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PAIN MANAGEMENT BARRIERS TO GOOD PRACTICE

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Title: PAIN MANAGEMENT BARRIERS TO GOOD PRACTICE


1
PAIN MANAGEMENTBARRIERS TO GOOD PRACTICE
  • Eric J.Warm M.D.
  • Division of General Internal Medicine
  • University of Cincinnati
  • 3/27/02

2
OBJECTIVES
  • After this presentation the learner should be
    able to
  • Describe the major barriers to adequate pain
    management
  • Understand the concept of the Hidden Agenda in
    medical education
  • Differentiate between tolerance, withdrawal and
    addiction
  • Describe the controlled substance regulatory
    system

3
Current State of Pain Management
  • Pain is a part of human experience
  • Minor annoyance
  • Life altering

4
Current State of Pain Management
  • Emily Dickinson
  • Pain has an element of blank.
  • It cannot recollect
  • When it began, or if there were
  • A day when it was not.
  • It has no future but itself.
  • Its infinite realms contain its past,
  • Enlightened to perceive
  • New periods of pain.

5
Current State of Pain Management
  • Pain is a public health problem
  • Millions suffer episodic or persistent pain from
    countless causes
  • Societal cost is conservatively estimated at 100
    billion dollars annually

6
Current State of Pain Management
  • Pain is a public health problem
  • Millions suffer episodic or persistent pain from
    countless causes
  • Societal cost is conservatively estimated at 100
    billion dollars annually
  • In addition to the pain itself!

7
Current State of Pain Management
  • Pain management in present day America is poor
  • SUPPORT study
  • Study to Understand Prognoses and Preferences for
    Outcomes and Risks of Treatment
  • 30 million dollar study commissioned by RWJ
  • 50 of conscious patients who died in the
    hospital reported moderate to severe pain at
    least half the time
  • The SUPPORT principle investigators. JAMA
    19952741591-1598.

8
Current State of Pain Management
  • Michigan Pain Study
  • 1500 adults
  • 20 of adults suffered from ongoing chronic or
    recurring pain (1.2 million people in Michigan
    alone)
  • 77 of these people had pain for more than 1 year
  • 40 stated that pain had major impact on their
    lives
  • 36 missed work because of the pain
  • 35 of these missed more than 20 days
  • EPIC/MRA Executive Brief State of Pain.
    Michigan pain study -- A statewide survey.
    NewsRelease, October 13,1997

9
Current State of Pain Management
  • Michigan Pain Study
  • 1500 adults
  • 10 of people contemplated suicide because of the
    pain (120,000 people in Michigan alone!)
  • 70 of people still experienced chronic pain even
    after treatment
  • EPIC/MRA Executive Brief State of Pain.
    Michigan pain study -- A statewide survey.
    NewsRelease, October 13,1997

10
Current State of Pain Management
  • Extrapolated to the entire US staggering numbers
  • Problem is only going to get worse
  • aging baby boomers
  • Gallagher RM, Primary Care and pain medicine.
    Medical Clinics of North America 83 (3), may,
    1999 pp. 555-583

11
Current State of Pain Management
  • Pain in older people is associated with
  • impaired physical and social functioning
  • depression
  • immune dysfunction
  • poorer socioeconomic status
  • increased use of health services
  • Gallagher RM, Primary Care and pain medicine.
    Medical Clinics of North America 83 (3), may,
    1999 pp. 555-583

12
Current State of Pain Management
  • Would there be as much interest in physician
    assisted suicide if pain were adequately
    controlled?
  • Much of this morbidity and suffering is
    unnecessary

13
Current State of Pain Management
  • Effort for improved care of pain has generally
    come from outside organized medicine and the
    academic medical establishment
  • hospice movement cancer pain has improved
  • Societal change is slow
  • cancer pain and chronic benign pain still vastly
    under-treated
  • Gallagher RM, Primary Care and pain medicine.
    Medical Clinics of North America 83 (3), may,
    1999 pp. 555-583

