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Report 4 of the Council on Scientific Affairs (A-95)
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Aspects of Pain Management in Adults
Note: This report represents the medical/scientific literature on this subject as of June 1995.
Full text
Resolution 503, "Pain Management," introduced at the 1993 Interim Meeting by the Medical Student Section and adopted as amended by the House of Delegates, asked that the American Medical Association (AMA): 1) focus attention on pain management education for physicians and medical students through existing AMA publications, and 2) investigate the barriers to appropriate management of pain by physicians, including factors such as institutional restrictions, intimidation by regulatory and law enforcement agencies, and attitudes of health care professionals. This report, developed as a response to the second resolve, addresses barriers to appropriate pain management. The report focuses on clinical situations of acute and chronic malignant pain. It does not deal with the controversial issue of opioid therapy for chronic or recurrent pain of nonmalignant origin.
Pain as a clinical problem
Pain is a common problem, encountered by every physician involved in the care of patients. The physician has an obligation to relieve a patient's pain and suffering. Despite good intentions and genuine concern for patients' comfort on the part of physicians, repeated evaluations of the state of pain therapy over the past 20 years suggest that many patients do not receive adequate pain relief. The classic paper by Marks and Sachar1 documented (in 1973) the undertreatment of pain in medical inpatients. A study in 1994 by Cleeland et al2 indicated that 42 percent of outpatients with metastatic cancer and pain were not given adequate analgesic therapy. The Agency for Health Care Policy and Research (AHCPR), commissioned to identify clinical problem areas and develop practice guidelines, recently published guidelines entitled, Management of Cancer Pain,3 and Acute Pain Management.4 Both guidelines start from the premise that inadequacy of pain management is "widespread." Portenoy has stated that "there is abundant evidence that unrelieved pain is highly prevalent and undertreatment by practitioners is a major cause of this outcome."5
Prologue
Pain management: Available techniques are adequate: Considering the availability of therapeutic tools adequate to the task of pain relief, there would appear to be little basis for an attitude of helplessness on the part of the physician. According to Max,6 it is the consensus of experts that most patients with both acute pain and chronic cancer pain can be kept comfortable when treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and an appropriately adjusted dose of an opioid agent. A commonly cited estimate3,7 is that 70 percent to 90 percent of patients with cancer pain can achieve adequate relief with properly applied opioid and/or non-opioid pharmacotherapy. When pharmacotherapy and basic procedures are not adequate, more specialized techniques, physical therapy, nerve blocks, and neurosurgical procedures may provide further relief.
Impediments to optimal pain management
A variety of factors are responsible for the undertreatment of pain; perhaps because these operate, as previously noted, to frustrate good intentions, they are called "barriers" to good pain management.
The AHCPR guideline, Management of Cancer Pain,3 provides a comprehensive outline but limited discussion of "Barriers to Effective Pain Management."
Specific barriers to pain management
Barriers to optimal management of cancer pain have been categorized as: factors influencing therapy related to knowledge deficits and inadequate practice of health care professionals, concerns or negative attitudes of patients, and disincentives to proper pain management in the health care system.8,9 The AHCPR guideline3 similarly categorizes the barriers as those consisting of factors related to the health care professional, factors related to patients, and factors related to the health care system.
Factors related to health care professionals
Inadequate knowledge of analgesic pharmacology and pain therapy: Pharmacologic agents, primarily opioids and NSAIDs, are the cornerstone of pain therapy. In their 1973 article, Marks and Sachar1 reported on the undertreatment of pain in hospitalized medical patients. Their questionnaire survey of housestaff physicians suggested that inadequate knowledge of opioid pharmacology and unfounded concern or lack of information about the addiction potential of opioid therapy were the main causes of inappropriate therapy.
Without stating directly that knowledge is presently inadequate, the American College of Physicians (ACP), position statement on "Drug Therapy for Severe Chronic Pain in Terminal Illness," declared that the ACP accepts its responsibility to "improve" the internist's knowledge of opioid therapeutics and drug therapy for such pain.10
Textbooks of medicine11 and oncology12 now contain discussions of pain management. Articles on pain management are common in medical journals,13 many continuing medical education courses are available,14,15 and specialty groups have developed curricula for the instruction of specialty trainees.15 Despite the availability of these educational materials, information is not always assimilated or translated into practice.
