Summer 2010 - The British Pain Society

ecame squalid and violent. Opium
was prohibited in many countries
during the early twentieth century,
leading to the modern pattern of
opium production as a precursor
for illegal recreational drugs or
tightly regulated legal prescription
drugs. Further International
regulation took place in 1961 and
1988. Illicit opium production, now
dominated by Afghanistan, has
increased steadily in recent years
to over 6600 tons yearly, nearly
one-fifth the level of production in
1906 despite the efforts of many
to limit it.
The right to analgesia, like opium,
is a sensitive and charged issue
and for many there are no easy
answers. It is so sensitive that the
pain faculty of ANZCA produced
a document of rights and
responsibilities, PS45, that has an
addendum that states – “A “right
to pain relief” does not imply that
all pain can or will be treated
successfully, that all patients will
be free from pain, or that any
analgesic treatment will necessarily
be provided on demand, including
the prescription of opioids. That
right requires that the professional
response be reasonable and
proportionate to the level and
character of the pain experience
and that the assessment and
management of a patient’s pain
be appropriate to that patient”.
Are we to dream like the American
Pain Society that we can alleviate
pain? If we cannot alleviate it, can
we therefore say, however noble,
that pain relief is a human right?
Will the dumbing down of this
sentiment and just cause lead to
the medical nihilism of yesteryear
when many chronic pain patients
were just ignored and passed off
as “malingerers” or “depressed”,
and given an even lower priority.
The clinical difficulties of managing
a pain to total alleviation may
inadvertently lead to the use of
opiates as a last resort. This is just
as wrong as failure to use them
as a first resort when it is obvious
that they are both efficacious and
necessary. Once again we still
have many unanswered questions
and we work in a system where
long-term, non pharmaceutically
sponsored, clinical based research
is both impossible financially and
technically and ethically difficult.
Is it no wonder that the poor pain
clinician, after years of just trying to
improve his service on the back of
arid support, gives up when faced
with a 64 page ethics form and the
competing interests of managerial
targets and ever demanding
patients. The research base has
many unanswered questions
and clinical judgement, rightly
or wrongly, has less clout than
previously. When was the last time
you heard a patient with a chronic
headache or severe rheumatoid
pain declare a persistent clinical
transformation on the back of
sustained release opiates? We still
have to make difficult and uncertain
decisions. In 1996 the Drug and
Alcohol Unit in New South Wales
reviewed the official records
of opiate prescribing for non
malignant pain in Australia from
1986-1996. Even then there were
concerns of dose escalation and the
use of “opiates in poorly defined
medical problem in patients
where the presence of social and
emotional problems was noted”.
The “quality and thoroughness of
medical information documented
in the health department files was
very limited”. This is in country, that
in the early 1990's and beyond,
where every time a potent opiate
is prescribed for anything but
palliative care, the local health
authority has to be notified. As
well as this regular auditing of
these patients took place. Is it not
time that, in response to these
concerns we attempt something
similar in the UK? A comprehensive
multicentre audit at least. Then we
can get an idea of both good and
bad practice out there.
To quote an IASP clinical update
the "marked change in prescribing
habits, related in large part to
the advent of “designer” opioids
(new long-acting formulations)
producing heightened commercial
interest and to the increasingly
active sponsoring of pain advocacy
by the pharmaceutical industry”
has not produced a new dawn.
Neither will opiophobia. We need
an open debate, we need more
evidence and as pain physicians
we need to admit when we are
faced with intractable clinical issues.
Intractable pain problems have not
and should not be an open door to
potent medications otherwise pain
clinicians may lead all, patients,
medical staff and pharmaceutical
companies to an “empire of dirt”
and that would be to no ones
benefit. Dr Cathy Stannard hosted
an excellent seminar at the ASM in
Manchester where some of these
difficulties were aired. We have an
excellent document that has just
been produced. We are publishing
an excellent document on cancer
pain. It is up to us to help to “find a
way”. It will not be easy but, as pain
clinicians, it is both our challenge
and our burden to both help and
prevent “Hurt”.
Mike Basler
newsletter@britishpainsociety.org
PAI N N E W S S U M M E R 2010 5