20 July 2005

More on pain and drug law

As a followup to the last post. Here's an earlier comment from Lindsay. I mentioned this here.
NYT article
There's been a lot of talk about medical malpractice "reform" lately. Bush says that OB-GYNs are unable to practice their "love" because they're afraid of getting sued. Nobody is talking about the much worse legal injustice facing the medical profession: doctors who are going to jail for practicing good medicine.

Pain specialists who prescribe large quantities of opiates to patients with chronic pain are being harassed by law enforcement. Some are losing their licences, some are even being sent to jail. The physicians are being flagged, charged, and convicted by law enforcement who want to keep drugs off the street.

The irony is that the doctors most likely to be targeted are those who deliver the standard of care for patients with severe pain. There are a lot of sanctimonious pronouncements in medical journals and in the mainstream media about how serious pain is and how important it is to treat pain aggressively.

[...] Last August, the D.E.A. publicly acknowledged the need for a "principle of balance" to address the necessity of access to pain medications and the approaches to containing abuse, addiction and diversion. It published "Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel," which thoughtfully explained the concepts, and offered clear descriptions of the circumstances under which the D.E.A. may prosecute a doctor. Mysteriously, however, in early October the agency pulled the document from the Web site, saying it had "misstatements."

The D.E.A. declined to elaborate on its reasons for pulling the document. Some people have speculated that the agency was worried that the information could be used to help clear physicians charged with trafficking.[...]

The current climate is forcing doctors to practice bad medicine:

"We are unable to refer patients to doctors who will treat pain, if only because once a name gets out there, patients understandably flock, and then the doctor is targeted," said Siobhan Reynolds of Pain Relief Network, a patient advocacy group based in New York. The Association of American Physicians and Surgeons, based in Tucson and dedicated to the concerns of private practitioners, has gone so far as to warn doctors against managing chronic pain, lest they face of years of harassment and legal fees, even prison. "If you do," the association enjoins, "first discuss the risks with your family."

Scattered evidence confirms these impressions. A 1998 survey of more than 1,300 physicians by the New York State Medical Society found that 60 percent were moderately or very concerned about the possibility of being investigated by regulatory authorities for prescribing opiates for noncancer pain.

A third said they prescribed lower quantities of pills and lower dosages "frequently" because of the possibility of eliciting an investigation. When asked how often they avoided prescribing a preferred drug for noncancer pain, because doing so required triplicate forms, half said "frequently."

Brings a whole new meaning to "evidence based medicine", doesn't it?


Pain and drug law

I've mentioned cases like this before. Its nice to see it broached so directly in a major newspaper.
The New York Times
July 19, 2005
Punishing Pain

Zephyrhills, Fla.

When I visited Richard Paey here, it quickly became clear that he posed no menace to society in his new home, a high-security Florida state prison near Tampa, where he was serving a 25-year sentence. The fences, topped with razor wire, were more than enough to keep him from escaping because Mr. Paey relies on a wheelchair to get around.

Mr. Paey, who is 46, suffers from multiple sclerosis and chronic pain from an automobile accident two decades ago. It damaged his spinal cord and left him with sharp pains in his legs that got worse after a botched operation. One night he woke up convinced that the room was on fire.

"It felt like my legs were in a vat of molten steel," he told me. "I couldn't move them, and they were burning."

His wife, Linda, an optometrist, supported him and their three children as he tried to find an alternative to opiates. "At first I was mad at him for not being able to get better without the medicines," she said. "But when he's tried every kind of therapy they suggested and he's still curled up in a ball at night crying from pain, what else can he do but take more medicine?"

The problem was getting the medicine from doctors who are afraid of the federal and local crusades against painkillers. Mr. Paey managed to find a doctor willing to give him some relief, but it was a "vegetative dose," in his wife's words.

"It was enough for him to lay in bed," Mrs. Paey said. "But if he tried to sit through dinner or use the computer or go to the kids' recital, it would set off a crisis, and we'd be in the emergency room. We kept going back for more medicine because he wasn't getting enough."

As he took more pills, Mr. Paey came under surveillance by police officers who had been monitoring the prescriptions. Although they found no evidence that he'd sold any of the drugs, they raided his home and arrested him.

What followed was a legal saga pitting Mr. Paey against his longtime doctor (and a former friend of the Paeys), who denied at the trial that he had given Mr. Paey some of the prescriptions. Mr. Paey maintains that the doctor did approve the disputed prescriptions, and several pharmacists backed him up at the trial. Mr. Paey was convicted of forging prescriptions.