Practice patterns are rooted in training. In one study of oncology services,16 88 percent of physicians rated their medical school training in cancer pain management as fair or poor, and 73 percent rated residency training in pain management similarly.
It has been suggested that a lack of progress in changing the undertreatment of pain despite considerable educational efforts may indicate that education is not the only aspect that must be altered to effect a change.6
Nonpharmacologic therapies can be applied concurrently with analgesic and ancillary medications. A variety of noninvasive physical measures such as cold and superficial heat, exercise, massage, relaxation, and mental distraction techniques can add substantially to pain relief. These measures are a supplement, not a substitute, for pharmacologic methods. The patient and the patient's family members can be actively involved in some of these applications. Patients may seek additional methods of therapy, such as transcutaneous electrical nerve stimulation (TENS) and acupuncture, for which the evidence base is incomplete. The physician should be open to discussion of these measures and provide the patient with guidance and/or evaluation of their application.
Invasive nonpharmacologic techniques such as nerve blocks, radiation, and neurosurgery will usually involve consultation with other specialists. Medical centers should have specialized pain management teams to aid the primary physician in evaluation and coordination of the treatment program. The availability of such teams can insure that complex methods of evaluation and management such as opioid infusions and patient-controlled analgesia (PCA) are available to the patient in pain.
Poor pain assessment: The only tool for assessment of pain is the patient's self-report. Traditionally, assessment has been qualitative, informal, irregular, driven only by the patient's spontaneous and unsolicited complaint, or non-existent. Formal assessment tools consist of pain inventory forms with descriptive numbered scales, and visual analog or numeric pain distress scales3(Appendix). With basic instruction, formal pain assessment can be conducted by virtually any member of the health care team. Simple formal techniques of regular pain assessment are particularly effective in improving the overall level of pain management.17
The term assessment also refers to the clinical evaluation of pain for the purpose of defining its cause. Medical evaluation of pain etiology requires detailed medical knowledge, consideration of common pain syndromes, and appropriate use of specialist consultation. Poor or incomplete evaluation may result in improper formulation of the therapeutic plan.
Concern about regulatory oversight: Physicians have continually expressed concern over restrictive regulations. Physicians feel threatened and fear harassment and/or prosecution by enforcement authorities, particularly from state or local agencies.
Federal laws and regulations governing controlled substances are intended to ensure the availability and therapeutic benefit of these important drugs while minimizing their nonmedical use. The intent of Congress in developing federal drug control laws was not to regulate medical practice or to inhibit appropriate practice by limiting the medical indications for which these drugs could be used.18 According to one expert,19 federal regulations, primarily those implementing the Controlled Substances Act of 1970 (CSA), were not designed or intended to influence the appropriate use of these agents in medical practice. The Drug Enforcement Agency (DEA), the federal agency responsible for enforcing the CSA, also states that the regulations were not intended to impose limitations on a physician to administer or dispense the controlled substances "to persons with intractable pain in which no relief or cure is possible or none has been found after reasonable efforts."20 State laws, however, may be more restrictive and often impose limits against practices that are actually considered fully within medical professional standards. In one state, prescribing controlled substances for other than FDA-approved indications is prohibited.
Some regulations may intrude on or at least strain the physician-patient relationship. Patients who develop physical dependence on appropriately prescribed opioid medications are sometimes defined in state regulations as "addicted" and must be reported to the state controlled substance authorities.
Particularly onerous are state prescription monitoring programs such as the multiple copy prescription programs (MCPP) in which the prescribing activity of individual practitioners is tracked by use of special prescription forms. Newer versions employ computers for record collection. In these systems, law enforcement agents (with no medical training and using criteria that are generally obscure) judge the appropriateness of prescribing activity and determine the need for investigation or sanction of a practitioner. State laws regulating controlled substances are frequently more restrictive than federal laws and will vary substantially from one state to another. The triplicate or multiple copy prescription systems are an example of a state regulatory control that is far more restrictive than any federal requirement.19 Some states restrict prescriptions for Schedule II agents to a maximum number of dosage units or a 30-day supply, whichever is less. When the patient has a large dose requirement as a result of tolerance development, the dosage unit restriction may be a severe limitation.
