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Evolving Role of the Neurologist in the Diagnosis and Treatment of Chronic Noncancer Pain
Neurologist’s Role in Chronic Noncancer Pain
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Mayo Clin Proc, January 2003, Vol 78
Review
Evolving Role of the Neurologist in the Diagnosis and Treatment of Chronic Noncancer Pain PETER LARS JACOBSON, MD, AND J. DOUGLAS MANN, MD The neurologist has become increasingly involved in the multidisciplinary treatment of patients with chronic noncancer pain (CNP). Chronic noncancer pain affects a diverse patient population with multiple underlying diagnoses and associated therapies. Following the model of the American Board of Anesthesiology and the American Society of Anesthesiologists for practice guidelines and subspecialty requirements, neurologic pain management is now recognized as a subspecialty of neurology by the American Academy of Neurology and the American Board of Psychiatry and Neurology. Current basic and clinical research into the neuropathology, neurophysiology, neurochemistry, and neuropharmacology of chronic pain continues to expand diagnostic and therapeutic options. In-
formed regulatory agencies and professional organizations such as the American Academy of Neurology recognize the undertreatment of patients with CNP and provide clear recommendations to help neurologists in the ethical and effective treatment of patients with pain. Improved education of neurologists, other health care professionals, patients, and the media about evolving standards of pain care and therapy will produce a more supportive environment for the compassionate and ethical treatment of patients with CNP. Mayo Clin Proc. 2003;78:80-84 AAN = American Academy of Neurology; CNP = chronic noncancer pain; DEA = Drug Enforcement Administration
T
he treatment of chronic noncancer pain (CNP) is a practical and ethical issue for neurologists. In current practice, patients with CNP are referred to neurology offices and clinics in increasing numbers,1 and daily documentation of pain control for all hospitalized patients, including those with neurologic disease, has become a requirement of the Joint Commission on Accreditation of Healthcare Organizations.2 In a recent special article, the American Academy of Neurology Ethics, Law and Humanities Committee outlined the ethical issues for neurologists who treat patients with CNP, including its recommendations for current multidisciplinary treatment and future approaches to research, education, and therapy.3 Unfortunately, multiple barriers (Table 14-18) impede the treatment of CNP by neurologists. Nonetheless, these concerns, problems, and myths are changing through multilevel medical education, ongoing research, and better informed regulatory agencies.3
the recent survey by the American Academy of Neurology (AAN); the Practice Characteristics Subcommittee of AAN indicates that neurologists provide extended and long-term management of several conditions associated with CNP, including headache (77.4% of respondents) and spine or limb pain (47.6%).1 The general neurologist will also be evaluating and possibly treating multiple disorders including neuropathy, “failed back” syndromes, radiculopathy, and postherpetic neuralgia.3,19 Neurology residency programs and postresidency neurology practice should provide the background and basic skills for the treatment of CNP. However, the current training programs and educational opportunities for practicing neurologists need further improvements. This enhanced education will translate to skills that will facilitate a better “comfort” level for general neurologists in the diagnostic assessment and treatment of patients with CNP.14 The AAN recognizes these issues and “encourages every neurologist to support and participate in initiatives in their institutions to improve the assessment and treatment of pain, and advocates a balanced public drug policy on the use of controlled substances to treat patients with chronic pain and neurologic disease.”3 Through a comprehensive neurologic assessment, appropriate diagnostic testing, individualized and strictly monitored treatment programs including multidisciplinary consultation, neurologists can improve a patient’s quality of life and functioning at all levels.3,8,13 Stabilization of the clinical situation through a structured treatment plan com-
THE NEUROLOGIST AND CNP The increasing role of the neurologist in treating CNP within a multidisciplinary treatment plan is documented in From the Department of Neurology, University of North Carolina School of Medicine, Chapel Hill. Address reprint requests and correspondence to Peter Lars Jacobson, MD, Department of Neurology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Campus Box 7025, Chapel Hill, NC 27599-7025 (e-mail: [email protected]). Mayo Clin Proc. 2003;78:80-84
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© 2003 Mayo Foundation for Medical Education and Research
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Mayo Clin Proc, January 2003, Vol 78
bined with patient and family education about CNP contributes to these benefits. Teaching is not limited to patients and their families. Educating other physicians and health care providers about the treatment of CNP is another opportunity for neurologists to improve the therapeutic environment for their patients with CNP. SUBJECTIVE AND OBJECTIVE ASPECTS OF CNP The subjective nature of pain is an issue for many physicians including neurologists. This concern has a historical precedent that arose from the separation of mind and body through Cartesian dualism.8,20 The mind (spiritual) was historically the realm of religion, whereas the body (objective) became the accepted territory of medicine.8,20 Ideally, medicine recognizes the importance of the mindbody connection, and current neurochemical research and neurophysiological research confirm this connection for CNP.5-7 Like the previously “subjective” migraine headache, research in neurochemistry, neuropharmacology, neuroimaging, and neurophysiology has moved CNP from the purely psychological (subjective) to the neuropathological (objective). The localization of subcortical pain centers on positron emission tomographic scans,5 identification of specific receptors like N-methyl-D-asparate receptor,6,7 and delineation of central and peripheral pain pathways with clinical neurophysiological testing help to clarify the problems and potential treatments of CNP.4-7 Preventive neurochemical regimens for CNP include agents that are familiar to neurologists, including anticonvulsants, anti-inflammatory agents, and antidepressants.21 The treatment plan for the patient with CNP may include use of medications like opioids, which are unfamiliar to many neurologists.3,17,22 Understanding the basic neurophysiology and neurochemistry will help to identify new neuropharmaceutical agents for patients with CNP. NEUROLOGIST EDUCATION AND ATTITUDES ABOUT CNP Regulatory requirements and bioethics dictate the need for a change in the emphasis on pain management in undergraduate, graduate, and postgraduate neurology education.2,3,8,12,14,20,22-24 The Joint Commission on Accreditation of Healthcare Organizations established pain control issues as the “fifth vital sign” with the assistance of the consensus statement of the American Academy of Pain Medicine and the American Pain Society.2,22 Health care providers will need to address pain control issues in patients in hospitals and affiliated outpatient facilities and clinics daily because documentation of treatment and response to pain control is now mandated. Unrelieved pain and suffering are unethical, and neurologists need to know the appropriate treat-
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Table 1. Barriers to Treatment of Chronic Noncancer Pain* Historical concern about the subjective and objective components of CNP and its pathophysiology4-7 Lack of emphasis in undergraduate, graduate, and postgraduate medical education on CNP8-14 Confusion with comorbid psychiatric disease15 Fear of audits and reprisals by regulatory agencies like the DEA and state medical boards16,17 Perceived and sometimes hostile environment, including health care professionals (physicians, nurses, and pharmacists), the media, and the public, regarding the issues of pain treatment18 Fear of contributing to patient drug addiction17 *CNP = chronic noncancer pain; DEA = Drug Enforcement Administration.
