, doctors have in the past steered clear of long-term prescribing of opioid (narcotic) analgesics except in cases of chronic cancer pain. There has been a preconception among physicians, regulators, and patients that opioids are highly addictive, dangerous mind-altering drugs whose use could only be excused in terminal patients in extreme pain.

Recent studies, however, have shown that opioids, if administered properly, are not only effective in managing chronic noncancer-related pain, but usually safe as well. As Dr. Portenoy commented, "The risk of addiction or abuse in patients with no prior history of drug abuse is wildly overstated. And that's one of the factors driving regulatory concern. The presumption that if you give a patient with no prior history of drug abuse an opioid drug he or she is likely to lose control and develop behaviors like addicts without painful disease is just nonsense."

Indeed, Dr. Portenoy argues that both primary caregivers and the state regulatory boards need to be educated about the changing role of opioid therapy that pain specialists have endorsed over the last decade. Unless a wider consensus is reached on the appropriate use of opioids for nonmalignant pain, patients will miss out on relief for chronic pain that often persists despite other treatments.

"Most patients with chronic pain never see a pain specialist. Osteoarthritis is the most common cause of chronic pain among the elderly, and people are treated for it by their family doctors," Dr. Portenoy explained. But if their family doctors don't know about the safety and benefits of opioids, or it they are worried that the state medical or pharmacy boards will call them on the carpet for prescribing them, patients whose pain does not respond to conventional measures will never have the opportunity to benefit from opioids.

The regulatory situation is particularly difficult to remedy since the knowledge and practices of medical boards vary from state to state, and therefore must be addressed individually. Furthermore, there may be resistance to revising policies an opioid therapies because opening the door to using opioids for noncancer-related pain would involve more complicated monitoring procedures to ensure that opioids were being used properly. As Dr. Portenoy explained, rather than simply sanctioning a doctor for using opioids for ailments other than cancer, boards would have to evaluate each case and determine whether the drugs are being dosed and monitored appropriately. This would mean acquiring more knowledge and expending more time and other resources that boards may not have at their disposal. Still, if opioid therapy is to be made available to those who need it, a dialogue needs to be opened between physicians who treat pain and the regulators who try to ensure that they treat it safely. Dr. Portenoy suggest that, to achieve this dialogue, pain experts in each state take the initiative to inform regulators of developments in the field of pain management.

Dr. Portenoy cautioned, however, that no amount of dialogue will help if doctors who intend to use opioids more widely to treat pain do no educate themselves as well. While stressing that the risk of opioid abuse of addiction in patients without prior histories of abuse is extremely rare, he went on to say that careful, structured dosing and close monitoring of drug- taking behavior is necessary to head off even this slight risk.

In short, doctors must learn pain management and pharmacological skills in order to use opioids responsibly and prevent a regulatory backlash. The American Pain Society believes that the healthcare of all patients should include assessment of pain and its impact on the patient, specific efforts by healthcare professionals to control pain, and referral to experts in pain management if initial efforts do not provide pain relief.