August 1997
Volume 61 |
Number 8
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| Shooting Flies
With Shotguns |
Mark J. Lema, M.D., Ph.D.
Committee on Pain Management
When a treatment exists that consistently and safely provides
upwards of 90 percent successful results, physicians unquestionably
use that method, except when pain is the issue. More than
47 percent of all patients recovering from surgery in this country,
or about 12 million people, do not receive adequate pain control.
About 40 percent of all cancer patients die in under-relieved
or unrelieved pain. Moreover, few chronic pain patients ever receive
opioids for their painful conditions. Pain and suffering are so
common when contracting cancer that it is the second most feared
complication next to incurability.
Opioid analgesia has been used since the time of the ancient
Sumerians. Theophrastus in the third  century
B.C. writes of the relieving effects from poppy juice. Arabian
physicians used opium and introduced it to the Orient. Paracelsus
in the 1500s popularized its use in Europe. In 1680, Sir Thomas
Sydenham wrote, "Among the remedies which it has pleased
Almighty God to give man to relieve his suffering, none is so
universal and so efficacious as opium." Finally, William
Osler called it "God's own medicine."
With more than 5,000 years of clinical experience in the relief
of pain, why has modern medicine essentially avoided and abandoned
the practical use of opioids? It seems somewhat ironic that a
society which readily embraces euthanasia as the "ultimate
compassionate act" to relieve pain and suffering conversely
chastises and stigmatizes those who prescribe or use opioids for
medicinal purposes! It appears that suffering and death are natural
elements of life, but pain relief is a hedonistic desire that
violates natural law.
The answer to this oxymoron of comfort and care without opioids
is seeded deep within man's evolutionary development. Endogenous
opioids reduce pain, alter personality, modulate suffering and
promote the healing process. Exogenous opioids, which produce
most of the same actions, were discovered very early by shamans,
medicine men and healers to be a mechanism by which the masses
could be controlled.
Likewise, the religious used pain and suffering as an indication
of disapproval by supreme beings resolved only through prayer
and sacrifice. This concept of religion controlling the masses
is so prevalent throughout mankind's history, that Karl Marx called
religion "the opiate of the masses" when promoting his
communistic philosophy. Thus, attitudes, religious beliefs, prejudices
and mythology have all contributed to the underprescribing of
opioids.
Four major barriers to controlling pain have been identified:
1) lack of knowledge by patients, their families, health care
professionals and the public; 2) inadequate education of professionals
promoting unfounded fears; 3) over-regulation and underutilization
of opioids, and 4) lack of accountability regarding the treatment
of cancer and intractable pain.
In this century, anesthesiologists have largely expanded the
field of pain medicine in order to address the undue and needless
suffering of millions of patients worldwide. Through the use of
patient-controlled analgesia, epidural analgesia and nerve blocks,
postoperative pain methods are readily becoming available in hospitals
across the United States. Pain clinics are developing in virtually
every community to treat painful chronic and cancer conditions.
Access to pain treatment facilities by patients in the United
States has never been greater than it exists today. It is important
for our specialty to continue efforts to establish pain management
as a specialty of anesthesiology and publicize this association.
 Despite
our positive impact in the development of pain management, abuses
and excesses in care do exist. However, it is also important for
organized anesthesiology to set guidelines for practice outcomes
to protect the public from untoward results based on aggressive
practice or insufficient knowledge. Without a consensus of what
is appropriate practice, situations will continue to occur similar
to the report of a pain physician administering more than 90 epidural
steroid injections to one patient!
We know our techniques work because we see satisfied patients
returning to our clinics. However, are we always sure that we
selected the most cost-effective therapy? Would a trial of oral
agents and a neck collar have benefited the patient with neck
pain as much as cervical epidural steroid injections? We won't
know until we encourage both study and follow-up of the long-term
benefits to our therapy coupled with the total cost of care.
Articles in this issue and future issues will attempt to address
the problems of practicing pain management and the mechanisms
for determining how effective and how cost-effective we are as
professionals. As we all know, there are several ways to kill
a fly: we can swat it or we can blast it. Most swat it because
it's effective, practical, cheaper and less damaging to other
structures.
Mark J. Lema, M.D., Ph.D., is Chair of
Anesthesiology at Roswell Park Cancer Institute, Buffalo, New
York. He is Associate Professor and Vice Chair of Anesthesiology
at the State University of New York at Buffalo School of Medicine
and Biomedical Sciences.
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