ment through training and education. Education should not be limited to medications, but other treatment modalities, including physical therapy, spiritual counseling, assessing family and social issues, diagnostic and therapeutic activities such as specialized imaging and block techniques, and evaluation for possible psychiatric comorbidities, should be addressed. Appropriate consultation with other health care specialists should be emphasized and defined. All members of the health care team will need to be aware of pain-modifying factors particularly related to medications, including dosing, routes of administration, equianalgesic dosing, half-lives, and adverse effects. The role of the neurologist in the multidisciplinary treatment of pain needs to be experienced by neurology residents. Educational goals should also include attention to attitudes and negative bias often surrounding patients with chronic pain. Undergraduate medical education can affect medical student attitudes toward patients with CNP. A specific 6hour course at the University of Kentucky had a lasting and positive effect on medical students regarding the perception of pain that patients experience.13 A study of pain medicine education among American neurologists published in 1999 suggests a need to improve the current neurology residency training in pain medicine and provide more pain symposia at the AAN meeting for practicing neurologists.14 In this study, 29% of residency programs had neurology pain specialists. Only 5% of the programs required residents to undergo rotation in a pain clinic; 62% of neurology residents had no clinical training in a pain clinic environment.14 Neurology pain fellowships were offered in only 9% of the 155 residency programs that responded to the survey (of 164). This situation will change because of the AAN emphasis on enhanced pain education during residency.3 A forum to exchange information on the treatment of patients with CNP is provided by the AAN Pain Medicine Section for its members.25 The American Board of Psychiatry and Neurology recognizes this subspe-
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Neurologist’s Role in Chronic Noncancer Pain
cialty and has specific examination and training requirements for certification in the subspecialty of pain management for neurologists.26 In 2000, the first year of certification, 39 certificates were issued.27 Educational approaches for neurologists in the diagnosis and treatment of CNP include increased acceptance by major neurology journals of quality articles on the topic of CNP, expansion of training under guidelines from the Accreditation Council for Graduate Medical Education for neurology residents, more neurology grand rounds on CNP issues, more opportunities for practicing neurologists through continuing medical education programs, and broadening the scope and number of courses on CNP topics at professional meetings such as the AAN annual meeting. Well-designed, controlled basic and clinical research on the pathophysiology and the treatment of CNP should be encouraged and supported.3 PSYCHIATRIC COMORBIDITY AND CNP At the graduate and postgraduate level, the few “difficult drug-seeking” patients can taint the neurologist’s perception of all patients with CNP. A 1-year study of patients with pain at all the emergency departments of Calgary, Canada, showed that only a small percentage (4%-5%) of all patients seen for chronic pain was responsible for about one third of the total emergency department visits. This minority of patients generated negative perceptions by physicians and nurses toward the 90% to 95% of patients with similar pain problems.18 Recommendations from this study included improvement in identifying patients with a diagnosis of drug dependency with referral to the appropriate specialists for detoxification and psychiatric treatment; there was an associated improvement in the medical staff perception of patients with pain in general with this approach and recognition of a different or comorbid psychiatric problem.18 Like other chronic syndromes and diseases in neurology, comorbid psychiatric illness can occur in patients with CNP.15 The comorbid psychiatric disease needs to be diagnosed and treated. For neurologists, an example would be the patient with Parkinson disease with the comorbidity of depression and anxiety; the presence of these psychiatric comorbidities does not discount the underlying Parkinson disease and its need for treatment. A review of psychiatric diagnoses associated with CNP would be helpful in educating practicing neurologists and staff. After identification of a comorbid psychiatric disease, referral of the patient to a psychiatrist should be a part of the treatment plan. Good communication between the neurologist and psychiatrist would help to address the pain needs of the patient with comorbid psychiatric disease. Documentation of the psychiatric comorbid disease, in-
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cluding addiction and depression, is essential. This documentation will protect the patient and the neurologist. FEAR OF PRESCRIBING CONTROLLED SUBSTANCES FOR CNP Despite recent changes in institutional attitudes and policies, fears of audits and reprisals by state and federal agencies for the use of controlled substances persist. Education in the use of opioids, including dosing, adverse effects, patient monitoring, avoidance of medication diversion, appropriate use in treatment plan, and current federal and state regulations, would help neurologists at all levels of training and practice. Regulatory agencies have recognized the undertreatment of CNP and have supported active and comprehensive treatment for this condition, including controlled substances. The Drug Enforcement Administration (DEA) in its Physician’s Manual: An Informational Outline of the Controlled Substances Act of 1970 (revised March 1990) specifically addresses the issue of pain medications and physician fear and anxiety of reprisals for narcotic pain prescriptions: “These drugs have a legitimate clinical use and the physician should not hesitate to prescribe, dispense or administer them when they are indicated for legitimate medical purpose. It is the position of the Drug Enforcement Administration that controlled substances should be prescribed, dispensed or administered when there is a legitimate medical need” (in the section entitled Narcotics for Patients With Terminal or Chronic Disorders).28 The American Academy of Neurology Ethics, Law and Humanities Committee describes the ethical obligations and the necessary assessment and treatment plan with documentation that would be consistent with the DEA recommendations.3 Controlled substance diversion is a major concern of the DEA, and steps by neurologists to avoid this problem are clear, simple, and straightforward. These steps are delineated by the DEA28 as well as the model guidelines established by the House of Delegates of the Federation of State Medical Boards of the United States, Inc.23 Patients with CNP are included within these guidelines; the model guidelines will help effective treatments, avoid medication diversion, and protect against patient addiction. CNP AND OPIOID ADDICTION Although prescription drug abuse and addiction are serious medical and societal concerns, myths about pain medications and their administration have contributed to the subtherapeutic dosing of opioids and other pain medications for patients with CNP throughout the past 3 decades.11,17 If the current analgesic medication or its dose does not provide pain relief for the patient, more potent medications should be prescribed or the dose increased
