Tuesday, September 11, 2007

The media looks at the other side of the (opioid) coin; International Pain, Part 2

Most television news is forgettable for one reason or another. A recent broadcast on MSN (is that television? looks & sounds like it, but it's on my computer screen. I can't tell the difference). The title of the 2-minute report, "Pros, cons of narcotics" is not promising, but 'narcotic' is not used again; remarkably, 'opioid' replaces it. The intro acknowledges that most reporting on prescription pain drugs is about crime or abuse, but opioids actually benefit "a lot" of people. Hydrocodone is the featured opioid. One of the people featured has persistent pain from a back injury. Opioids (and other drugs) alleviate the pain enough for him to get through the day (the point: opioids aren't just for cancer pain). The final words of the piece: " . . . no one doubts the value of hydrocodone and other opioids for critical pain relief." This is a wildly optimistic and misleading statement, but it is a tiny, tiny hint of a step toward rebalancing reportage and normalizing the use of opioids for pain.

Yesterday Christian blogged on an article in the New york Times on the horrific state of end-of-life pain management in the poorest countries. The second of the two-article series, in today's Times, highlights the situation in India. In a bow to the adage "Better to light a single candle than to curse the darkness," Dr. M.R. Rajagopal has established a hospice, Pallium India, and trained other doctors in the use of morphine in tiny Kerala State . His program is an anomaly in this huge, rapidly advancing but still poor and largely rural country. The opium poppy is an important cash crop, but almost exclusively for export. Some cancer centers do not stock morphine. Government regulations are arcane and suffocating. Another bright spot: the Health Minister recently got Parliament to approve the national cancer plan's palliative care budget.

Both articles in this series cited a major barrier to increased morphine use for end-of-life pain: the belief that "morphine inevitably addicts and kills." The author states that these notions have "long faded in the West." Would that it were so. These beliefs are still strongly held by lay people and clinicians alike. Yes, they have "faded," but they are still present and still interfering with appropriate care.

Both NYT articles also highlighted legal and regulatory issues, and mentioned the Pain and Policy Studies Group at the University of Wisconsin, Madison. PPSG is working with individual countries, including India, and the WHO to make opioid analgesics more accessible. In July the PPSG issued it's latest federal and state-by-state report cards on legal and regulatory barriers to balanced prescribing of opioids. Last week I mentioned the new Washington State opioid dosing guidelines as being a barrier to adequate pain management. Yet our most restrictive laws and regulations would be a major improvement in many of the poorest countries of the world.

Before someone out there blasts me for defending the status quo in this country or for saying "Buck up, you don't have it so bad," I'm doing nothing of the sort. We have a long way to go in this country to heal our attitudes and laws, to start treating patients in pain with compassion and good medicine rather than suspicion and disdain. We also need to be sensitive, as human beings, to the dramatic disparities in health care that exist on many levels. This is one of them.

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