It seems likely that such restrictions have an inhibitory effect on the legitimate prescription of controlled substances. Unfortunately, there has been limited investigation and, therefore, little objective evidence for such an effect. In one study, 18 percent of physicians associated with oncology groups ranked state regulation of analgesics among the top four most important barriers to proper pain management.16 Physicians who practiced in states with MCPPs ranked concern about regulatory oversight higher than physicians from states without such programs. Some physicians acknowledge that a potential for regulatory scrutiny or censure will occasionally influence their prescribing for pain patients to the extent that the prescribed therapy is suboptimal.21
Concern about oversight and censure may be a factor in the extensive use of propoxyphene (Schedule IV drug) rather than oxycodone and hydrocodone (Schedule II/III drugs) as discussed below. Methadone can be a very useful oral opioid agent for long-term pain control. However, the extensive regulation related to its use in opioid addiction therapy virtually precludes its consideration for outpatient pain therapy by physicians concerned about oversight.
Survey data indicate that 54 percent of physicians occasionally modify their pain prescription (lower dose, fewer refills) based on concerns about regulatory oversight.22 Portenoy commented on the difficulty of educating physicians in appropriate therapy when the clinically appropriate regimens are precisely the patterns of prescribing that raise concerns and precipitate investigations by law enforcement agents.8 For example, the physician is told to give high doses and multiple drugs for long durations in some instances. Terminal cancer patients may need large amounts of an opioid because of the development of tolerance over many months of illness. Or they may appropriately be given multiple controlled substances such as large dose opioid for pain, with a stimulant drug in the morning to reverse opioid-induced sedation and a benzodiazepine at bedtime for sleep. The author pointed out that while there is no difference between oxycodone and morphine (both short-acting mu agonists of equal analgesic efficacy), morphine carries a stigma and its prescription for outpatient use invites legal investigation.
Portenoy8 described ways in which regulations limit access to the opioid drugs. In some cases they prohibit access to clinically preferred drug regimens, impose a 120-day dosage rule, a 30-day maximum supply, a 3-day emergency supply rule, or involve personnel who impose "letter of the law" requirements that amount to harassment of physicians.
Physicians believe that restrictive regulations increase the cost of pain medication by increasing pharmacy costs for special handling and record keeping. These costs are passed on to the patients. Triplicate prescription systems are seen as intrusive, an unnecessary "hassle" for practitioners, and ineffective in reducing availability of drugs in the illegal street market. There is some evidence that a triplicate program covering schedule II agents induced physicians to prescribe older, less effective, higher scheduled medications in order to avoid the problems and concerns surrounding this regulatory system.23 From a practical standpoint the special forms present a logistical problem. Simply not having the forms immediately available when the prescription is written may influence the prescriber's drug choice.
Fear of patient addiction: Physical dependence is a pharmacological phenomenon produced by opioids and is manifested by the occurrence of a withdrawal syndrome on abrupt discontinuation of the opioid or administration of an antagonist. Physical dependence is an expected occurrence in any patient receiving opioids on a regular basis for a sustained period. Because physical dependence will develop after multiple doses for several days, the opioid dose should be reduced gradually when the drug is no longer needed in order to avoid the discomfort of a withdrawal syndrome. Administration of an opioid antagonist such as naloxone may precipitate a significant withdrawal syndrome after only a few doses of an opioid agonist.
Addiction, however, is a behavioral or psychological state defined by compulsive use of a substance (drug) resulting in physical, psychological, or social harm to the user; continued use despite that harm; and compulsive actions directed toward drug acquisition ("drug-seeking behavior"). Addiction is highly unlikely after short-term use of even large doses of opioid analgesics in patients with acute pain.