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Mayo Clin Proc, January 2003, Vol 78
until pain relief or pain medication adverse effects occur.19 The myths add to a hostile environment for using opioids in conjunction with other therapies for patients with CNP.17 Continuing education programs for physicians, nurses, pharmacists, patients, and their families are necessary to remove the stigma associated with CNP. Using the database of the Drug Abuse Warning Network (source for drug abuse data) and the Automation of Reports and Consolidated Orders System (source for medical use data), a retrospective study from 1990 to 1996 concluded that the increasing medical use of opioid analgesic medications to treat pain does not appear to contribute to an increase in opioid analgesic abuse.29 The Pain and Policies Studies Group at the University of Wisconsin Medical School, Madison, is an excellent source for current information on pain treatment and the latest federal and state policies on pain management.29 Opioid tolerance is not abuse. It is an adverse effect of long-term opioid therapy, and both a verbal and a written description of this and other adverse effects of opioid therapy need to be given to the patient if opioid therapy is considered a component of the comprehensive CNP treatment plan. A policy statement by the Federation of State Medical Boards of the United States, Inc, and a position statement by the North Carolina Medical Board on management of chronic nonmalignant pain delineate the differences between medication tolerance and substance addiction.23,24 Substance addiction is a psychiatric condition, whereas medication tolerance is an expected adverse effect of opioid therapy. As with other medications for chronic neurologic syndromes, the doses of opioids require scheduled monitoring and adjustment because of the potential long-term adverse effects. For example, effective longterm treatment of Parkinson disease usually requires an increase in the dose of levodopa/carbidopa, and its longterm use has potential adverse effects. In addition, a dependence on this drug will occur, and the immediate withdrawal of levodopa/carbidopa may lead to severe medical complications.30 As with therapy for Parkinson disease, counseling, scheduled monitoring, and medication adjustments are essential in CNP treatment. A consensus statement from the American Academy of Pain Medicine and the American Pain Society provides excellent definitions for tolerance, physiological dependence, medication withdrawal, addiction, and pseudoaddiction (Table 2).22,23,29 Controlled substance diversion can be prevented. The model guidelines for the use of controlled substances for treating pain are outlined by the policy of the House of Delegates of the Federation of State Medical Boards as cited previously and the American Academy of Neurology Ethics, Law and Humanities Committee.3,23
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Table 2. Current Definitions of Pain Treatment With Opioids22,23,29 Addiction—a compulsive disorder in which an individual becomes preoccupied with obtaining and using a substance, the continued use of which results in a decreased quality of life Pseudoaddiction—pattern of drug-seeking behavior of patients with pain who are receiving inadequate pain management that can be mistaken for addiction Tolerance—physical adaptation of the body to an opioid with decreasing pain relief with the same dose over time Physical dependence—physical adaptation of the body to the presence of an opioid; it is characterized by signs of withdrawal when use of an opioid is stopped abruptly or an antagonist is administered Withdrawal—acute physiological response to the abrupt discontinuation of long-term opioid therapy or to the administration of an opioid antagonist
A treatment contract with a patient is a powerful instrument for preventing drug diversion and for identifying patients who need treatment for substance abuse. The signed and witnessed contract should contain the key elements noted in Table 3. Copies of this contract are retained by both the patient and the physician. Informing pharmacists and emergency department personnel about use of the treatment contract for patients on controlled substances may provide valuable input concerning deviations and compliance. In this instance, neurologists can assist in creating a positive and responsive environment for pain management by sharing their experience and knowledge in an educational setting with local pharmacists and emergency department staff. BIOETHICS AND CNP As described by the American Academy of Neurology Ethics, Law and Humanities Committee, neurologists who treat CNP “have an ethical duty to address pain and suffering” with special responsibilities and ethical obligations to their patients and society.3 Practicing general neurologists, neurology residents, and neurology pain specialists should have the skills and training to reduce the pain and suffering of patients with Table 3. Key Elements of Contract to Avoid Drug Diversion Informed consent One physician prescribing controlled substances One pharmacy named in contract Refills during office hours only Notification of the physician’s office of any controlled substance prescriptions from another physician during emergency treatment Description of the prescription flowchart in the patient’s record Immediate referral to a drug treatment program or dismissal from the practice for violations of the contract
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CNP while complying with and understanding well-established bioethical principles. The 4 basic bioethical issues for neurologists are patient autonomy, nonmaleficence, beneficence, and justice.31 Patient autonomy is in part provided through a comprehensive informed consent contract that clearly describes the therapeutic risks, benefits, and obligations inherent in the physician-patient relationship in the treatment of CNP. Nonmaleficence (avoidance of causing harm) is protected by (1) a well-documented medical and pain history and neurologic examination; (2) appropriate neurodiagnostic testing; (3) solid working diagnoses; (4) identification and treatment of comorbidities; (5) clear discussion of medications and their benefits and adverse effects as well as other aspects of the total treatment plan; (6) monitoring of controlled substances to avoid medication diversion and patient addiction; and (7) routine follow-up appointments to assess any clinical changes or necessary adjustments in the medication or treatment plan. Beneficence (benefits and balancing the benefits against risks and costs) is evident in the relief of CNP, which can increase function and reduce suffering, anxiety, depression, and emotional and social isolation of the patient. These benefits are balanced against the risks and costs, including medication adverse effects, required follow-up examinations, compliance with the informed consent-treatment contract, and medication tolerance if opioids are used. Finally, justice (distributing benefits, risks, and costs fairly) is approached through the neurologist’s provision of equal access for consultation and treatment of CNP and the patient’s choice of accepting or declining the treatment plan and contract. The neurologist can be an effective part of the multidisciplinary pain management team. Through education, research, and communication, neurologists can contribute to the ethical relief of pain and suffering in patients with CNP.