14
Current State of Pain Management
  • Normally this level of substandard performance
    and its negative economic, legal, and regulatory
    ramifications would be considered intellectually
    and morally intolerable to organized medicine
    (and society) and would inevitably lead to
    correction of the causal deficiencies in
    physicians knowledge, attitudes, and skills.
    This tolerance of poor performance indicates
    exceptionally powerful barriers to change.
  • Gallagher RM, Primary Care and pain medicine.
    Medical Clinics of North America 83 (3), may,
    1999 pp. 555-583

15
  • What are the barriers?
  • Why do they exist?

16
Barriers to Pain Management
  • Medical Education
  • Knowledge
  • Attitudes
  • Skill

17
Barriers to Pain Management
  • Medical Education
  • Knowledge
  • Attitudes
  • Skill

18
Barriers to Pain Management
  • What kind of doctor do you want to be?

19
Barriers to Pain Management
  • What kind of doctor do you want to be?
  • Ghost of Rotations Future

20
Hidden Agenda
  • Medical education is a highly stratified system
    of power and authority relationships
  • Students function in multiple conflicting roles
  • learners
  • providers of care
  • Sociologists recognize above all else, medical
    training involves the transmission of a
    distinctive medical morality
  • Hafferty FW, Franks, R. The Hidden Curriculum,
    Ethics Teaching and the Structure of Medical
    Education. Academic Medicine 69(11) Nov. 1994,
    pp. 861-871.

21
Hidden Agenda
  • Only a fraction of the medical culture is found
    in formal curriculum based hours
  • Most of what you will internalize in terms of
    values, attitudes, beliefs and behaviors takes
    place in the hidden curriculum
  • Hafferty FW, Franks, R. The Hidden Curriculum,
    Ethics Teaching and the Structure of Medical
    Education. Academic Medicine 69(11) Nov. 1994,
    pp. 861-871.

22
Hidden Agenda
  • Hidden curriculum is more concerned about
    replicating the culture of Medicine, than with
    the teaching of knowledge and techniques
  • Possible result progressive decline in moral
    reasoning during medical school
  • Hafferty FW, Franks, R. The Hidden Curriculum,
    Ethics Teaching and the Structure of Medical
    Education. Academic Medicine 69(11) Nov. 1994,
    pp. 861-871.

23
Hidden Agenda
  • Medical training is not just about learning how
    to become a physician -- it is how to cease to
    be a lay person
  • Physician identity and character to acquire
  • You may arrive at the gates of medical school
    with established values, but it is rare to leave
    with them intact or unmodified
  • Hafferty FW, Franks, R. The Hidden Curriculum,
    Ethics Teaching and the Structure of Medical
    Education. Academic Medicine 69(11) Nov. 1994,
    pp. 861-871.

24
Hidden Agenda
  • Enter medical school to help people
  • Treatment vs. Maintenance
  • Patients
  • victims of disease
  • objects for learning
  • subjects for research
  • Hafferty FW, Franks, R. The Hidden Curriculum,
    Ethics Teaching and the Structure of Medical
    Education. Academic Medicine 69(11) Nov. 1994,
    pp. 861-871.

25
Hidden Agenda
  • Residency
  • Patients
  • objects of work
  • sources for frustration and antagonism
  • enemy
  • hits
  • gomers
  • dirtball
  • squirrels
  • Hafferty FW, Franks, R. The Hidden Curriculum,
    Ethics Teaching and the Structure of Medical
    Education. Academic Medicine 69(11) Nov. 1994,
    pp. 861-871.

