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    Monday, October 07, 2002

    Anguish Hath Taken Hold of Us, and Pain: Pain is all the rage these days. Doctors have been told that they undertreat it, the public have been told that they suffer too much from it, and its assessment has been raised to the status of a vital sign. It’s no longer adequate to record in our records that the patient was in “no acute distress” or that he was “writhing in pain,” we have to assign it a number from 1 to 10. We’ve been told that we must eliminate every pain if we are to practice good medicine, even if it takes hefty doses of narcotics. There’s a lot wrong with this approach. Pain, especially chronic pain, is an extremely complicated entity. There is pain caused by physical wounds. That kind is easy to recognize and to treat. There is pain caused by purely emotional wounds - more difficult to recognize and much more difficult to treat. Then, there’s the most difficult of all - pain caused by both. There’s also a “pity-wanting pain” that makes us complain of pain for the sake of the pity it will gain us. Pain isn’t a vital sign. It can’t be adequately represented by a simple numerical scale. And, in some cases, it can’t be eliminated with all the morphine in the world.

    Vital signs are just what their name implies - objectively measured signs of life. There are four of them: pulse, respiratory rate, blood pressure, and temperature. If any of them are a zero, the patient is dead. Pain is a symptom not a sign. I have had patients amble into my office with pleasant smiles and nimbly jump up on my exam table and tell me their pain level is a ten. On the other hand, I’ve had patients hobble in with a grimace and tell me their pain level is a two. Pain cannot be measured. It’s purely subjective. And the absence of pain, unlike true vital signs, does not equate with death.

    So, how did pain come to be considered and accepted as a vital sign? That was the work of the American Pain Society, a group founded in the 1970’s by pain researchers, some of whom worked in the pharmaceutical industry. In the past several years, the APS has branched out from research into making treatment recommendations and lobbying Congress to keep narcotics freely available. At first glance there may seem to be nothing wrong with this, they’re an organization of pain experts, after all. But how expert are they? And at what are they experts? The greatest percentage of their membership come from specialties that don’t treat patients in on-going relationships, such as anesthesiology (30%), or who have no background in treating patients pharmacologically, such as nursing (12%), and psychology (15%). Membership also includes those wholly employed by the pharmaceutical industry: clinical pharmacy (3%) and clinical research (2%). They may be experts on treating pain within their fields, but none of them have any experience in dealing with the long term consequences of the liberal use of narcotics.

    It’s even worse when you look at the list of their corporate donors. It’s chock full of companies with a vested interest in promoting narcotic use:

    - Abbott Laboratories, makers of morphine, Dilaudid, and Vicoprofen.

    - Bristol-Myers Squibb - Products, makers of Stadol, a narcotic you spray in your nose.

    - Cephalon Products, makers of fentanyl.

    - Elan Pharmaceuticals, makers of the muscle relaxants Skelaxin and Zanaflex

    - Eli Lilly, makers of Darvocet.

    - Endo Pharmaceuticals makers of Percocet and morphine

    - Faulding Pharmaceuticals, makers of a prolonged morphine product and sister company of Purepac Pharmaceutical Company which makes a host of generic narcotics.

    - Janssen Pharmaceutica, maker of Duragesic.

    - McNeil Consumer Healthcare, the over the counter branch of Ortho-McNeil Pharmaceutical , makers of Tylenol and Parafon Forte.

    - Nellcor, a division of Tyco which owns Mallinckrodt, maker of morphine and synthetic narcotics derived from it.

    - Pain Therapeutics, Inc., devoted to developing new narcotics.

    - Purdue Pharma, makers of OxyContin and all its "oxy" brethern

    - Roxane Laboratories, makers of acetaminophen with codeine, just plain old codeine, methadone, hydromorphone, meperidine hydrochloride (generic demerol), morphine, various oxycodone products, and Roxanol (concentrated morphine) to name just a few.

    - Whitehall-Robbins owned by Wyeth, makers of the muscle relaxer Robaxin, as well as other non-narcotic pain medication.

    It’s not unusual for medical societies to get funding from drug companies, but it is unusual, as the American Pain Society has, to earmark some of the donations specifically for the financing of a clinical treatment guideline. These companies pay at least $5,000 a year (warning: pdf file) to be corporate members, some of them pay even more for special status, and some are identified as donors who support the APS works in progress, Pain Management for the Primary Care Clinician, and Clinical Practice Guidelines. No doubt they expect some influence in what those guidelines will say.

    UPDATE: Lest you think that the American Pain Society is alone in its reliance on narcotics manufacturers for funds, here’s a list of donors to the American Academy of Pain Medicine.

    posted by Sydney on 10/07/2002 07:22:00 AM 0 comments


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