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6. 7. 8. 9.
10.
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
22. 23.
We thank Dr Larry Churchill, Stahlman Professor of Medical Ethics at the Vanderbilt University Medical Center, Nashville, Tenn, for his valuable review of the submitted manuscript.
24.
REFERENCES
26.
1. 2. 3. 4.
5.
American Academy of Neurology Practice Characteristics Subcommittee. Neurologists 2000. St Paul, Minn: American Academy of Neurology; 2001:18. Joint Commission on Accreditation of Healthcare Organizations. 2001 Hospital Accreditation Standards. Oakbrook Terrace, Ill: JCAHO Publications, Inc; 2001. American Academy of Neurology Ethics, Law and Humanities Committee. Ethical considerations for neurologists in the management of chronic pain. Neurology. 2001;57:2166-2167. Doubell TP, Mannion RJ, Woolf CJ. The dorsal horn: state-dependent sensory processing, plasticity and the generation of pain. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed. Edinburgh, United Kingdom: Churchill Livingstone; 1999:165-181. Petrovic P, Ingvar M, Stone-Elander S, Petersson KM, Hansson P. A PET activation study of dynamic mechanical allodynia in patients with mononeuropathy. Pain. 1999;83:459-470.
25.
27. 28. 29. 30. 31.
Urban MO, Gebhart GF. Central mechanisms in pain. Med Clin North Am. 1999;83:585-596. Carver A, Foley K. Facts and an open mind should guide clinical practice. Curr Neurol Neurosci Rep. 2001;1:97-98. Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306:639-645. Weinstein SM, Laux LF, Thornby JI, et al. Physicians’ attitudes toward pain and the use of opioid analgesics: results of a survey from the Texas Cancer Pain Initiative. South Med J. 2000;93:479487. Weinstein SM, Laux LF, Thornby JI, et al. Medical students’ attitudes toward pain and the use of opioid analgesics: implications for changing medical school curriculum. South Med J. 2000;93: 472-478. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med. 1973;78:173-181. Pilowsky I. An outline curriculum on pain for medical schools [editorial]. Pain. 1988;33:1-2. Wilson JF, Brockopp GW, Kryst S, Steger H, Witt WO. Medical students’ attitudes toward pain before and after a brief course on pain. Pain. 1992;50:251-256. Galer BS, Keran C, Frisinger M. Pain medicine education among American neurologists: a need for improvement. Neurology. 1999; 52:1710-1712. Fishbain DA. Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient. Med Clin North Am. 1999;83:737-760. Hill CS Jr. Government regulatory influences on opioid prescribing and their impact on the treatment of pain of nonmalignant origin. J Pain Symptom Manage. 1996;11:287-298. Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11: 203-217. MacLeod DB, Swanson R. A new approach to chronic pain in the ED. Am J Emerg Med. 1996;14:323-326. Carver A, Payne R, Foley K. Herpes zoster [letter]. N Engl J Med. 2000;343:221. Rich BA. A legacy of silence: bioethics and the culture of pain. J Med Humanit. Winter 1997;18:233-259. Mohamed SA, Mohamed K, Borsook D. Choosing a pharmacotherapeutic approach: nonopioid and adjuvant analgesics. In: Borsook D, LeBel AA, McPeek B, eds. The Massachusetts General Hospital Handbook of Pain Management. Boston, Mass: Little, Brown and Co; 1996:76-104. The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13:6-8. Federation of State Medical Boards of the United States, Inc. Model guidelines for the use of controlled substances for the treatment of pain, May 1998. Available at: www.fsmb.org/policy. Accessibility verified December 3, 2002. North Carolina Medical Board. Management of chronic non-malignant pain. Available at: www.ncmedboard.org/pain.htm. Accessibility verified December 9, 2002. American Academy of Neurology. 2001-2002 Membership Directory. Neurology. 2001;57(suppl 1):34A. American Board of Psychiatry and Neurology. 2002 Information for Applicants for Certification in the Subspecialty of Pain Medicine. Deerfield, Ill: American Board of Psychiatry and Neurology; 2001. American Board of Psychiatry and Neurology. Certification statistics as of January 1, 2001. Available at: www.abpn.com/certification/statistics.html. Accessibility verified December 3, 2002. Drug Enforcement Administration. Physician’s Manual: An Informational Outline of the Controlled Substances Act of 1970. Washington, DC: US Dept of Justice; 1990. Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283:17101714. Lang AE, Lozano AM. Parkinson’s disease: second of two parts. N Engl J Med. 1998;399:1130-1143. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. Oxford, England: Oxford University Press; 2001.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
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Mayo Clin Proc, January 2003, Vol 78
Review
Evolving Role of the Neurologist in the Diagnosis and Treatment of Chronic Noncancer Pain PETER LARS JACOBSON, MD, AND J. DOUGLAS MANN, MD The neurologist has become increasingly involved in the multidisciplinary treatment of patients with chronic noncancer pain (CNP). Chronic noncancer pain affects a diverse patient population with multiple underlying diagnoses and associated therapies. Following the model of the American Board of Anesthesiology and the American Society of Anesthesiologists for practice guidelines and subspecialty requirements, neurologic pain management is now recognized as a subspecialty of neurology by the American Academy of Neurology and the American Board of Psychiatry and Neurology. Current basic and clinical research into the neuropathology, neurophysiology, neurochemistry, and neuropharmacology of chronic pain continues to expand diagnostic and therapeutic options. In-
formed regulatory agencies and professional organizations such as the American Academy of Neurology recognize the undertreatment of patients with CNP and provide clear recommendations to help neurologists in the ethical and effective treatment of patients with pain. Improved education of neurologists, other health care professionals, patients, and the media about evolving standards of pain care and therapy will produce a more supportive environment for the compassionate and ethical treatment of patients with CNP. Mayo Clin Proc. 2003;78:80-84 AAN = American Academy of Neurology; CNP = chronic noncancer pain; DEA = Drug Enforcement Administration
T