26
Hidden Agenda
  • Common enemy The Pain Patient

27
Barriers to Pain Management
  • Societal Barriers
  • cultural
  • attitudinal
  • Knowledge deficits
  • Influence of drug regulatory agencies

28
Barriers to Pain Management
  • Underlying all impediments to good care
    societys deeply rooted unsavory image of opioids
  • opium
  • opium dens
  • addiction
  • Think narcotics division of police department
  • Society fails to distinguish between the
    legitimate and illegitimate use of opioids

29
Barriers to Pain Management
  • Confusion over
  • Tolerance
  • Physical Dependence
  • Addiction (Psychological Dependence)

30
Barriers to Pain Management
  • Tolerance decreasing response to the same dosage
    of a drug over time as a result of physiologic
    adaptation
  • the need to increase the drug in order to obtain
    the same effect
  • true tolerance is rare when treating a stable
    pain condition

31
Barriers to Pain Management
  • Physical Dependence A physiologic state of
    adaptation to a specific drug characterized by a
    withdrawal syndrome following the abrupt
    cessation of the drug or the administration of an
    antagonist

32
Barriers to Pain Management
  • Addiction a compulsive disorder in which an
    individual becomes preoccupied with obtaining and
    using a substance despite adverse social,
    psychological, and/or physical consequences, the
    continued use of which results in decreased
    quality of life

33
Barriers to Pain Management
  • Addiction use despite harm
  • Tolerance and physical dependence may or may not
    be present
  • Tolerance and physical dependence do not prove
    psychological dependence (addiction)

34
Barriers to Pain Management
  • Society fails to distinguish between the
    legitimate and illegitimate use of opioids
  • Illegitimate view dominates

35
Barriers to Pain Management
  • Irrational fear of addiction
  • common misconception giving opioids leads to
    euphoria that once experienced will lead to
    addiction
  • misinterpretation of patients emotional relief
    following alleviation of pain as euphoria
  • cancer patients rarely experience opioid induced
    euphoria
  • patients in pain respond differently than those
    not in pain
  • addiction is extremely rare when using opioids
    for pain

36
Barriers to Pain Management
  • Illegitimate view
  • Requirement of a biomedical or disease model to
    explain the pain (Cartesian Requirement)
  • Often patients complain of symptoms for which we
    have no answer

37
Barriers to Pain Management
  • Knowledge deficits concerning opioids
  • Curricula of medical schools and residencies have
    lagged behind in the science of pain medicine
  • most lectures are pre-clinical least amount of
    clinical context
  • lectures are usually piecemeal
  • no comprehensive view of the problems or
    solutions

38
Barriers to Pain Management
  • Physicians Dont Know What They Dont Know About
    Pain Management

39
Barriers to Pain Management
Weissman, D.E. unpublished data 2000
40
Barriers to Pain Management
Weissman, D.E. unpublished data 2000
41
Barriers to Pain Management
  • Knowledge deficits
  • Confusion over addiction, physical dependence and
    tolerance
  • Lack of knowledge of pharmacology
  • Exaggerated fear of respiratory depression
  • Fear of sanction from ethical impropriety

42
Barriers to Pain Management
  • End result of knowledge deficit
  • Prescription of opioids by customary practice
    rather than pharmacologic action
  • multiple studies have shown under
    underutilization of opioids as characteristic of
    inpatients
  • Prescribing by custom leads to perpetuation of
    the norms of the community and override rational
    opioid use
  • Stratton CH. The Barriers to Adequate Pain
    Management with Opioid Analgesics. Seminars in
    Oncology 20 (2) Suppl 1 (April)1993pp.1-5.

43
Barriers to Pain Management
  • If a patient makes an atypical claim about the
    severity of pain, or complains of pain after
    supposedly effective treatment is given
  • likely care giver will label the patient a drug
    abuser
  • iatrogenic pseudoaddiction
  • Stratton CH. The Barriers to Adequate Pain
    Management with Opioid Analgesics. Seminars in
    Oncology 20 (2) Suppl 1 (April)1993pp.1-5.

