Multidisciplinary Approach Urged For Pain Relief

NEW YORK--An interdisciplinary approach is key to helping Americanmedicine face the "analgesic dilemma,"

David Joranson, MSW, said at a media briefing on pain sponsoredby the American Medical Association and Ortho-McNeil Pharmaceutical.

Physicians and patients must grapple with the choice between effectivepain relief and exposure to the undesirable side effects associatedwith commonly available pain relief options, including excessivesedation and fear of addiction.

The answer lies in a combination of modalities: physical and behavioraltherapy, psychosocial interventions, and medication. "Underutilizationof medication and the failure to use medication in combinationwith other effective interventions is a significant problem inthe United States, and it is especially serious in treatment ofcancer pain," said Mr. Joranson, associate director for policystudies, Pain Research Group, University of Wisconsin, Madison.

Mr. Joranson, whose research focus has been policies regulatingthe availability of opioid analgesics, believes that addictionissues have been overemphasized. "When opioids are used carefullyin carefully selected and monitored patients, addiction risk isminimal, especially in cancer patients." He decried the factthat uninsured patients may get less intense pain treatment thaninsured patients.

Ca Patients Suffer from Pain Myths

Underutilization of opioid analgesics is particularly unjustifiedin cancer patients, who suffer from many myths about pain andcancer that make physicians reluctant to prescribe effective dosesof medication. Among these, he said, are that pain medicationsare often addictive when given postoperatively; that pain is aninevitable consequence of cancer; and that if used too early ortoo often, pain medication won't work later.

Joining Mr. Joranson in advocating a multidisciplinary approachwas Warren A. Katz, MD, chairman of the Department of Medicine,Presbyterian Medical Center of Philadelphia. Although there aremany effective medications currently available, he said, whenused alone, medication is doomed to failure.

The components of an effective multidisciplinary approach, Dr.Katz said, are patient education; physical therapy; such minimallyinvasive modalities as acupuncture, hypnosis, behavior modification,imagery, and yoga; and psychosocial considerations, especiallya good doctor-patient relationship.

"Patient education is important because lack of informationbreeds fear, anxiety, and depression, which leads to noncompliance,"he said. The value of physical therapy rests on the notion thatdeconditioning can contribute to greater pain whereas fitnessmay raise the pain threshold by raising endorphin levels.

Calling the doctor-patient relationship "a potential analgesicmodality," Dr. Katz stressed the importance of the therapeutictouch as well as effective communication, including active listeningand reassurance on the part of the caregiver. He mentioned anongoing study at Presbyterian Medical Center in which some cancerpatients are touched during visits by the pastoral care staffand others are not.

Finally, he said, behavior modification that teaches stress managementand coping skills empowers patients. "It is essential thatthe patient let neither the physician nor the disease controlthe situation. The patient must be the one in control."

Both Mr. Joranson and Dr. Katz acknowledged that a multidisciplinaryapproach may involve several referrals, with resultant increasein cost and, for some treatments, lack of coverage by insurers.

However, they asserted that many elements of pain relief can beintroduced by an individual's primary care physician and may costvery little. Ultimately, they believe, the costs to society ofunsuccessfully treated pain are greater.