he treatment of chronic noncancer pain (CNP) is a practical and ethical issue for neurologists. In current practice, patients with CNP are referred to neurology offices and clinics in increasing numbers,1 and daily documentation of pain control for all hospitalized patients, including those with neurologic disease, has become a requirement of the Joint Commission on Accreditation of Healthcare Organizations.2 In a recent special article, the American Academy of Neurology Ethics, Law and Humanities Committee outlined the ethical issues for neurologists who treat patients with CNP, including its recommendations for current multidisciplinary treatment and future approaches to research, education, and therapy.3 Unfortunately, multiple barriers (Table 14-18) impede the treatment of CNP by neurologists. Nonetheless, these concerns, problems, and myths are changing through multilevel medical education, ongoing research, and better informed regulatory agencies.3
the recent survey by the American Academy of Neurology (AAN); the Practice Characteristics Subcommittee of AAN indicates that neurologists provide extended and long-term management of several conditions associated with CNP, including headache (77.4% of respondents) and spine or limb pain (47.6%).1 The general neurologist will also be evaluating and possibly treating multiple disorders including neuropathy, “failed back” syndromes, radiculopathy, and postherpetic neuralgia.3,19 Neurology residency programs and postresidency neurology practice should provide the background and basic skills for the treatment of CNP. However, the current training programs and educational opportunities for practicing neurologists need further improvements. This enhanced education will translate to skills that will facilitate a better “comfort” level for general neurologists in the diagnostic assessment and treatment of patients with CNP.14 The AAN recognizes these issues and “encourages every neurologist to support and participate in initiatives in their institutions to improve the assessment and treatment of pain, and advocates a balanced public drug policy on the use of controlled substances to treat patients with chronic pain and neurologic disease.”3 Through a comprehensive neurologic assessment, appropriate diagnostic testing, individualized and strictly monitored treatment programs including multidisciplinary consultation, neurologists can improve a patient’s quality of life and functioning at all levels.3,8,13 Stabilization of the clinical situation through a structured treatment plan com-
THE NEUROLOGIST AND CNP The increasing role of the neurologist in treating CNP within a multidisciplinary treatment plan is documented in From the Department of Neurology, University of North Carolina School of Medicine, Chapel Hill. Address reprint requests and correspondence to Peter Lars Jacobson, MD, Department of Neurology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Campus Box 7025, Chapel Hill, NC 27599-7025 (e-mail: [email protected]). Mayo Clin Proc. 2003;78:80-84
80
© 2003 Mayo Foundation for Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, January 2003, Vol 78
bined with patient and family education about CNP contributes to these benefits. Teaching is not limited to patients and their families. Educating other physicians and health care providers about the treatment of CNP is another opportunity for neurologists to improve the therapeutic environment for their patients with CNP. SUBJECTIVE AND OBJECTIVE ASPECTS OF CNP The subjective nature of pain is an issue for many physicians including neurologists. This concern has a historical precedent that arose from the separation of mind and body through Cartesian dualism.8,20 The mind (spiritual) was historically the realm of religion, whereas the body (objective) became the accepted territory of medicine.8,20 Ideally, medicine recognizes the importance of the mindbody connection, and current neurochemical research and neurophysiological research confirm this connection for CNP.5-7 Like the previously “subjective” migraine headache, research in neurochemistry, neuropharmacology, neuroimaging, and neurophysiology has moved CNP from the purely psychological (subjective) to the neuropathological (objective). The localization of subcortical pain centers on positron emission tomographic scans,5 identification of specific receptors like N-methyl-D-asparate receptor,6,7 and delineation of central and peripheral pain pathways with clinical neurophysiological testing help to clarify the problems and potential treatments of CNP.4-7 Preventive neurochemical regimens for CNP include agents that are familiar to neurologists, including anticonvulsants, anti-inflammatory agents, and antidepressants.21 The treatment plan for the patient with CNP may include use of medications like opioids, which are unfamiliar to many neurologists.3,17,22 Understanding the basic neurophysiology and neurochemistry will help to identify new neuropharmaceutical agents for patients with CNP. NEUROLOGIST EDUCATION AND ATTITUDES ABOUT CNP Regulatory requirements and bioethics dictate the need for a change in the emphasis on pain management in undergraduate, graduate, and postgraduate neurology education.2,3,8,12,14,20,22-24 The Joint Commission on Accreditation of Healthcare Organizations established pain control issues as the “fifth vital sign” with the assistance of the consensus statement of the American Academy of Pain Medicine and the American Pain Society.2,22 Health care providers will need to address pain control issues in patients in hospitals and affiliated outpatient facilities and clinics daily because documentation of treatment and response to pain control is now mandated. Unrelieved pain and suffering are unethical, and neurologists need to know the appropriate treat-
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81
Table 1. Barriers to Treatment of Chronic Noncancer Pain* Historical concern about the subjective and objective components of CNP and its pathophysiology4-7 Lack of emphasis in undergraduate, graduate, and postgraduate medical education on CNP8-14 Confusion with comorbid psychiatric disease15 Fear of audits and reprisals by regulatory agencies like the DEA and state medical boards16,17 Perceived and sometimes hostile environment, including health care professionals (physicians, nurses, and pharmacists), the media, and the public, regarding the issues of pain treatment18 Fear of contributing to patient drug addiction17 *CNP = chronic noncancer pain; DEA = Drug Enforcement Administration.
