Meeting the Challenge of Chronic Pain

In this issue of JFP, Potter and colleagues¹ point out that there are few reliable empirical data to guide family physicians in the use of narcotics for chronic nonmalignant pain (CNMP). They have, however, contributed to our understanding of the issue with their careful survey of physicians in Northern California. I would have been interested to see 2 other hypotheses addressed.

Using the same methods, the authors might have asked whether those physicians who are more willing to prescribe stronger narcotics for CNMP are also those who have had more experience in the care of pain in terminal illness. Hospice physicians have been among the first to report that their clinical experience in the use of high-dose narcotics has been at odds with the dire warnings that were prevalent in medical training until very recently. For example, tolerance is hardly ever a serious problem in malignant pain; when a patient’s dosage needs to be increased it usually means the tumor is advancing and not that the patient has developed tolerance. Anecdotal evidence suggests that physicians who have had their eyes opened by the way narcotics perform in end-stage malignancy may be more willing to employ such drugs for CNMP.

Another hypothesis would require a different research method. The finding that the study physicians were more concerned about addiction and dependency issues than regulatory oversight may be the correct story. However, fear of addiction may have seemed the socially more acceptable answer. These physicians might have been unwilling to admit that they withheld needed drugs because of their fears of administrative repercussions. Therefore, deciding that the drugs were contraindicated based on the risk of addiction may have been a more comforting theory. A focus group or semistructured interview method would have allowed for the follow-up questions needed to tease out these strands and to see how closely the fear of addiction was tied to fears of regulatory oversight.

The time to prescribe

By turning to the study findings and making the assumption that potent narcotics do have a role to play in managing some cases of CNMP, Potter and coworkers show us the harm caused by physicians who are unable or unwilling to spend sufficient time with each patient. They point out that the state of California had taken care to inform physicians they could be virtually assured freedom from adverse consequences for prescribing narcotics for CNMP, provided they adhere to some documentation guidelines. Many in the sample were unwilling to prescribe the drugs at all, however, and many who did admitted that their documentation fell far short of what had been recommended. The more patients seen per unit time, the less likely the physician was to prescribe narcotics. It might be suggested by these data (though the connection is admittedly indirect) that high-quality care of CNMP patients takes extra time, and physicians who lack enough time will either shy away from taking care of such patients or will be tempted to skimp on documentation (and potentially land in trouble despite having provided a reasonable quality of service).

Appropriate management of CNMP in primary care, including the appropriate use of narcotics, is one of the most vexing problems now facing family physicians. Given the astonishing prevalence of chronic pain in the United States population, it is a sad indictment that so little solid evidence is available to guide our treatment.

In this issue of JFP, Potter and colleagues¹ point out that there are few reliable empirical data to guide family physicians in the use of narcotics for chronic nonmalignant pain (CNMP). They have, however, contributed to our understanding of the issue with their careful survey of physicians in Northern California. I would have been interested to see 2 other hypotheses addressed.

Using the same methods, the authors might have asked whether those physicians who are more willing to prescribe stronger narcotics for CNMP are also those who have had more experience in the care of pain in terminal illness. Hospice physicians have been among the first to report that their clinical experience in the use of high-dose narcotics has been at odds with the dire warnings that were prevalent in medical training until very recently. For example, tolerance is hardly ever a serious problem in malignant pain; when a patient’s dosage needs to be increased it usually means the tumor is advancing and not that the patient has developed tolerance. Anecdotal evidence suggests that physicians who have had their eyes opened by the way narcotics perform in end-stage malignancy may be more willing to employ such drugs for CNMP.

Another hypothesis would require a different research method. The finding that the study physicians were more concerned about addiction and dependency issues than regulatory oversight may be the correct story. However, fear of addiction may have seemed the socially more acceptable answer. These physicians might have been unwilling to admit that they withheld needed drugs because of their fears of administrative repercussions. Therefore, deciding that the drugs were contraindicated based on the risk of addiction may have been a more comforting theory. A focus group or semistructured interview method would have allowed for the follow-up questions needed to tease out these strands and to see how closely the fear of addiction was tied to fears of regulatory oversight.

