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UC Davis Health System

UC Davis Health System

Physicians navigate medical, political complexities of pain management

Photo of Scott Fishman

Scott Fishman is chief of the Division of Pain Medicine and professor of anesthesiology at UC Davis Health System. 

UC Davis pain specialist Scott M. Fishman, chief of the Division of Pain Medicine and professor of anesthesiology, recently completed a one-year term as president of the American Academy of Pain Medicine at a time of unprecedented attention on treating pain and fighting drug abuse. Time Magazine devoted its cover to the political and legal furor surrounding the treatment of pain while NBC's Today show aired a week-long segment on the topic. ABC News, USA Today and the Wall Street Journal similarly covered the issue. Fishman was the featured expert in these media reports and the academy's spokesperson, advocating a more balanced governmental approach between the war on drugs and the war on pain.

Fishman discusses in the July issue of Physicians Practice pressing issues facing physicians today regarding pain management.

UC Davis: What is the most common problem physicians face in treating patients with pain?

Dr. Fishman: With today's legal and regulatory scrutiny of pain medicines, physicians often feel paralyzed in treating patients. They fear being seen as either undertreating or overtreating patients for pain, both avenues that can result in criminal or civil charges and regulatory sanctions. The fact is treating pain can be tricky. You can't prove that someone has or doesn't have pain or pain relief. It makes physicians uncomfortable. Those who most successfully treat pain focus on an outcome that is not subjective, i.e., "do you feel better?" They look at a patient's ability to function. Is the patient able to complete his or her daily tasks with relative ease; can he or she eat or sleep, enjoy life? When you focus on a measurable outcome such as function, treatment becomes a different experience.

UC Davis: What is often missed in the treatment of pain?

Dr. Fishman: People, including physicians, often focus on where it hurts. It's a logical response, but what we have discovered is that pain — especially chronic pain — affects the whole person. A person in pain may be unable to sleep, eat or complete other daily functions normally. Pain can precipitate depression, anxiety, fear and distress, affecting a person's ability to be happy and to maintain good relationships. It can also influence a person's spiritual well-being. In other words, pain is not a sensation but an experience. In fact, research using functional MRI to scan patients in pain or after pain relief have shown that the activated centers of the brain are not necessarily what we would expect. The part of the brain tied to sensation shows much less activity than the part of the brain tied to emotion.

UC Davis: Why is there a state law requiring additional training for physicians in treating pain?

Dr. Fishman: The new state law, AB 487, requires all California physicians to complete 12 units of continuing education for pain and end-of-life care before the Dec. 31, 2006. It also requires the California Medical Board  to disclose its policies thought to be beneath the standard of care. The law is the outcome of one family's grief over the death of their father who died in pain. After their father died, they reported the treating physician to the medical board for undertreating their father. They also brought charges of elder abuse against this physician for which the jury brought a guilty verdict and initially awarded a $1.5 million penalty. This family pushed for legislation after the medical board declined to sanction that particular physician. Since the law passed, the medical board has sanctioned at least one physician for undertreating pain. UC Davis has been conducting many continuing medical education courses throughout the year to help physicians meet the 12-hour CME requirement. The final conference for this year is scheduled for Oct. 29-Nov. 2 at the Grand Wailea in Maui, Hawaii.

Cycle of pain graphic

UC Davis: Why is there increasing legal and political furor surrounding pain medicine and what can physicians do to navigate through the current turmoil?

Dr. Fishman: We have two serious public health crises occurring simultaneously. Unfortunately, the war on pain has become a focus for the war on drugs. At stake are whether we physicians are going to feel safe aggressively treating our patients with pain and is the government going to accept the medical community as the best judge in treating those suffering from pain. During my year as president of the American Academy of Pain Medicine, I advocated for reason and balance in defining acceptable parameters between treating pain and being criminally abusive. The fact is drugs of potential abuse are often necessary for legitimate therapeutic purposes and must not be confused as addictive. On the other hand, prescription drug abuse is a serious and growing problem in which solutions will require physicians to play a role. Whatever is ultimately decided at the federal level, it will require that physicians adopt a position of pharmacovigilance. This should not be viewed as onerous because the outcome of the patient who receives good pain relief is diametrically opposite the outcome of the patient who is addicted — functionality versus decreased function. Adopting practices that allow us to see improved function, as well as dysfunction, will more clearly position us as acting in the best interests of our patients — and society.

UC Davis: How does a physician differentiate between addiction and dependency, especially when pain is not the same in any two people?

Dr. Fishman: Function is the most important consideration. Drug addiction is essentially the compulsive use of a drug that causes dysfunction and the continued use despite that dysfunction. Both addiction and chronic pain produce dysfunction. An addicted patient takes increasing amounts of a drug but his or her function does not improve — in fact, the drug they are addicted to only intensifies their craving and unmodulated use. A patient treated effectively for pain with the same "addictive" drug finds a stable dose that helps balance pain with improved function. A person can become pharmacologically dependant to a pain medication but addiction does not always or usually occur. For instance, clonidine is a well-known drug that produces pharmacological dependence without addiction. In the treatment of chronic pain, if function does not improve, one must question the effectiveness of the treatment, and although there are many more reasons for the lack of functional improvement other than addiction, changes in the treatment should be sought.

UC Davis: Health disparities is an emerging issue. What disparities exist in pain treatment and what can be done about them?

Dr. Fishman: Many of the same disparities exist for pain as for other aspects of medicine — racial, socioeconomic, gender and age. For instance, many pharmacies in economically depressed or minority areas don't carry many of the medications we use to treat pain. There is also a gender gap in pain treatment. Studies have shown that women report pain more often than men to their physicians but receive less treatment. We continue to perpetuate myths that women can tolerate more pain than men or that women make up pain where it does not exist. Women are still given subtle messages that their pain is just all in their heads. Another false perception about pain involves children. The medical community seems to bring so much of its resources to bear when a child is ill, yet children are routinely undertreated for pain. We continue to perpetuate myths that children don't feel pain or that somehow pain builds character. I still hear some argue not to treat the pain too much in children because they will have more side effects than adults, as though leaving a child in pain is acceptable. Children left untreated for pain suffer significant harm including major emotional trauma that directly undermines their ability to heal. Some children can't complain as loudly or clearly, or they present differently when in pain. For an infant in pain, he or she may simply withdraw, appearing depressed or lethargic. Appropriate assessment and management can be very different in children from adults.

UC Davis: Pain medicine is emerging as a specialty. What is driving the need for it?

Dr. Fishman: Pain medicine is emerging as a specialty largely because medicine has wandered from its traditional mandate "to relieve often, to comfort always." The medical community became too focused on curing and extending longevity. Quantity versus quality, so to speak. Pain medicine as a specialty brings medicine back to its foundation of alleviating suffering. It spans all stages in life and focuses on improving quality of life for anyone who is suffering in pain. Some programs like ours are multidisciplinary and offer all of these options under one roof. As a specialty, pain medicine can set guidelines and improve assessment and treatment tools to help general practitioners treat pain. The field is actively working to provide much needed education for medical students, residents and practicing physicians.