ment through training and education. Education should not be limited to medications, but other treatment modalities, including physical therapy, spiritual counseling, assessing family and social issues, diagnostic and therapeutic activities such as specialized imaging and block techniques, and evaluation for possible psychiatric comorbidities, should be addressed. Appropriate consultation with other health care specialists should be emphasized and defined. All members of the health care team will need to be aware of pain-modifying factors particularly related to medications, including dosing, routes of administration, equianalgesic dosing, half-lives, and adverse effects. The role of the neurologist in the multidisciplinary treatment of pain needs to be experienced by neurology residents. Educational goals should also include attention to attitudes and negative bias often surrounding patients with chronic pain. Undergraduate medical education can affect medical student attitudes toward patients with CNP. A specific 6hour course at the University of Kentucky had a lasting and positive effect on medical students regarding the perception of pain that patients experience.13 A study of pain medicine education among American neurologists published in 1999 suggests a need to improve the current neurology residency training in pain medicine and provide more pain symposia at the AAN meeting for practicing neurologists.14 In this study, 29% of residency programs had neurology pain specialists. Only 5% of the programs required residents to undergo rotation in a pain clinic; 62% of neurology residents had no clinical training in a pain clinic environment.14 Neurology pain fellowships were offered in only 9% of the 155 residency programs that responded to the survey (of 164). This situation will change because of the AAN emphasis on enhanced pain education during residency.3 A forum to exchange information on the treatment of patients with CNP is provided by the AAN Pain Medicine Section for its members.25 The American Board of Psychiatry and Neurology recognizes this subspe-
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
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cialty and has specific examination and training requirements for certification in the subspecialty of pain management for neurologists.26 In 2000, the first year of certification, 39 certificates were issued.27 Educational approaches for neurologists in the diagnosis and treatment of CNP include increased acceptance by major neurology journals of quality articles on the topic of CNP, expansion of training under guidelines from the Accreditation Council for Graduate Medical Education for neurology residents, more neurology grand rounds on CNP issues, more opportunities for practicing neurologists through continuing medical education programs, and broadening the scope and number of courses on CNP topics at professional meetings such as the AAN annual meeting. Well-designed, controlled basic and clinical research on the pathophysiology and the treatment of CNP should be encouraged and supported.3 PSYCHIATRIC COMORBIDITY AND CNP At the graduate and postgraduate level, the few “difficult drug-seeking” patients can taint the neurologist’s perception of all patients with CNP. A 1-year study of patients with pain at all the emergency departments of Calgary, Canada, showed that only a small percentage (4%-5%) of all patients seen for chronic pain was responsible for about one third of the total emergency department visits. This minority of patients generated negative perceptions by physicians and nurses toward the 90% to 95% of patients with similar pain problems.18 Recommendations from this study included improvement in identifying patients with a diagnosis of drug dependency with referral to the appropriate specialists for detoxification and psychiatric treatment; there was an associated improvement in the medical staff perception of patients with pain in general with this approach and recognition of a different or comorbid psychiatric problem.18 Like other chronic syndromes and diseases in neurology, comorbid psychiatric illness can occur in patients with CNP.15 The comorbid psychiatric disease needs to be diagnosed and treated. For neurologists, an example would be the patient with Parkinson disease with the comorbidity of depression and anxiety; the presence of these psychiatric comorbidities does not discount the underlying Parkinson disease and its need for treatment. A review of psychiatric diagnoses associated with CNP would be helpful in educating practicing neurologists and staff. After identification of a comorbid psychiatric disease, referral of the patient to a psychiatrist should be a part of the treatment plan. Good communication between the neurologist and psychiatrist would help to address the pain needs of the patient with comorbid psychiatric disease. Documentation of the psychiatric comorbid disease, in-
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cluding addiction and depression, is essential. This documentation will protect the patient and the neurologist. FEAR OF PRESCRIBING CONTROLLED SUBSTANCES FOR CNP Despite recent changes in institutional attitudes and policies, fears of audits and reprisals by state and federal agencies for the use of controlled substances persist. Education in the use of opioids, including dosing, adverse effects, patient monitoring, avoidance of medication diversion, appropriate use in treatment plan, and current federal and state regulations, would help neurologists at all levels of training and practice. Regulatory agencies have recognized the undertreatment of CNP and have supported active and comprehensive treatment for this condition, including controlled substances. The Drug Enforcement Administration (DEA) in its Physician’s Manual: An Informational Outline of the Controlled Substances Act of 1970 (revised March 1990) specifically addresses the issue of pain medications and physician fear and anxiety of reprisals for narcotic pain prescriptions: “These drugs have a legitimate clinical use and the physician should not hesitate to prescribe, dispense or administer them when they are indicated for legitimate medical purpose. It is the position of the Drug Enforcement Administration that controlled substances should be prescribed, dispensed or administered when there is a legitimate medical need” (in the section entitled Narcotics for Patients With Terminal or Chronic Disorders).28 The American Academy of Neurology Ethics, Law and Humanities Committee describes the ethical obligations and the necessary assessment and treatment plan with documentation that would be consistent with the DEA recommendations.3 Controlled substance diversion is a major concern of the DEA, and steps by neurologists to avoid this problem are clear, simple, and straightforward. These steps are delineated by the DEA28 as well as the model guidelines established by the House of Delegates of the Federation of State Medical Boards of the United States, Inc.23 Patients with CNP are included within these guidelines; the model guidelines will help effective treatments, avoid medication diversion, and protect against patient addiction. CNP AND OPIOID ADDICTION Although prescription drug abuse and addiction are serious medical and societal concerns, myths about pain medications and their administration have contributed to the subtherapeutic dosing of opioids and other pain medications for patients with CNP throughout the past 3 decades.11,17 If the current analgesic medication or its dose does not provide pain relief for the patient, more potent medications should be prescribed or the dose increased