44
Barriers to Pain Management
  • iatrogenic pseudoaddiction
  • behavioral manifestations of addiction occurring
    as a result of under-treated pain
  • typically in the setting of severe continuos pain
  • inadequate doses
  • excessive intervals

45
Barriers to Pain Management
  • Why dont doctors just give patients the benefit
    of the doubt?
  • After all, pain is subjective
  • Real vs. Fake pain
  • Surgical model appendicitis

46
Barriers to Pain Management
  • Attitudes
  • Misunderstanding addiction (and pseudoaddiction)
  • Fear of creating addicts
  • Aversion to feeling manipulated by addicts
  • Lack of knowledge professional arrogance
  • Many of your teachers wont know what they dont
    know about pain management
  • Fear of regulatory sanctions
  • View of patients as the enemy

47
Barriers to Pain Management
  • DEA Bogeyman
  • Dark, evil, powerful force ready to get you
  • after a certain number of prescriptions
  • after a certain dosage
  • after a certain number of pills
  • Most investigations do not arise from prospective
    monitoring!
  • Fear of sanctions turns pain management into an
    Us against Them mentality

48
Barriers to Pain Management
  • Fear rooted in the history of drugs in America
  • Drug control policy in America has vacillated
    between tolerance and intolerance of drugs
  • War on drugs
  • In the past regulatory agencies have exercised
    aggressive surveillance and control

49
Barriers to Pain Management
  • Pain lobby has created more enlightened
    regulations and policies
  • Fear of sanctions is greatly exaggerated

50
Regulatory System
  • Controlled substances regulatory system
  • International
  • Federal
  • State

51
Regulatory System
  • International
  • International Narcotic Control Board
  • works through treaties to track worldwide
    production and distribution of opioids
  • effective at preventing legitimate drugs from
    going to illicit markets

52
Regulatory System
  • Federal Laws
  • Controlled Substance Act (CSA) 1970
  • Federal Food, Drug and Cosmetic Act

53
Regulatory System
  • CSA created the schedules of drugs
  • Schedule I high abuse potential -- no accepted
    use (heroin, marijuana)
  • Schedule II high abuse potential and severe
    dependence liability (morphine, codeine, percocet
    etc.)
  • Schedule III Moderate dependence liability
    (Tylenol 3, Vicodin)
  • Schedule IV Limited dependence liability
    (benzodiazepines, fioricet)
  • Schedule V Limited abuse potential (Lomotil)

54
Regulatory System
  • Drug Enforcement Administration (DEA)
  • administers federal laws
  • maintains opioid records
  • registers health professionals
  • sets quotas
  • enforces violations of the CSA

55
Regulatory SystemFederal Law
  • CSA recognizes opioids are necessary for public
    health
  • CSA provides a mechanism for external medical
    input in making drug control decisions
  • Availability of drugs to meet medical needs in
    guaranteed
  • Weissman DE. Doctors opioids and the law the
    effects of controlled substance regulations on
    cancer pain management. Seminars in Oncology 20
    (2) Suppl 1 (April)1993pp.53-58.

56
Regulatory SystemFederal Law
  • The federal definition of addict does not apply
    to chronic pain patients
  • Federal regulations recognize that the treatment
    of intractable pain is not synonymous with
    addiction
  • There are no federal restrictions on the amount
    of opioids that can be dispensed at one time
  • Weissman DE. Doctors opioids and the law the
    effects of controlled substance regulations on
    cancer pain management. Seminars in Oncology 20
    (2) Suppl 1 (April)1993pp.53-58.

57
Regulatory SystemFederal Law
  • In summary there are no federal restrictions on
    the use of opioids to treat intractable pain
  • State laws tend to be more strict (and less
    enlightened) than federal law
  • Weissman DE. Doctors opioids and the law the
    effects of controlled substance regulations on
    cancer pain management. Seminars in Oncology 20
    (2) Suppl 1 (April)1993pp.53-58.

