Monday, August 15, 2011

Uncontrolled pain a problem in Canada

Excessive drug controls and exaggerated fears about opioids are contributing to uncontrolled pain and suffering in Canada, the nation's top medical journal says.

"Few things in life are as intolerable and incomprehensible as chronic physical pain," says an editorial published this week in the Canadian Medical Association Journal.

"A signal meant to alert us to protect our tissues has run amok . . . in its clutches, we all become irritable, insomniac and anhedonic. It confronts all clinicians and challenges all areas of health care."

An estimated 500,000 Canadians ages 12 to 44, 38 per cent of seniors in long-term care facilities and 27 per cent of seniors living at home experience chronic pain, the journal says.

According to the authors, "experts agree that much can be done now with newer analgesics, nonpharmacologic techniques such as nerve blocks and physical therapies, as well as spiritual and supportive care."

But pain is under-treated in Canada, the journal says. Specialized pain clinics are mainly clustered in big city hospitals. In many areas of the country, especially rural and remote regions, services are sparse, limited or "non-existent," the journal says.

"Patchy" pain education in medical schools, excessive drug controls and regulations, doctors who fear disciplinary action if they prescribe narcotics, myths about addiction and old attitudes that pain is unavoidable and a normal part of aging are all contributing to the problem, the journal says.

"Although the potential for opioid addiction and abuse is real, it is frequently exaggerated. Moreover, this concern is not an acceptable excuse for failure to control chronic pain."

The editorial comes amid concerns among pain-management advocates and patient groups that tighter controls on the use of opioids could worsen the already widespread problem of poorly controlled pain and make it harder for legitimate pain patients to get the medicine they need.

Ontario is preparing to start tracking all prescriptions for narcotics and to start keeping personal health information in a provincial narcotics database in response to a rise in opioid-related overdoses and deaths.

According to the College of Physicians and Surgeons of Ontario's report released last September, Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis, prescription opioids — which include oxycodone (the active ingredient in OxyContin), morphine, codeine and methadone — are more likely to be found on the street than heroin and are now "a street drug of choice for teens."
Between 1991 and 2009, the number of prescriptions in Ontario for oxycodone rose by 900 per cent. Meanwhile, the number of people seeking treatment for addiction to oxycodone is increasing. The college says deaths due to oxycodone increased to 119 in 2006 from 35 in 2002.

Canada is one of the highest consumers in the world of opioid medications.

Dr. Ken Flegel, senior associate editor of the CMAJ and an internal medicine doctor in Montreal, said the journal isn't arguing that abuse of OxyContin is not a problem.

"We're not not part of the cautionary movement here," Flegel told Postmedia News.

"There are many other narcotic choices, and there are many other choices short of using narcotics for chronic pain," he said.

But Flegel said the burden of chronic pain on individual lives "is way too costly and it's worth taking a risk on the habituation side." Flegel said the medical literature shows that the vast majority of people who take narcotics for chronic pain "aren't addicts. They just have chronic pain and all they want to do is be rid of the pain," he said. "And the day they're rid of the chronic pain they also want to be rid of the narcotics."

"We think that the urban myth in the profession that using narcotics for chronic pain is a bridge to becoming a drug addict is probably overblown," he said.

He and his co-authors argue for a broad strategy to improve chronic-pain care for Canadians, including increased pain management education and expertise, telemedicine networks connecting doctors in rural and remote regions with pain centres, and programs that help teach patients and families ways to cope with and reduce chronic pain.

One of the biggest barriers is attitudes inside the profession, Flegel says. Many doctors graduated before chronic, non-cancer pain was even taken seriously. The thinking was "it wasn't important," he says, that "the ones (patients) who have bad pain are cancer patients who are dying, and that's where you should focus, and surgical patients — of course everybody agrees they shouldn't have pain."

But Flegel said chronic pain is prevalent and leads to anxiety and depression, "and we all know depression itself is associated with strokes, heart attack and cancer.

"The profession needs to get more expert at this," he said. "Most people with chronic pain can have the chronic pain managed, and some of them can actually have it relieved."

He said awareness needs to be raised among the public that "there is help out there, if they keep looking, and if they get good at finding the help they can take ownership of the management of the pain, or their families can, and do a lot more about it than has been done about it now."

In Canada, the Canadian Pain Society and other groups are calling for a national pain strategy that would officially recognize chronic pain as a disease in its own right — not merely a symptom of something else. The strategy urges better co-ordination of resources, more undergraduate and graduate training in pain, better prevention and improved treatment across the country, including more multi-disciplinary pain clinics.

Severe chronic pain can affect every aspect of a person's life, "and it can lead people to really deciding to live no longer," says Dr. Mary Lynch, past president of the Canadian Pain Society and director of the pain management unit at Queen Elizabeth II Health Sciences Centre in Halifax. Studies suggest that people with chronic pain have at least twice the rate of suicide as people living without pain.

"We know that there's a huge problem out there about unaddressed pain . . . and all the emotional and mental suffering that goes with it," Lynch said.

If more isn't done to address it, "the rates of chronic pain are going to climb, the need for the use of stronger and stronger pain medications is going to climb and we're going to have an even bigger problem on our hands."

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