Thank you for Amanda Vogt’s thoughtful piece pointing out one of the serious gaps in the practice of medicine–the treatment of pain (June 14 Perspective, “Care beyond cure”).
Pain is both the most common symptom and the least understood, just now being termed by some as “the fifth vital sign.” In a time when specialists are able to make diagnoses with greater and greater precision, patients for whom no diagnostic label is available often suffer in pain without relief because doctors hesitate to provide palliative care while a long process of further testing continues. Pain-management specialists–doctors who are trained, tested and board-certified–are available to help these and other patients, such as the people with incurable cancer mentioned in Vogt’s article.
There are four obstacles to the provision of optimal pain management for cancer patients near the end of life. First is a reticence of other doctors to refer to pain-management specialists. Doctors are, in general, a self-reliant group who regard the act of referring a patient to another doctor in some cases as a sign of weakness. Traditionally, medical training has never regarded the symptom of pain as being complex enough to warrant the involvement of another doctor.
The second obstacle is the cancer patient and his or her family’s grim resignation that end-of-life pain is unavoidable, coupled with an unfounded fear of addiction.
Third, the pain-management specialty is a fledgling one, somewhat confusing in that three different professional societies offer an examination process for board certification in this field. Its adolescence also has been complicated by some doctors who call themselves pain specialists without the benefit of this training or certification process. The use of narcotics by this specialty, a class of drugs stigmatized by patients and professionals alike, has slowed the acceptance of pain management as a mainstream medical practice.
Finally, the antiquated regulatory system of several states has made it difficult for doctors to prescribe and pharmacists to dispense the drugs appropriate to the care of patients with cancer or other incurable conditions that are painful in nature.
None of these obstacles will be overcome easily. Articles like Ms. Vogt’s are particularly helpful in that they educate patients to have a higher level of expectation for the successful treatment of their pain and they educate doctors to re-evaluate the efficacy of their treatments.