He was subject to a 25-year minimum penalty because he illegally possessed Percocet and other pills weighing more than 28 grams, enough to classify him as a drug trafficker under Florida's draconian law (which treats even a few dozen pain pills as the equivalent of a large stash of cocaine).

Scott Andringa, the prosecutor in the case, acknowledged that the 25-year mandatory penalty was harsh, but he said Mr. Paey was to blame for refusing a plea bargain that would have kept him out of jail.

Mr. Paey said he had refused the deal partly out of principle - "I didn't want to plead guilty to something that I didn't do" - and partly because he feared he'd be in pain the rest of his life because doctors would be afraid to write prescriptions for anyone with a drug conviction.

If you think that sounds paranoid, you haven't talked to other chronic-pain patients who've become victims of the government campaigns against prescription drugs. Whether these efforts have done any good is debatable (and a topic for another column), but the harm is clear to the millions of patients who aren't getting enough medicine for their pain.

Mr. Paey is merely the most outrageous example of the problem as he contemplates spending the rest of his life on a three-inch foam mattress on a steel prison bed. He told me he tried not to do anything to aggravate his condition because going to the emergency room required an excruciating four-hour trip sitting in a wheelchair with his arms and legs in chains.

The odd thing, he said, is that he's actually getting better medication than he did at the time of his arrest because the State of Florida is now supplying him with a morphine pump, which gives him more pain relief than the pills that triggered so much suspicion. The illogic struck him as utterly normal.

"We've become mad in our pursuit of drug-law violations," he said. "Generations to come will look back and scarcely believe what we've done to sick people."

For Further Reading:

For more information on Richard Paey's case and others like it, visit the Pain Relief Network.

Treating Doctors as Drug Dealers: The DEA’s War on Prescription Painkillers (pdf) by Ronald T. Libby. Cato Institute, 28 pp., June 2005.

Cartoons by Richard Paey.
* Copyright 2005 The New York Times Company

Thanks Lindsay for the pointer.

10 July 2005

Cox-2's in Canada

A roundup of recent developments.


Arthritis and accupuncture

There has been no doubt for a good long while that accupuncture does have analgesic effects on certain types of pain. Though, as in the last graf here, its usefulness as a treatment is more dubious (though my sense from an admittedly superficial understanding of the literature is that, Dr. Moore's comment is a bit too strong).

Results of a randomised trial in this week's issue of The Lancet suggest that acupuncture could reduce pain and improve joint functioning in the short-term for people with osteoarthritis of the knee.

Osteoarthritis most frequently affects the knee joint. Despite a limited evidence base, arthritis patients are increasingly turning to acupuncture, especially as side-effects of non-steroidal anti-inflammatory drugs are common and wide-ranging.

Around 300 patients with chronic osteoarthritis of the knee were randomly assigned to acupuncture, minimal (sham) acupuncture (superficial needling at non-acupuncture points), or a waiting list control.

Patients were allowed to use non-steroidal anti-inflammatory drugs throughout the study. Physicians administered acupuncture and minimal acupuncture in 12sessions over 8 weeks.

Patients completed questionnaires at the start of treatment, and after 8 weeks, 6 months, and 1 year. Analgesic use was similar for patients in the three groups. After 8 weeks, patients given acupuncture had a substantially lower score on an established osteoarthritis index than patients in the control group (26 points and 50 points, respectively).

Minimal acupuncture also had short-term benefit compared with no acupuncture (36 points on the osteoarthritis index). However, at 1-year follow-up there was no significant difference in scores between the three groups. Lead investigator Claudia Witt (Charite University Medical Center, Berlin, Germany) comments:

“Acupuncture treatment had significant and clinically relevant short-term effects when compared to minimal acupuncture or no acupuncture treatment in patients with osteoarthritis of the knee. We now need to assess the long-term effects of acupuncture, both in comparison to sham interventions and to standard treatment.”

In an accompanying Comment, Andrew Moore (Pain Research, University of Oxford, UK), states: “The bottom line from Witt and colleagues' large, long, and high-quality study of acupuncture for knee osteoarthritis is that doing something is better than doing nothing.”

However he cautions that it is too soon to draw firm conclusions from the current study: “We are still some way short of having conclusive evidence that acupuncture is beneficial in arthritis or in any other condition, other than in a statistical or artificial way. There is limited evidence of effect and, with exceptions, of cost-effectiveness. Most importantly, the need for needles is still in doubt.”

