VANCOUVER, BC--How much insulin do you give a patient with diabetes--as
much as is required to control blood sugar. "The same is
true for opioids and patients with cancer pain, "Richard
B. Patt, MD, said at a symposium held in conjunction with the
8th World Congress on Pain. "The only difference is we don't
have a blood test to measure a patient's opioid requirement the
way we do with insulin."
Dr. Patt, director of Anesthesia Pain Services at The University
of Texas M.D. Anderson Cancer Center, argues that there is a "dual
standard" in the management of pain versus other medical
problems. "We wouldn't talk about withholding a diabetic
patient's insulin to build his character," he said, although
physicians routinely mete out opioids in inadequate doses.
Nonetheless, huge strides have been made in recent years in the
treatment of cancer pain, and Dr. Patt believes that medicine
is at the beginning of a movement to medicalize pain treatment,
"not in the sense of ignoring the psychological, behavioral,
and environmental aspects of the experience of pain but simply
to encourage physicians to address pain as a legitimate medical
He pointed out that management of a patient who presents with
pain should involve all the same steps that would be used if the
patient had a cardiovascular or gastrointestinal problem.
"Consider the differential diagnosis," he said, "do
a diagnostic workup to determine the cause of the problem, formulate
and discuss with patients and their families a treatment plan
that includes contingencies should the primary treatment be unsuccessful,
and develop a plan for serial assessment of the problem."
Instead, he said, patients with pain are often simply handed a
prescription for an opioid with very little explanation. "This
is at the heart of the myth of opioid allergy," he said.
Without proper education about what to expect from opioid treatment,
the patient may assume that he is "allergic" to opioids
when normal, manageable side effects such as nausea occur. "The
patient calls the nurse and says, I'm allergic to codeine or morphine,
and ends up with a sticker on his chart that may be hard to remove."
Pain patients referred to the Pain and Symptom Management Program
at M.D. Anderson often come in with "a hodgepodge of analgesic
drugs, dosages, and schedules that don't make sense," Dr.
Patt said. Their regimen may include contradictory formulas, for
example, narcotic agonists and antagonists.