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until pain relief or pain medication adverse effects occur.19 The myths add to a hostile environment for using opioids in conjunction with other therapies for patients with CNP.17 Continuing education programs for physicians, nurses, pharmacists, patients, and their families are necessary to remove the stigma associated with CNP. Using the database of the Drug Abuse Warning Network (source for drug abuse data) and the Automation of Reports and Consolidated Orders System (source for medical use data), a retrospective study from 1990 to 1996 concluded that the increasing medical use of opioid analgesic medications to treat pain does not appear to contribute to an increase in opioid analgesic abuse.29 The Pain and Policies Studies Group at the University of Wisconsin Medical School, Madison, is an excellent source for current information on pain treatment and the latest federal and state policies on pain management.29 Opioid tolerance is not abuse. It is an adverse effect of long-term opioid therapy, and both a verbal and a written description of this and other adverse effects of opioid therapy need to be given to the patient if opioid therapy is considered a component of the comprehensive CNP treatment plan. A policy statement by the Federation of State Medical Boards of the United States, Inc, and a position statement by the North Carolina Medical Board on management of chronic nonmalignant pain delineate the differences between medication tolerance and substance addiction.23,24 Substance addiction is a psychiatric condition, whereas medication tolerance is an expected adverse effect of opioid therapy. As with other medications for chronic neurologic syndromes, the doses of opioids require scheduled monitoring and adjustment because of the potential long-term adverse effects. For example, effective longterm treatment of Parkinson disease usually requires an increase in the dose of levodopa/carbidopa, and its longterm use has potential adverse effects. In addition, a dependence on this drug will occur, and the immediate withdrawal of levodopa/carbidopa may lead to severe medical complications.30 As with therapy for Parkinson disease, counseling, scheduled monitoring, and medication adjustments are essential in CNP treatment. A consensus statement from the American Academy of Pain Medicine and the American Pain Society provides excellent definitions for tolerance, physiological dependence, medication withdrawal, addiction, and pseudoaddiction (Table 2).22,23,29 Controlled substance diversion can be prevented. The model guidelines for the use of controlled substances for treating pain are outlined by the policy of the House of Delegates of the Federation of State Medical Boards as cited previously and the American Academy of Neurology Ethics, Law and Humanities Committee.3,23
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Table 2. Current Definitions of Pain Treatment With Opioids22,23,29 Addiction—a compulsive disorder in which an individual becomes preoccupied with obtaining and using a substance, the continued use of which results in a decreased quality of life Pseudoaddiction—pattern of drug-seeking behavior of patients with pain who are receiving inadequate pain management that can be mistaken for addiction Tolerance—physical adaptation of the body to an opioid with decreasing pain relief with the same dose over time Physical dependence—physical adaptation of the body to the presence of an opioid; it is characterized by signs of withdrawal when use of an opioid is stopped abruptly or an antagonist is administered Withdrawal—acute physiological response to the abrupt discontinuation of long-term opioid therapy or to the administration of an opioid antagonist
A treatment contract with a patient is a powerful instrument for preventing drug diversion and for identifying patients who need treatment for substance abuse. The signed and witnessed contract should contain the key elements noted in Table 3. Copies of this contract are retained by both the patient and the physician. Informing pharmacists and emergency department personnel about use of the treatment contract for patients on controlled substances may provide valuable input concerning deviations and compliance. In this instance, neurologists can assist in creating a positive and responsive environment for pain management by sharing their experience and knowledge in an educational setting with local pharmacists and emergency department staff. BIOETHICS AND CNP As described by the American Academy of Neurology Ethics, Law and Humanities Committee, neurologists who treat CNP “have an ethical duty to address pain and suffering” with special responsibilities and ethical obligations to their patients and society.3 Practicing general neurologists, neurology residents, and neurology pain specialists should have the skills and training to reduce the pain and suffering of patients with Table 3. Key Elements of Contract to Avoid Drug Diversion Informed consent One physician prescribing controlled substances One pharmacy named in contract Refills during office hours only Notification of the physician’s office of any controlled substance prescriptions from another physician during emergency treatment Description of the prescription flowchart in the patient’s record Immediate referral to a drug treatment program or dismissal from the practice for violations of the contract
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CNP while complying with and understanding well-established bioethical principles. The 4 basic bioethical issues for neurologists are patient autonomy, nonmaleficence, beneficence, and justice.31 Patient autonomy is in part provided through a comprehensive informed consent contract that clearly describes the therapeutic risks, benefits, and obligations inherent in the physician-patient relationship in the treatment of CNP. Nonmaleficence (avoidance of causing harm) is protected by (1) a well-documented medical and pain history and neurologic examination; (2) appropriate neurodiagnostic testing; (3) solid working diagnoses; (4) identification and treatment of comorbidities; (5) clear discussion of medications and their benefits and adverse effects as well as other aspects of the total treatment plan; (6) monitoring of controlled substances to avoid medication diversion and patient addiction; and (7) routine follow-up appointments to assess any clinical changes or necessary adjustments in the medication or treatment plan. Beneficence (benefits and balancing the benefits against risks and costs) is evident in the relief of CNP, which can increase function and reduce suffering, anxiety, depression, and emotional and social isolation of the patient. These benefits are balanced against the risks and costs, including medication adverse effects, required follow-up examinations, compliance with the informed consent-treatment contract, and medication tolerance if opioids are used. Finally, justice (distributing benefits, risks, and costs fairly) is approached through the neurologist’s provision of equal access for consultation and treatment of CNP and the patient’s choice of accepting or declining the treatment plan and contract. The neurologist can be an effective part of the multidisciplinary pain management team. Through education, research, and communication, neurologists can contribute to the ethical relief of pain and suffering in patients with CNP.
