Inflammatory Accusations

Sunday's Boston Globe had a nice article on pain management, particularly the historical assumptions and laws behind pain medication. It was particularly timely, given recent arrests and criticisms of pain clinics.
Medically speaking, then, pain has come to be understood not as the character-building crucible of old but as a dangerous medical problem. As a result, doctors have started to look to stronger measures to treat it - including so-called opioid analgesics like morphine and oxycodone (the active ingredient in Oxycontin). According to Portenoy, such drugs are "by far the most reliable and the most powerful analgesics available to humankind."

While morphine was the wonder drug of the 1800s, for most of the 20th century doctors prescribed such drugs sparingly, partly out of addiction concerns and partly from fear of prosecution. In the three decades after the 1914 passage of the Harrison Act, the nation's first drug law, 25,000 doctors were arrested for prescribing opiates.

In the 1970s, however, doctors treating terminal cancer found that their patients were much less likely than had previously been feared to develop an addiction - or even to experience the trademark opiate high. As a result, physicians began to see opioids as a possible treatment for more ordinary types of chronic pain, such as back pain or rheumatoid arthritis. In a highly influential 1986 paper, Portenoy and Foley argued that opioid therapy could be "a safe, salutary, and more humane alternative" to existing treatments for chronic pain. Two other pain specialists, J. David Haddox of Emory University (now an official at Purdue Pharma, maker of Oxycontin) and David E. Weissman of the University of Wisconsin, coined the term "pseudo-addiction" to describe how some patients who displayed what might be seen as addictive behavior were simply trying to treat their pain.

I think most doctors -- particularly emergency physicians -- develop a good sense of who's seeking and who's hurting. I'm not there yet, and tend to err on the side of comfort. It'd be nice to know, though, that I won't be prosecuted for guessing wrong.

Some of the doctors and pain centers that have recently come under fire were prescribing astronomical doses of pain meds. But then again, I've seen a few patients who routinely require four or five fentanyl patches a day -- a dose that'd take my breath away (literally). I'm curious how these trials will turn out.