Pain Control

Are we doing enough?

A pediatric journal recently conducted a survey of pain management practices involving infants and young children. These children's pain was due to extensive burns or to fractures of long bones (usually in the leg).

Disappointingly, only about a third of these patients received what was judged to be "adequate pain relieving medication."

Physicians are understandably reluctant to use drugs which might have troublesome or even dangerous side effects in little patients. They know that the child will recover from the burns or the broken bones as a matter of time, and from experience, have not seen kids suffer serious long term consequences from inadequately controlled pain. To the doctor, it always seems like it's the parents who are suffering the most. None of us wants the distinction of being the agent of a bad reaction to narcotics (including death), even when used properly.

Another area of pain relief used inadequately is in older patients with discomforts not due to cancer. (We don't necessarily do well with cancer pain either, but that's another subject.) These patients have problems like low back pain, headaches, arthritis, and fibromyalgia. To their doctors they often appear perfectly normal, and are thus easy to label as "malingerers" or "drug seekers".

The arrival of the NSAIDs (ibuprofen, Naprosyn and others) provided us with a non-narcotic alternative to aspirin and Tylenol and these drugs became rapidly and widely used for the conditions mentioned. When the pharmaco-chemists produced the second generation NSAIDs (Celebrex, Bextra, Vioxx) all adult chronic pain patients, for practical purposes, became candidates for their use.

Although there are numerous studies showing little advantage in using 2nd generation NSAIDs for chronic pain relief, most patients who get them think they are "effective". Perhaps this has to do with extensive advertising of the drugs, the attitude of the physician prescriber, or just the fact that they're new and expensive "so they must be good".

Physicians' prescribing habits are of concern to State licensing boards, particularly in the realm of narcotic use for chronic pain patients. Some doctors have appropriately been reprimanded or stripped of their licenses due to obviously excessive narcotic prescribing behavior. These examples serve to steer the rest of us away from using very effective pain medications even when their use is justified.

Physicians in "pain clinics" often use large amounts of narcotic drugs, and are able to do so by keeping careful records, following their patients closely, and making frequent attempts to lower dosages. Licensing boards aren't composed solely of drug police, and are willing to accommodate properly documented special circumstances.

Nevertheless. physicians in the trenches are more likely to use NSAIDs for chronic pain, even though they are much more expensive, have more side effects, and aren't much better than OTC preparations.

As for the babies - well, they do have advocates in the person of their parents who can and should ask their doctors to pay more attention to pain relief when warranted. After all, very few of us could be called heartless.