The controversy over non-treatment of pain with pain medicine has filled the pages of pain advocacy journals in recent months.
Let’s face it. The CDC is going to do what it likes behind closed doors, regardless of what we say here, without consulting the American Academy of Pain Medicine (AAPM), and in spite of the Washington Legal Foundation. Our opinions, as people who live in pain and the doctors that treat us, are irrelevant. So say Ballantyne, Freiden, and the insular CDC junta.
They are missing the point.
Pain Medicine is and has never been about a patient’s comfort level – that’s called palliative medicine. Instead, the treatment of chronic pain is a necessary medical intervention to attenuate the progression of physiological disease, and to affect an improvement in a patient’s quality of life or QOL. When medical care creates a positive change in the QOL of someone who lives with daily intractable pain, it improves that patient’s ability to function as a parent, employee, student, or other participating member of society.
Pain medicine and its use of opioid analgesics as a modality in the treatment of chronic pain, seeks to improve a person’s QOL for the benefit of all. The anti-analgesic cartel thinks only in terms of the harms of treatment, and claims that they outweigh the benefits.
Again, they are missing an important point.
It is a physician’s ethical duty to treat pain and suffering.
So says emergency physician Dr. Andrew Luke Aswegan, MD in his September 2007 story for the American College of Emergency Physicians , who reminds us that:
“Pain as a presenting complaint accounts for up to 70% of emergency department visits, making it the most common reason to seek health care. Often, it is the only reason patients seek care.”
Breakthrough pain is very real. I won’t bother to list the many authorities who recognize the existence of this phenomenon in the person with intractable pain treated with chronic opioid therapy (COT).
Many in the chronic pain community have experienced rejection in the emergency department at their local hospitals, and new rules developed from the poorly-named concept of Universal Precautions in Pain Medicine  put many who are treated for chronic pain at risk of losing their COT if they receive analgesic treatment from any doctor other than their pain doctor.
“Patients should be allowed to make autonomous decisions when appropriate, and the principle of justice guides us to evaluate and alleviate pain in a nonprejudicial and nonjudgmental manner. Our ethical duty to relieve suffering is clear. If we don’t provide adequate pain relief, we risk losing our patients’ trust, and, ultimately, our patients,” concludes Dr. Aswegan.
Emergency room physicians ignoring an ethical imperative by refusing to treat people on COT who experience acute exacerbations of pain are considered by many to be limited by an extreme professional bias called Opiophobia.
What is Opiophobia?
In their authoritative article for the BJA, Chronic Pain and Prescription Opioid Misuse, Dr. Simon G Tordoff FRCA, FIPP and Dr. Praveen Ganty, FRCA write that
“Opiophobia describes the reluctance of prescribers to use opioid medication for fear of causing addiction or toxicity. There are many factors involved, for example, pressure from peers or patients or carers, regulatory restrictions by government agencies, a lack of education and understanding of the use of opioids, or social and moral prejudice. Staff might be fearful to prescribe or administer opioids for fear of causing respiratory depression, addiction, or both.” 
In short, Opiophobia is a doctor’s reluctance to prescribe an opioid analgesic for a person in pain.
Dr. Tordoff’s definition implies that Opiophobia can mean different things to different doctors. To one, it’s a fear of reprisal from an authority for prescribing these medications. To another, Opiophobia is caused by a concern for doing harm to the patient. Finally, some people have a bias against the use of drugs – a bias that is re-enforced in our business culture.
Many people treated for pain believe that the authority that doctors fear is the Drug Enforcement Agency. While this may have been true in the last decade, what we’re finding is that doctors today are much more likely to be disciplined by their state board of medicine for “over-prescribing” opioids. The case of Dr. Mark Ibsen of Helena, MT, as reported in these pages, is a typical example of the risks physicians face when they attempt to effectively treat pain.  
As for that other reason – the treatment of pain with opioid analgesics causes more harm than benefit – let’s examine the nature of pain, and how forces are attempting to change our ideas about it.
What is Chronic Pain?