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6. 7. 8. 9.
10.
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
22. 23.
We thank Dr Larry Churchill, Stahlman Professor of Medical Ethics at the Vanderbilt University Medical Center, Nashville, Tenn, for his valuable review of the submitted manuscript.
24.
REFERENCES
26.
1. 2. 3. 4.
5.
American Academy of Neurology Practice Characteristics Subcommittee. Neurologists 2000. St Paul, Minn: American Academy of Neurology; 2001:18. Joint Commission on Accreditation of Healthcare Organizations. 2001 Hospital Accreditation Standards. Oakbrook Terrace, Ill: JCAHO Publications, Inc; 2001. American Academy of Neurology Ethics, Law and Humanities Committee. Ethical considerations for neurologists in the management of chronic pain. Neurology. 2001;57:2166-2167. Doubell TP, Mannion RJ, Woolf CJ. The dorsal horn: state-dependent sensory processing, plasticity and the generation of pain. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed. Edinburgh, United Kingdom: Churchill Livingstone; 1999:165-181. Petrovic P, Ingvar M, Stone-Elander S, Petersson KM, Hansson P. A PET activation study of dynamic mechanical allodynia in patients with mononeuropathy. Pain. 1999;83:459-470.
25.
27. 28. 29. 30. 31.
Urban MO, Gebhart GF. Central mechanisms in pain. Med Clin North Am. 1999;83:585-596. Carver A, Foley K. Facts and an open mind should guide clinical practice. Curr Neurol Neurosci Rep. 2001;1:97-98. Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306:639-645. Weinstein SM, Laux LF, Thornby JI, et al. Physicians’ attitudes toward pain and the use of opioid analgesics: results of a survey from the Texas Cancer Pain Initiative. South Med J. 2000;93:479487. Weinstein SM, Laux LF, Thornby JI, et al. Medical students’ attitudes toward pain and the use of opioid analgesics: implications for changing medical school curriculum. South Med J. 2000;93: 472-478. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med. 1973;78:173-181. Pilowsky I. An outline curriculum on pain for medical schools [editorial]. Pain. 1988;33:1-2. Wilson JF, Brockopp GW, Kryst S, Steger H, Witt WO. Medical students’ attitudes toward pain before and after a brief course on pain. Pain. 1992;50:251-256. Galer BS, Keran C, Frisinger M. Pain medicine education among American neurologists: a need for improvement. Neurology. 1999; 52:1710-1712. Fishbain DA. Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient. Med Clin North Am. 1999;83:737-760. Hill CS Jr. Government regulatory influences on opioid prescribing and their impact on the treatment of pain of nonmalignant origin. J Pain Symptom Manage. 1996;11:287-298. Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11: 203-217. MacLeod DB, Swanson R. A new approach to chronic pain in the ED. Am J Emerg Med. 1996;14:323-326. Carver A, Payne R, Foley K. Herpes zoster [letter]. N Engl J Med. 2000;343:221. Rich BA. A legacy of silence: bioethics and the culture of pain. J Med Humanit. Winter 1997;18:233-259. Mohamed SA, Mohamed K, Borsook D. Choosing a pharmacotherapeutic approach: nonopioid and adjuvant analgesics. In: Borsook D, LeBel AA, McPeek B, eds. The Massachusetts General Hospital Handbook of Pain Management. Boston, Mass: Little, Brown and Co; 1996:76-104. The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13:6-8. Federation of State Medical Boards of the United States, Inc. Model guidelines for the use of controlled substances for the treatment of pain, May 1998. Available at: www.fsmb.org/policy. Accessibility verified December 3, 2002. North Carolina Medical Board. Management of chronic non-malignant pain. Available at: www.ncmedboard.org/pain.htm. Accessibility verified December 9, 2002. American Academy of Neurology. 2001-2002 Membership Directory. Neurology. 2001;57(suppl 1):34A. American Board of Psychiatry and Neurology. 2002 Information for Applicants for Certification in the Subspecialty of Pain Medicine. Deerfield, Ill: American Board of Psychiatry and Neurology; 2001. American Board of Psychiatry and Neurology. Certification statistics as of January 1, 2001. Available at: www.abpn.com/certification/statistics.html. Accessibility verified December 3, 2002. Drug Enforcement Administration. Physician’s Manual: An Informational Outline of the Controlled Substances Act of 1970. Washington, DC: US Dept of Justice; 1990. Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283:17101714. Lang AE, Lozano AM. Parkinson’s disease: second of two parts. N Engl J Med. 1998;399:1130-1143. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. Oxford, England: Oxford University Press; 2001.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.