Concern about addiction should never result in undermedication for acute pain. The occurrence of addictive behaviors after chronic pain therapy is also rare. Fear of inducing addiction should never be the basis for withholding opioid agents from a patient without a history of substance abuse. Patients with a history of opioid abuse present a special problem, but opioids can be used safely and effectively to control pain in such individuals and should be used when indicated to control pain. Withholding of therapy in the patient with a history of addiction when opioid drugs are clearly indicated is inappropriate and unacceptable.
A condition referred to as "opioid pseudoaddiction" is related to inadequate pain therapy. A patient with severe pain, being undertreated with opioid analgesics, seems to exhibit aggressive "drug-seeking behavior," by demands and hostility, in an effort to obtain relief.24 Drug-seeking behavior ceases when the patient is provided adequate analgesia.
Concern about the side effects of analgesics: Opioids are relatively potent agents with narrow therapeutic ranges and effects on multiple organ systems. Physicians are trained to exercise care in their use. Morphine-like opioids characteristically induce respiratory depression, hypotension, nausea, vomiting, dizziness, sedation, mental clouding, dysphoria, pruritus, constipation, increased pressure in the biliary tract, myoclonus, and urinary retention.
The life-threatening adverse effects of respiratory depression and hypotension are subject to simple noninvasive clinical monitoring of vital signs and can be reversed by administration of specific antagonists and/or fluid loading. These hazards are, therefore, to a great extent, controllable with the application of due diligence in clinical care. Furthermore, patients with severe pain are resistant to the respiratory depressant effects of morphine-like agents (although this resistance also will diminish if pain subsides quickly). Some evidence suggests that clinicians are reluctant to exceed the "usual" dose range for opioid analgesics despite poor pain control out of concern for respiratory depression. Respiratory depression is most likely to develop in an opioid-naive patient after an acute opioid dose. Tolerance develops to the respiratory depressant effect rather quickly, and this is seldom a problem in the patient with chronic pain. Other adverse effects are also manageable.
In the patient who is terminally ill, the physician has an obligation to provide effective palliative treatment including pain control even though it may foreseeably hasten death (Policy 140.966, AMA Policy Compendium). Proper evaluation, pain treatment, and support may often alleviate the suffering that leads terminal patients to request assisted suicide (Policy 140.952).
Concern about development of tolerance to analgesics: The development of tolerance and the consequent requirement for larger doses of medication is another characteristic of opioid agonists. Tolerance to different opioid effects develops at different rates; the degree of tolerance development is variable among patients. Therefore, tolerance may or may not be a significant factor in a particular course of therapy. Tolerance to the analgesic effects of opioids is a poorly understood phenomenon. Numerous surveys have demonstrated that dose requirements usually remain stable in the absence of progressive diseases. Tolerance to analgesic effect as the major factor in opioid dose escalation appears to be uncommon. Regardless, when tolerance develops it may be manifest first as a decrease in duration of analgesic effect. More frequent doses and/or increasing doses of medication continue to produce the desired analgesia without introducing any additional adverse consequences of drug therapy. The large doses sometimes required by a tolerant patient may make the inexperienced physician concerned about the safety of such doses (and the possibility of censure, as discussed). The larger doses, however, continue to be effective and safe. It is necessary to counter the notion in both patients and clinicians that equates the tolerance phenomenon with addiction.
Factors elated to patients
Reluctance to report pain: A number of factors may be responsible for patient under-reporting of pain. Some patients prize the personal characteristic of stoicism. The notion that the pain of life's misfortunes should be borne in silence has a basis in some religious value systems.
Patients also may engage in denial of the disease process because of fear that continued pain means that the disease is progressing. Acknowledgement of pain is equated in the patient's mind with acknowledgment of the serious nature of the disease.
Other factors may follow on the patient experience; for example, the response of medical personnel to requests for additional pain medication when the "usual" dose has not resulted in adequate relief. Such "atypical" medication requirements are often taken by clinicians as an indication of addiction susceptibility or patient hostility or "drug-seeking" behavior as a manifestation of addiction. Repeated requests for medication after an assumed adequate dose has been administered may elicit hostility from the clinician and subsequent attempts by the patient to be "good" by not complaining of continued pain.
