Where is the Pain?

Over the past 10 years one of the greatest burdens on US primary care physicians has become pain management. Since the mid-90s there’s been a steady drumbeat of academic opinion that primary care doctors are ignorant of and insensitive to their patients’ pain. It was an easy and seamless transition for the media and the pharmaceutical industry to transform this academic insight into an information and advertising campaign directed at increasing the demand for the prescription of chronic opioid pain medication. By the millennium it was not uncommon to hear from patients that doctors “don’t know anything about pain”-- often followed by demands for opioids,even followed by formal complaints if these demands were resisted.

But just what lay behind the academic assertions that primary doctors were not treating pain and that the drugs were falsely feared and underutilized? Assuming for a moment that there is no conflict of interest in the academic research world (a topic which Barbara Angel, M.D., a former editor of the New England Journal of Medicine has explored in disturbing detail to the contrary), the academicians may be forgiven for being stereotypically ignorant of real-world practice and the problems these recommendations have unleashed. after all they don’t see patients day in and day out in the community setting.

But for the marketing departments of the drug companies it was a very different story. Doctors were told, for example, that long-acting oxycodone formulations, the most heavily marketed of which was the now infamous OxyContin, were less addicting and less euphoria-inducing than once commonly feared. That’s certainly what the marketing team at Purdue Pharmaceuticals was telling physicians during their intensive marketing campaign. The problem was that Purdue had evidence to the contrary which it systematically suppressed. At least that was the verdict of a federal ruling which resulted in a $634 million fine levied against Purdue Pharma’s CEO Michael Friedman and his head Corporate lawyer Howard Udell when they were found guilty of intentionally “mislabeling” the drug. Those who followed this case closely, however, were disappointed that criminal penalties weren’t handed down because not only was OxyContin found to be addictive as result of its euphoria induction, but it was also implicated in a number of deaths stemming from these properties.

The problem is this: between the late 1990s and 2003, accidental poisoning, 90% of which was due to prescription opioid overdosage, became second only to motor vehicle accidents is the leading cause of accidental death in many communities of the United States. Thousands of deaths have been linked to the misuse, abuse, and diversion of prescription opioids, most of it prescribed for subjective non-cancer chronic pain.

There is little discussion about this today but just about any practicing primary care doctor will confirm that as a result of this upsurge in prescribing opioids for the treatment of chronic subjective noncancer pain, medical practice in the US has been fundamentally transformed. Significant time is now required for the monitoring, ongoing pain reassessment, and occasionally, dispute resolution engendered by the upsurge in the use of chronic opioids. When covering for a colleague, the situation becomes even more difficult. And clinically determining the treatment endpoint for a problem that often revolves solely around the patient’s subjective assertion of pain is often frustrating and difficult if not impossible.

The impossibility of the task is highlighted by the extent of the misuse of these drugs. In the Puget Sound region of the US, OxyContin sells for around one dollar per milligram on the street. Recommended chronic pain doses of OxyContin are 20 to 40 mg twice a day with doses of upwards of 60 to 80 mg twice a day for what the prescribing instructions provided by the pharmaceutical company terms “opioid dependent” users. Do the math. There are powerful black market incentives to divert and misuse these drugs. Why? Because someone seeking the euphoria produced by oxycodone can ingest 12 hours worth of oxycodone in seconds by pulverizing and snorting, dissolving and injecting, or crushing and smoking the drug. The abuse potential is enormous.

And how does my experience New Zealand compare with that in the US? In the four communities I’ve practiced in so far, the problem simply does not exist. Patients are more than happy to take a few days of codeine and utilize nondrug management such as immobilization for broken bones. They use ibuprofen or acetaminophen (called paracetamol here) for strains and sprains. And most astonishingly, many are happy to have an accurate diagnosis and prognosis as to the degree and nature of pain, and if it will be mild, they even respond positively to reassurance. And lest you think that I’m callous and uncaring, I have seen a few cases where pain issues were developing and it was addressed after adequate clinical assessment and a care plan was developed.

Are New Zealanders that much tougher than their American counterparts? I doubt it, but there is some recognition that a moment to moment pain-free existence (with euphoria on the side, if possible) is not always necessary or desirable. Could there be an urban versus rural difference? Admittedly, I have spent no time in large urban areas, but some of the highest levels of OxyContin addiction and abuse in the US have occurred in rural states like Kentucky Ohio and West Virginia -- -- so much so that the drug has acquired the moniker “hillbilly heroin”. No, I think it has a lot to do with expectations and, to come full circle, mistaken assertions and unconscionable marketing which has set in motion and continues to perpetuate this serious public-health problem.

And the solution in the US? Meaningful regulation and criminal prosecution of the executives of irresponsible pharmaceutical companies would have a great impact. (The $634 million fine was a fraction of Purdue’s profits and the executive perpetrators vigorously denied any responsibility for Purdue's policies-- blaming the victims, the doctors and the regulators for the problem instead). It also probably comes down to each and every physician taking a hard look at their own prescribing practices. After all, only we can sign the prescription. Helpful too, would be the expansion of detox facilities so that those who are addicted can be properly treated. Additionally,an honest conversation between physicians and patients about the perils of chronic opioids will also be needed. And perhaps most importantly, it will take a concerted education program at both the public health and individual patient level to remind us that pain is a symptom which compels a proper diagnosis as to its source and an exhaustive effort to correct the underlying problem by employing multiple treatment modalities of which chronic opioids are a last, not a first, resort.