The Right (and Wrong) Way to Treat Pain

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Although high-profile cases of addiction to OxyContin and other opioid pain-killers have scared off many doctors and patients, such drugs have an important role to play in chronic pain. They are particularly useful, says Palmer, for elderly patients, many of whom can't tolerate the side effects of anti-inflammatories. Younger people develop tolerances to opiates more quickly than the elderly, says Palmer, which means the young wind up needing ever higher doses. That is not a big problem in older patients. "I like to use low-dose opioids in the elderly because there aren't any liver effects, there aren't any cardiac effects, and the biggest problem you have is some constipation," which you can treat. On the other hand, Palmer believes that the COX-2 drugs are much safer in the young than in the old. "I'll bet if you break down all those Bextra, Celebrex and Vioxx studies and look at the age group under 40 vs. the age group over 70, you're going to see dramatic differences." The problem, she says, is that most drug studies treat patients from 18 to 80 as a single group.

WHY DON'T MORE DOCS GET IT RIGHT?

If comprehensive pain-management centers are so good at providing relief, why aren't more doctors following their lead? The sad fact is that virtually every trend in medicine--from the training doctors get to the treat-'em-fast pressures of managed care to the way insurance companies cover or fail to cover alternative therapies--works against this. "We don't teach medical students enough about pain, even though it's the most common reason people go to doctors," complains Fishman of U.C. Davis. "We've really wandered from a basic philosophy in medicine, where you cure what you can but always treat suffering, to being focused only on curing."

Fishman, who is president of the American Academy of Pain Medicine, laments the way insurance plans favor quick pharmaceutical fixes over the kinds of physical and psychological therapies that chronic-pain patients need. The bias toward drug treatment is not only bad medicine but is also expensive. "When somebody comes in with 25 years of chronic pain," says Fishman, "I might sit with them for 90 minutes to get the beginning of the story, to really understand what's happening. The insurers would rather pay me $1,000 to do a 20-minute injection than pay me a fraction of that to spend an hour or two talking with a patient."

Inevitably, many patients who find their way to pain-management centers wind up paying out of pocket for some of the nontraditional parts of their treatment. Still, demand for these services is soaring. Six years ago, the center at U.C. Davis received 50 to 60 patient referrals a month; now it receives 500. With fewer than 200 multidisciplinary centers across the U.S., the need simply cannot be met. "The bottom line is that there will never be enough specialists to deal with the problem," says Fishman. "So we have to train primary-care physicians at the front lines to be able to do this as part of the basic care that we give patients." For that to happen, more doctors and patients will have to heed the lessons of Vioxx and Celebrex and refuse to settle for prescription-pad medicine. --With reporting by Dan Cray/ Los Angeles, Chris Daniels/ Toronto, Alice Park/ New York and Maggie Sieger/ Chicago