Hostility may arise in the clinician as a result of frustration at perceived inability to adequately control pain with typical opioid doses, common uncertainty in dealing with issues of drug addiction, and perceived questioning of the clinician's competence by a patient with unrelieved pain.
The physician should be aware that the analgesic response to opioids varies markedly among patients. The appropriate and effective opioid dose for a particular individual in a particular setting can only be determined by the response. "Usual" doses represent an initial estimate. Doses must then be titrated to effect.
Reluctance to take pain medications: The patient is subject to societal notions of the addictive potential of opioid drugs and patients may wait as long as tolerable before requesting medication out of fear of addiction. The origin of such fears, firmly entrenched in American society, is not clearly defined. Some would trace them to unscientific or unsubstantiated notions used in the "War on Drugs" to dissuade children from experimenting with abused drugs. Well-meaning opponents of drug abuse have popularized the idea that even a single dose or experience with the euphoriant drugs will likely induce addiction.
Reaction of the patient's family to the information that a "dangerous" addictive drug is being used in therapy may reinforce the patient's own fears of addiction. Lack of relief from initially prescribed opioid doses may suggest addiction susceptibility and cause the patient to suppress requests for additional medication.
In keeping with a common misconception or misinterpretation of information about other drugs, some patients believe that use of the analgesic drug in repeated doses will induce tolerance that will prevent the drug from being effective when they "really" need it. This translates to an idea that they should not take opioid medication on a regular basis but only when pain is severe. Development of tolerance and the need for larger doses also may be interpreted by the patient as the onset or initial manifestation of addiction.
Patients may fear the consequences of unmanageable side effects and often express the concern that sedation or cognitive clouding from the opioids will diminish their quality of life.
Factors related to the health care system
Low priority given to pain management: As pointed out by Max,6 clinicians from various specialties increasingly have taken interest in the clinical area of pain management. In the past, however, no one on the patient care team was held responsible for the adequacy of pain relief. If pain intensity (quantified by use of linear analog scales) were plotted at regular intervals like "vital signs," and the plot displayed prominently at the bedside or on the front of the chart, perhaps the patient's pain level would then "intrude" on the "cognitive world of those who write the medication orders."6 Hospital review committees might then question the physician about unresolved pain problems just as they would an unexplained fever or persistent hypertension. This suggestion (to plot pain intensity in the front of the medical record) could well be the key element in the solution to the problem of undertreated pain. Evaluation of pain therapy should be an integral part of institutional quality assurance programs.
Inadequate or inappropriate provisions for reimbursement: This issue has recently been reviewed extensively by Joranson.25 He notes, as have others, that the lack of a Medicare outpatient drug benefit may contribute to inadequate pain control because some cancer patients cannot pay for the prescribed medications. Vagaries of Medicare coverage may induce manipulation of the system and/or a shift to more expensive, invasive, uncomfortable and inherently more hazardous treatment methods solely because they are covered procedures. Examples are given by Ferrell26 of a patient whose insurance may cover the $4000 cost of parenteral Patient Controlled Analgesia (PCA) morphine but not $100 of oral morphine solution, and by Joranson,25 of cancer patients who may receive parenteral, rather than oral, analgesia in the home so that the recipient can qualify for home nursing care. Although Medicaid programs generally cover outpatient oral medications, budget limitations and the perception that drugs were overutilized have led to attempts to control costs by placing limitations on prescription quantities. Such caps on prescription benefits appear to affect patient care as noted above when patients have limited resources with which to purchase the needed amount of medication.
