Rheumatoid Arthritis Fingers by david__jones
The Agony of Pain the Hope of Science
Alen J Salerian MD
This article is about the agony of chronic pain and addiction and the hardships faced by physicians treating people with chronic pain and addiction.
We speak the names of "pain doctors" in trouble, in a hushed and nervous way. Our intuition is to avoid the doctors who have stumbled down. Even when a highly respectable doctor suddenly retires after allegations of over prescribing narcotics we look away, we refuse to find out more, we change the topic when the conversation is about pain, pain doctors and personal agonies of doctors and patients in pain.
There are good reasons why we should not continue to ignore the problems associated with pain treatment. First they are very common. Chronic pain is a problem for some 1 20 million people in the United States. Second the current solutions don't seem to be working. In June 2012 the Institute of medicine released a summary report which said the under treatment of pain is a major national challenge (1). Third and the single most important reason is the advances in neuroscience.
In this article there will be brief discussions of recent discoveries in neuroscience. It is these brief discussions that represent the basic premise of my belief that science has effective solutions. It is a widely held belief that the narcotic pain medications are harmful and their benefits are dwarfed by the potential risks including addiction abuse and death.
Nowadays, it is known that harm from the judicious use of narcotic pain medications is impossible as long as the liver functions normally. It is also recognized that the most common alternatives to narcotic pain medications such as surgery or various medications are not risk free. We also know that there is a serious risk of brain injury shown by neuroimaging studies from chronic pain (2).
In general the addictive potency of a substance is sensitively dependent upon its property to elicit initial greater and faster euphoria and calm and upon it's withdrawal to induce greater and quicker dysphoria and discomfort (3).
A major discovery has been the significance of withdrawal symptoms in promoting addictive behavior. Any withdrawal associated discomfort is a biological cue for relief and thus a trigger for a fresh intake. Basil and colleagues did some fascinating work on mice. By using bioengineered mice absent of M5 receptors they were able to show that morphine dependent mice may experience analgesia without withdrawal symptoms (4). This finding is consistent with the relatively low addictive potential of long-acting morphine like substances such as methadone and heroin (intramuscular) for pain or addiction.
There are many examples to illustrate the shortcomings of our regulatory guidelines and I shall pick two of them: the death reporting system and the controlled substance s classification system. The death reporting system is inaccurate and exaggerates the deaths from morphine like substances. Wrongly any trace of any morphine like substance in the system is registered as a death because of a narcotic. Thus contributing to a false alarm of narcotic painkiller overdose epidemic.
Thanks to an extraordinary study by Dr. Webster and Dr. Dasgupta the flaws of the reporting system are well documented with practical solutions (5). Of equal significance, our control substance classification system is neither medical nor neuroscientific. The fact is that what we know about pharmacological agents today is very different than what we knew in the 70s. The omission of any pharmacokinetic or pharmacodynamic data compromises the systems validity.
The flaws of the major systems bring us to the core issue: People with pain and addiction and the doctors treating them live in a world of false alarms often vilified for social and medical problems.
This also means every physician prescribing controlled substances must watch out.... must remain vigilant to remain off the law enforcement radar. Reality says it makes sense to avoid red flags (high or frequent prescription of narcotics.) The important thing to note here is that the fear factor may dampen the Hippocratic spirit: The duty to place the need of a patient ahead of all other influences. The fear factor is toxic. Rooted in survival instincts it compromises sound judgment and individual needs.
In summary, the way we treat people with chronic pain and addiction is wrong. Science, not law must lead neuroscience In Washington DC, Rome Istanbul now or 1000 years from now. Science has the solutions but only if we let science lead the practice of medicine.
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