The more data on accupuncture's usefulness we have, the clearer its mechanism may become. This is, in part, because the sites where an accupuncture regime is indicated for a particular pain turns out to vary greatly between conditions --sometimes its on the spot of the pain, other times it is applied elsewhere on the body in accordance with a traditional theoretical constellation of points (in such cases the relevant neuroanatomy can be less clear).

Along with certain kinds of transcutaneous electrical nerve stimulation, accupuncture is a 'counter-irritation analgesia'. We know that these forms of analgesia involve both opioid and non-opioid systems (for example, naloxone --an opioid antagonist-- has been shown to reduce accupuncture's analgesic effects). The mechanisms of the notorious placebo effect and hypnotic analgesia also play some role in the effects of accupuncture.

See Price and Mayer's 1995, "Evidence for endogenous opiate analgesic mechanisms triggered by somatosensory stimulation (including accupuncture) in humans." Pain Forum 1995, 4(1) 40-43.

Hypnotic analgesia and the placebo effect do have a good deal of theoretical importance for us philosophers (the former is especially useful in understanding why pain is bad). Thus the more light accupuncture sheds on these topics, the better for us.

Oh, and the empirical explanations are always nice for smacking down those who claim it involves 'mind-over-matter' in some metaphysical sense. Though you, gentle reader, don't believe that should be necessary. Right?

07 July 2005

Daily Mail: Gender and pain

Of course, you, diligent reader of PFP, already knew all this, right?

Women feel the pain more than men

Women feel pain more than men, more often and for longer periods of time, researchers claim.

Despite the popular belief that men are wimps when it comes to dealing with pain and the female experience of childbirth gives women the upper hand, scientists found that the opposite was true.

Several studies have now concluded that not only do women report more pain during their lives, they also experience it in more parts of the body, more often and for a longer duration compared to men.

Researchers from the University of Bath said there appeared to be a difference in how men and women thought about pain, and anxiety may affect them in different ways.

The different strategies that men and women have in coping with pain may also actually make their experience worse.

Dr Ed Keogh, a psychologist from the university's Pain Management Unit, said men may take a more problem-solving approach to pain, meaning that they think about what they can do to deal with the pain and get on with their lives.

Women, on the other hand, may be more emotional and focus on the pain and how it is making them feel, rather than thinking about how they can deal with it and get back to work, for example.

Much to learn

But scientists admit that there is still much more to learn about gender differences in coping with pain.

Dr Keogh said: "Yes, there are important differences between men and women, but that is only half the story.

"What we have to start thinking about is why are there these differences and what are the treatment implications?"

One study carried out by the university involved asking volunteers to place their arm in a bath of warm water before plunging it into a container of ice water.

The researchers measured the pain threshold - the point at which the participants first noticed pain - and pain tolerance - the point at which they could no longer stand the pain.

Women were found to have both a lower pain threshold and tolerance.

"Until fairly recently it was controversial to suggest that there were any differences between males and females in the perception and experience of pain, but that is no longer the case," Dr Keogh said.

"Research is telling us that women experience a greater number of pain episodes across their lifespan than men, in more bodily areas and with greater frequency.

"Unfortunately, all too often the differences between males and females are not considered in pain research or practice and instead are either ignored or statistically averaged."

Genetic differences

Dr Keogh said most explanations for the gender variation concentrated on biological mechanisms, such as genetic and hormonal differences.

But he said it was becoming increasingly clear that social and psychological factors were also important.

The researchers suggested that while women tended to focus on the emotional aspects of the pain they experienced, men tended to concentrate on the physical sensations.

"Our research has shown that whilst the sensory-focussed strategies used by men helped increase their pain threshold and tolerance of pain, it was unlikely to have any benefit for women.

"Women who concentrate on the emotional aspects of their pain may actually experience more pain as a result, possibly because the emotions associated with pain are negative," Dr Keogh said.

The university is also investigating chronic pain in children.

The researchers said that as many as one in 50 children and adolescents live with severely debilitating and recurrent pain, but there is little information on how best to treat them.

Professor Chris Eccleston, director of the Pain Management Unit, said: "Many people used to think that chronic pain was a uniquely adult problem, but recent studies have shown that a number of children are severely affected by pain.

"There can be a significant effect on the child's family and our studies have shown that many parents of children who suffer with chronic pain report higher than normal levels of anxiety, as well as martial and financial problems."

Find this story at http://www.dailymail.co.uk/pages/live/articles/health/womenfamily.html?in_article_id=354638&in_page_id=1799
©2005 Associated New Media