According to Johns-Hopkins Medicine,
“Pain is an uncomfortable feeling that tells you something may be wrong. It can be steady, throbbing, stabbing, aching, pinching, or described in many other ways. Sometimes, it’s just a nuisance, like a mild headache. Other times it can be debilitating.
Pain can bring about other physical symptoms, like nausea, dizziness, weakness or drowsiness. It can cause emotional effects like anger, depression, mood swings or irritability. Perhaps most significantly, it can change your lifestyle and impact your job, relationships and independence.” 
At that point, the discussion continues into the difference between acute and chronic pain.
The other day I was traveling in the Wayback Machine  and read this very same page at Johns-Hopkins from December 8, 2013. Then, the discussion of chronic pain continued with …
“Chronic pain has been said to be the most costly health problem in U.S. Increased medical expenses, lost income, lost productivity, compensation payments, and legal charges are some of the negative economic consequences of chronic pain. Consider the following:
- Low back pain is one of the most significant health problems. Back pain is the most frequent cause of activity limitation in people younger than 45 years old
- Cancer pain affects the majority of patients in intermediate or advanced stages of cancer
- Arthritis pain affects nearly 50 million Americans each year
- Headaches, according to the National Institute of Neurological Disorders and Stroke, affect millions of U.S. adults. The three most common types of chronic headaches are migraines, cluster headaches, and tension headaches
- Other pain disorders such as the neuralgias and neuropathies that affect nerves throughout the body, pain due to damage to the central nervous system (the brain and spinal cord), as well as pain where no physical cause can be found–psychogenic pain–increase the total number of reported cases.” 
On another 2013 Hopkins page discussing pain management in acute pain, we read:
“Pain is your body’s way of telling you something is wrong.” 
Two years ago, one of the most respected medical organizations in the world tells us that chronic pain is the most important health care problem in America, and that certain pain disorders cause damage to the central nervous system. They say, rightly, that pain is a sign of disease.
Today, they call pain a “feeling”, a “nuisance” that may interfere with your relationships and lifestyle.
Is the truth about chronic pain being minimized and ‘spun’?
Sadly, Johns-Hopkins appears to be another American medical institution who has succumbed to the politicization of pain, and has therefore redacting any reference to the physiological damage caused by untreated chronic pain, and the millions who suffer from this silent epidemic – the American Pain Epidemic.
Untreated Chronic Pain as an Acute Clinical Episode
People who live with chronic pain are treated with COT, which are usually extended release formulations of common opiates like morphine. A good doctor will titrate pain medication to an effective therapeutic dose providing the patient with a better QOL.
However, people with chronic pain disease experience frequent episodes of increased pain, called breakthrough pain, even if their day-to-day pain is well-managed with opioid analgesics and other modes of therapy. Although not well studied, when it was studied, the prevalence of breakthrough pain is found in 50% to 75% of patients receiving COT. 
Moderate to severe pain causes physiological changes in the body’s sensory and endocrine systems. There is an evolutionary connection to these physiological responses to pain within the body. From the brain through the nervous system, and the chemical messengers known as hormones, this response is classically understood as the “fight or flight” reaction, explained by physiologist W.B. Cannon in The Emergency Function of the Adrenal Medulla in Pain and the Major Emotions, published in the 1914 American Journal of Physiology.
Cannon’s elegant words describe how adrenalin, “Liberated Normally in Fear, Rage, Asphyxia and Pain,” is a reflex response to pain and major emotion, which leads to a release of glycogen into the bloodstream, necessary…
“for putting forth supreme muscular efforts,” and to the vascular changes that shunt blood away from vital organs in the gastrointestinal and urinary system in order that the “tripod of life – the heart, lungs and brain (as well as the skeletal muscles) – are, in times of excitement… abundantly supplied with blood…” 
Cannon concludes this well-known medical tract with these words:
“These changes in the body are, each one of them, directly serviceable in making the organism more efficient in the struggle which fear or rage or pain may involve; for fear and rage are organic preparations for action, and pain is the most powerful known stimulus to supreme exertion.” 