When making analgesic drug selections, physicians have a responsibility to consider the patient's ability to pay for a prescribed treatment. Although the primary responsibility of the physician is to treat pain effectively, equally effective and appropriate analgesic drugs may vary tremendously in price.27 Obviously, the physician should not prescribe a drug that is relatively ineffective and also more expensive than other available agents. Propoxyphene (with acetaminophen) was the analgesic most frequently dispensed from U.S. community pharmacies in 1993.28 Propoxyphene, however, is on at least one list29 of drugs that should never be prescribed to elderly patients, including those with cancer, and is not even mentioned among the analgesic agents discussed in the extensive AHCPR guidelines, Management of Cancer Pain3 and Acute Pain Management.4 An equivalent dose of generic propoxyphene (with acetaminophen) is about one-half again more expensive than codeine (with acetaminophen).27
Restrictive regulation of therapeutic agents that are controlled substances: As noted, most of the essential analgesic agents also happen to be controlled substances and, therefore, subject to strict regulation. An institution may foster pain management barriers by transmitting to the attending medical staff undue concern about potential legal liability from iatrogenically addicted patients or potential diversion of pharmacy controlled drug supplies. Hospital medical staff committees that oversee clinical operating procedures and monitor quality of care also may foster the imposition of barriers by failing to establish and review standards of pain management. Presumably, institutions could also be remiss in failing to provide equipment, facilities, and personnel for the application of more technically complex pain management approaches such as Patient Controlled Analgesia or providing for the development of specialized pain management teams.
Recommendations
The following Directives, recommended by the Council on Scientific Affairs, were approved by the AMA House of Delegates at the 1995 AMA Annual Meeting:
- The AMA will focus attention on pain management education for physicians and medical students through existing AMA publications and electronic offerings. Continuing efforts are indicated to enhance education of physicians in all aspects of the clinical issue of pain management. Information must be translated to practice.
- The AMA encourages physicians to monitor pain intensity and patient comfort on a formal basis in the same way that vital signs are monitored, and the clinical management team should be evaluated for quality performance in this area as in others. Outcome measures must be developed to provide a basis for appropriate assessment of pain treatment modalities.
- The AMA will continue its efforts to change inappropriate and restrictive controlled substance regulations.
- The AMA encourages physicians to counter patient factors involved in the undertreatment of pain (such as concern about addiction and reluctance to take medications) by taking time to understand and counsel the patient.
References
1. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med. 1973;78:173-181.
2. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592-596.
3. Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. Rockville, Md: AHCPR; 1994. US Department of Health and Human Services, Public Health Service Publication 94-0592.
4. Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma.Clinical Practice Guideline. AHCPR. Pub. No. 92-0032. Rockville, Md. AHCPR, Public Health Services, US Department of Health and Human Services. February 1992.
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10. Health and Public Policy Committee, American College of Physicians. Drug therapy for severe chronic pain in terminal illness. Ann Intern Med. 1983;99:870-873.
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17. Gould TH, Crosby DL, Harmer M, et al. Policy for controlling pain after surgery: effect of sequential changes in management. BMJ. 1992;305:1187-1193.
18. Shapiro RS. Legal bases for the control of analgesic drugs. J Pain Symptom Management . 1994;9:153-159.
19. Angarola RT, Wray SD. Legal impediments to cancer pain treatment. In: Hill CS, Fields WS, eds.Advances in Pain Research and Therapy. New York, NY. Raven Press; 1989;11.
20. Physicians' Manual. Drug Enforcement Administration, U.S. Department of Justice; July 1985.
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22. Weissman DE, Joranson DE, Hopwood MG. Wisconsin physicians' knowledge and attitude about opioid regulations. Wisconsin Med J. 1991;Dec:671-675.
23. Wientraub M, Singh S, Byrne L, Maharaj K, Guttmacher L. Consequences of the 1989 New York state triplicate benzodiazepine prescription regulations. JAMA. 1991;266:2392-2397.
24. Weissmann DE, Haddox JD. Opioid pseudoaddiction: an iatrogenic syndrome. Pain. 1989;36:363-366.
25. Joranson DE. Are health care reimbursement policies a barrier to acute and cancer pain management? J Pain Symptom Management. 1994;9:244-253.
26. Ferrell BR, Griffith H. Cost issues related to pain management. J Pain Symptom Management. 1994;9:221-234.
27. American Medical Association, Report to the Board of Trustees # 33, A-94 (Resolution 510, A-93) The disclosure of prices for all drugs and pharmaceuticals.
28. The top 200 drugs dispensed from community pharmacies in 1993. Am Druggist. February 28, 1994.
29. Wilcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA. 1994;272:292-296.
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