58
Regulatory SystemState Law
  • Examples of aggressive surveillance and control
  • Multiple copy prescription program
  • When instituted Schedule II prescriptions drop
    by 50 (first year)
  • Successive reduction in physician requests for
    triplicate pads
  • 10 states still have these laws

59
Regulatory SystemState Law
  • Examples of aggressive surveillance and control
  • Limits on number pills dispensed
  • NJ only 120 pills per month
  • Poor definitions of addiction
  • NY all cancer patients on opioid were registered
    as addicts

60
Regulatory SystemOhio Law
  • 4731-21-02 Utilizing prescription drugs for the
    treatment of intractable pain.
  • (A) When utilizing any prescription drug for the
    treatment of intractable pain on a protracted
    basis (greater than 12 weeks) or when managing
    intractable pain with prescription drugs in
    amounts or combinations that may not be
    appropriate when treating other medical
    conditions, a practitioner shall comply with
    accepted and prevailing standards of care which
    shall include, but not be limited to, the
    following

61
Regulatory SystemOhio Law
  • (1) An initial evaluation of the patient shall be
    conducted and documented in the patient's record
    that includes a relevant history, including
    complete medical, pain, alcohol and substance
    abuse histories
  • (2) A medical diagnosis shall be established and
    documented in the patient's medical record that
    indicates not only the presence of intractable
    pain but also the signs, symptoms, and causes
    and, if determinable, the nature of the
    underlying disease and pain mechanism

62
Regulatory SystemOhio Law
  • (3) An individualized treatment plan shall be
    formulated and documented in the patient's
    medical record. The practitioner shall document
    the patient's response to treatment and, as
    necessary, modify the treatment plan
  • (4)(a) The practitioner's diagnosis of
    intractable pain shall be made after having the
    patient evaluated by one or more other
    practitioners who specialize in the treatment of
    the anatomic area, system, or organ of the body
    perceived as the source of the pain.

63
Regulatory SystemOhio Law
  • (5) The practitioner shall ensure informed
    consent to treatment of prescription drug therapy
    on a protracted basis

64
Regulatory SystemOhio Law
  • (1) Patients shall be seen by the practitioner at
    appropriate periodic intervals to assess the
    efficacy of treatment, assure that prescription
    drug therapy remains indicated, evaluate the
    patient's progress toward treatment objectives
    and note any adverse drug effects.
  • (3) Based on evidence or behavioral indications
    of addiction or drug abuse, the practitioner may
    obtain a drug screen on the patient

65
Regulatory SystemOhio Law
  • (C) If the practitioner believes or has reason to
    believe that the patient is suffering from
    addiction or drug abuse, the practitioner shall
    immediately consult with an addiction medicine or
    other substance abuse specialist.

66
Regulatory SystemOhio Law
  • 4731-21-04 Tolerance, physical dependence and
    addiction.
  • (A) Physical dependence and tolerance by
    themselves do not indicate addiction.
  • (B) Physical dependence and tolerance are normal
    physiological consequences of extended opioid
    therapy, and do not, in the absence of other
    indicators of drug abuse or addiction, require
    reduction or cessation of opioid therapy.

67
Regulatory SystemOhio Law
  • 4731-21-06 Exceptions.
  • (A) A practitioner who treats pain by utilizing
    prescription drugs is not subject to disciplinary
    action pursuant to this chapter of the
    Administrative Code under the following
    circumstances
  • (1) The treatment of pain for a patient with a
    terminal condition
  • (2) The treatment of pain associated with a
    progressive disease that, in the normal course of
    progression, may reasonably be expected to result
    in a terminal condition

68
Regulatory SystemState Law
  • Now you know more than most practicing physicians

69
Barriers to Pain Management
  • What kind of doctor do you want to be?

70
Barriers to Pain Management
  • He who knows and knows that he knows is
    conceited avoid him
  • He who knows not and knows not that he knows not
    is a fool instruct him
  • He who knows and knows not that he knows is
    asleep awaken him
  • He who knows not and knows that he knows not is a
    wise man follow him
  • Arab Proverb
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