This is a pain flare, wherein, chronic pain becomes acute pain. The fight/flight mechanism is all wound up, and all body systems are under enormous stress.
When pain levels rise above acceptable, people in pain are moved by these physiological forces to find relief. If they cannot find that relief through attention, distraction, mindfulness, exercise, ice, meditation, CBT, OTCs, positive attitudes, soaking in the tub, or their regular prescription medication, they seek treatment in an emergency room.
And in American emergency rooms, people in acute pain are being denied care. Why – because they are diagnosed and treated for chronic pain. This Opiophobia-based discrimination is tantamount to torture.
And torture is a violation of human rights, prohibited under international law.
Another great reference on ethics and Opiophobia in the treatment of chronic pain can be found on Dr. Forest Tennant’s Practical Pain Management site:
 The authoritative Medscape article by Gourlay and Heit on Universal Precautions in Pain Medicine http://www.medscape.org/viewarticle/503596
Read why pain patients have regular UDTs and sign additional contracts for treatment, and consider this: who do universal precautions protect?
 Dr. Tordoff’s informative article titled Chronic Pain and Prescription Opioid Misuse can be found here. http://www.medscape.com/viewarticle/728575_2
It is a recommended read for anyone interested in the patterns of opioid use and abuse in the chronic pain community.
 For an introduction to the Dr. Mark Ibsen story, see:
And search for the name Ibsen for other stories. Although we reported in June that Dr. Ibsen “won” his case, as of this week, Dr. Ibsen’s Montana medical license is under threat of removal by the Montana BOM. Breaking 12/4/15 – See note  below.
 What is Pain? from Johns-Hopkins Blaustein Pain Treatment Center
 In his seminal volume, The Life of Reason or The Phases of Human Progress: Reason in Common Sense (2nd ed., Charles Scribner and Sons, NY, 1924.), the philosopher George Santayana wrote “Those who cannot remember the past are condemned to repeat it.”
The Wayback Machine is the closest thing we the people have to a historical record in our modern era. Use it, and support it.
 From the site HopkinsMedicine.org, December 5, 2013
 Bennett, DS, Simon, S., et. al. (2007) Prevalence and characteristics of breakthrough pain in patients receiving opioids for chronic back pain in pain specialty clinics.
“Eighty-seven subjects (74 percent) experienced 93 types of BTP.”
 Portnoy, RK, Bennett, DS, et. al. (2006). Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain.
“This article presents results from a survey that demonstrates that breakthrough pain is highly prevalent and varied in opioid-treated patients with chronic noncancer pain. These findings will assist clinicians in assessing and managing this type of pain.”
 Gatti A, Mediati RD, et. al. (2012). Breakthrough pain in patients referred to pain clinics: the Italian pain network retrospective study.
“Despite breakthrough pain (BTP) being one of the most severe forms of pain, there are no definitive data on its prevalence.”
“The authors analyzed records of 1,401 patients (58% women, 33.1% patients with cancer). Transient episodes of severe pain or BTP were referred by 790 patients (56.4%), including 58.2% of the men (342 of 588) and 55.1% of the women (448 of 813). Among the 464 patients with cancer, 70.3% reported daily exacerbation of pain.”
 Cannon, W. B. (1914). The emergency function of the adrenal medulla in pain and the major emotions, Am J Physiol, 33(2), 356–372.
 Cannon (1914), op. cit., page 372.
 Sadly, Dr. Mark Ibsen was forced to close his urgent care clinic this week.
“The Healing Begins When You Walk Through the Door” is still painted on the front door of the Helena, MT clinic. Our condolences Mark, to you, your staff, patients, and the citizens of Helena. Illegitimi non carborundum.
At this time of Thanksgiving, I would like to express my gratitude to my friends and copyeditors for their generous contributions of time and expertise to these stories. Thank you. Also, I wish to send a special thank you to my friend Alex, who inspired this story and taught me much about the nature of pain and pain medicine.
Copyright © 2015 by Kurt W.G. Matthies and National Pain Report. All Rights Reserved.