The time to prescribe

By turning to the study findings and making the assumption that potent narcotics do have a role to play in managing some cases of CNMP, Potter and coworkers show us the harm caused by physicians who are unable or unwilling to spend sufficient time with each patient. They point out that the state of California had taken care to inform physicians they could be virtually assured freedom from adverse consequences for prescribing narcotics for CNMP, provided they adhere to some documentation guidelines. Many in the sample were unwilling to prescribe the drugs at all, however, and many who did admitted that their documentation fell far short of what had been recommended. The more patients seen per unit time, the less likely the physician was to prescribe narcotics. It might be suggested by these data (though the connection is admittedly indirect) that high-quality care of CNMP patients takes extra time, and physicians who lack enough time will either shy away from taking care of such patients or will be tempted to skimp on documentation (and potentially land in trouble despite having provided a reasonable quality of service).

Appropriate management of CNMP in primary care, including the appropriate use of narcotics, is one of the most vexing problems now facing family physicians. Given the astonishing prevalence of chronic pain in the United States population, it is a sad indictment that so little solid evidence is available to guide our treatment.

In this issue of JFP, Potter and colleagues¹ point out that there are few reliable empirical data to guide family physicians in the use of narcotics for chronic nonmalignant pain (CNMP). They have, however, contributed to our understanding of the issue with their careful survey of physicians in Northern California. I would have been interested to see 2 other hypotheses addressed.

Using the same methods, the authors might have asked whether those physicians who are more willing to prescribe stronger narcotics for CNMP are also those who have had more experience in the care of pain in terminal illness. Hospice physicians have been among the first to report that their clinical experience in the use of high-dose narcotics has been at odds with the dire warnings that were prevalent in medical training until very recently. For example, tolerance is hardly ever a serious problem in malignant pain; when a patient’s dosage needs to be increased it usually means the tumor is advancing and not that the patient has developed tolerance. Anecdotal evidence suggests that physicians who have had their eyes opened by the way narcotics perform in end-stage malignancy may be more willing to employ such drugs for CNMP.

Another hypothesis would require a different research method. The finding that the study physicians were more concerned about addiction and dependency issues than regulatory oversight may be the correct story. However, fear of addiction may have seemed the socially more acceptable answer. These physicians might have been unwilling to admit that they withheld needed drugs because of their fears of administrative repercussions. Therefore, deciding that the drugs were contraindicated based on the risk of addiction may have been a more comforting theory. A focus group or semistructured interview method would have allowed for the follow-up questions needed to tease out these strands and to see how closely the fear of addiction was tied to fears of regulatory oversight.

The time to prescribe

By turning to the study findings and making the assumption that potent narcotics do have a role to play in managing some cases of CNMP, Potter and coworkers show us the harm caused by physicians who are unable or unwilling to spend sufficient time with each patient. They point out that the state of California had taken care to inform physicians they could be virtually assured freedom from adverse consequences for prescribing narcotics for CNMP, provided they adhere to some documentation guidelines. Many in the sample were unwilling to prescribe the drugs at all, however, and many who did admitted that their documentation fell far short of what had been recommended. The more patients seen per unit time, the less likely the physician was to prescribe narcotics. It might be suggested by these data (though the connection is admittedly indirect) that high-quality care of CNMP patients takes extra time, and physicians who lack enough time will either shy away from taking care of such patients or will be tempted to skimp on documentation (and potentially land in trouble despite having provided a reasonable quality of service).

Appropriate management of CNMP in primary care, including the appropriate use of narcotics, is one of the most vexing problems now facing family physicians. Given the astonishing prevalence of chronic pain in the United States population, it is a sad indictment that so little solid evidence is available to guide our treatment.