Painkiller politics

SORE POINTS -- Chronic non-malignant pain: pain that lasts six months or more and does not respond to conventional.


SORE POINTS

— Chronic non-malignant pain: pain that lasts six months or more and does not respond to conventional treatment

— Common causes: post-accident trauma, systemic lupus, headaches, degenerative arthritis, fibromyalgia

— Consequences of unrelieved pain: increased stress, metabolic rate, blood clotting and water retention delayed healing hormonal imbalances impaired immune system and gastrointestinal function lack of sleep depression, suicide

— Groups at greatest risk for under-treatment: women, racial/ethnic minorities, children, the elderly, workers’ compensation patients and the disabled Rating: NNNNN

Chronic pain is a personal and lonely project, but imagine how much more desolating it becomes when the person most able to alleviate the torment, the physician, decides not to.

Then picture how doubly depressing it is when the doctor does go all out for the patient, and prescribes potent soothers — only to discover he or she has become the target of the College of Physicians and Surgeons of Ontario (CPSO).

That’s the strange fate of Kingston psychiatrist and widely esteemed pain specialist Frank Adams.

In April, Adams was summoned to a disciplinary hearing of the College following a raid on his office and the seizure of medical records. His offence, apparently, was the over-prescription of opiates — painkillers derived from the opium poppy. On July 21, the discipline committee will decide whether Adams may continue to practise.

While College investigators may believe the case against the psychiatrist is clear-cut, it’s evident from the flood of emotions the hearings have unleashed that a shocking mess of conflicting values surrounds the treatment of chronic pain.

Supporters of the embattled doctor believe there is an epidemic of under-treated pain in Ontario and that medical procedures for dealing with pain are hopelessly outmoded and dangerously unregulated.

Thousands of people, they say, are suffering needlessly, victims not only of their own aching bodies but also of a kind of vacant moralism that’s more concerned with the fear of patient addiction than with freeing them from torment.

At its root, the conflict boils down to a power struggle, as doctor and patient wrestle with the question, who decides how much pain is too much?

Adams, an internationally published pain management expert and a member of the National Brain Council of the Society of Nuclear Medicine, graduated from McMaster University and was recruited by the University of Texas Cancer Center in the 70s to set up a division of neuropsychiatry specializing in pain medicine.


Chief witness

The Kingston doc comes highly recommended by colleagues. The chief witness for Adams at his sentencing hearing was Harold Merskey, professor emeritus at the University of Western Ontario and one of the world’s leading pain specialists.

Defending Adams is high-profile lawyer Michael Code, a former assistant deputy attorney general in two administrations.

Merskey, past president of the Canadian Pain Society and current editor of the society’s journal, unhesitatingly tells me of his “enormous respect” for Adams’s skill, competence and achievements.

“Frank Adams is perhaps the most experienced person in the whole of Canada in the use of opioids for pain in a medical setting,” says Merskey. Adams was even consulted by the CPSO itself some years back to critique guidelines on pain management issued in Alberta.

Yet the College’s respect for Adams’s expert opinion somehow took a turn for the worse on May 25, 1998, when two inspectors walked into his Kingston office, demanding some 25 patient files.

The records were sent to McMaster psychiatrist Alan McFarlane, who wrote a scathing report on Adams’s practice. Adams filed a rebuttal citing numerous factual errors in McFarlane’s review.

The College then sent the files to a second reviewer, Dwight Moulin at the University of Western Ontario, who isolated what he considers six areas of deficiency. Yet in the hearings, Moulin has said that he holds Adams in high regard and does not believe he should lose his licence.

Nonetheless, on April 14 the discipline committee found Adams guilty of incompetence and professional misconduct including neglecting to perform physical examinations or take proper case histories on eight patients. His care was deemed “below the accepted standard of practise.”

The problem, however, is that no one agrees on what constitutes the “accepted standard of practise.”

For decades it’s been deemed acceptable to treat cancer-related pain with opiates. But before the early 80s, there was a widespread belief that long-term opioid use was not appropriate for chronic non-cancerous pain because of the danger of addiction and the possibility of the drugs interfering with a patient’s recovery.

Notes Doug Saunders, of U. of T.’s department of public health sciences, who works to develop strategies in chronic pain management, “We can’t underestimate the value of the judicious use of medications in helping people break pain cycles. At the same time, when people end up being passive and are unable to develop other strategies, you get the potential for addiction.”

But recent pharmacological research shows that properly selected and monitored patients with chronic non-cancer pain can benefit from the use of long-term opioid therapy, with few adverse effects and a low risk of addiction.

Adams tells me he recognized early on in his career the deleterious effects of chronic pain on other processes within the body — regardless of its underlying cause.


No difference

“What’s the difference between chronic pain from cancer or chronic pain from some other mishap — failed back surgery, osteoporosis, etc? Why is it reserved for people who are going to die? What about people who are not lucky enough to die and escape this and are forced to live with it for another 40, 50 years?”

The American Pain Society and the American Academy of Pain Management seem to agree. In a joint statement, they argue that the use of opioids may be both helpful and safe in the non-malignant pain setting.

These guidelines have assumed the force of law in the states of Texas, California and Massachusetts, which have adopted what are known as Intractable Pain Treatment Acts. The legislation recognizes a doctor’s right to use opioids to treat intractable pain, whether or not the source of pain is cancer.

Similarly, the U.S. National Institutes of Health has also placed chronic pain management in the category of a medical emergency requiring immediate medical intervention. In fact, doctors there have been prosecuted for not providing adequate pain management.

Here in Ontario, however, “the College is still stuck in a mode that is exceptionally behind its peers,” Merskey says.

Even an elected member of the CPSO council (the College’s governing body) — who declined to be named for this article — confesses to me, “This case bothers me a great deal. The guidelines are hopelessly out of date now. They do not reflect year 2000 knowledge.”

The CPSO is holding Adams to 1993 guidelines published by the College of Physicians and Surgeons of Alberta. These strongly discourage, although they do not forbid, the use of injectable opioids to treat chronic non-cancer-related pain.

But these Alberta regulations have never been formally adopted by the Ontario College. Subsequent 1998 guidelines from the Canadian Pain Society (CPS) — which Harold Merskey helped prepare — stipulate that “while opioid analgesics are not currently recommended as first-line therapy,” a trial of “long-term opioid therapy is a legitimate medical practice.”

As far as the College is concerned, however, the CPS guidelines are irrelevant, since they were not in existence when Adams was treating the patients in question.

The committee, says the College’s Hefley, “has to make a decision based on when the treatment was provided. Those are the standards in place they have to work from.”

Perhaps, but the College itself may not have strictly adhered to the law either in its investigation of Adams, who was never informed that he was entitled to have a lawyer present when CPSO officials came knocking. Nor were any of his patients asked for their consent before the removal of their charts.


Below standard

These moves, says criminal lawyer and Charter expert Michael Code, violate various provisions of Ontario’s Regulated Health Professions Act.

“The law in this province,” notes Code, “requires the CPSO to meet a fairly high standard of reasonable and probable cause before subjecting a doctor to seizure of their files” — a standard the College doesn’t even begin to approach in this case, he says.

This is not the first time docs who stray from accepted College wisdom on pain management have provoked the authorities into action, Code points out. Peter Rothbart and colleague George Gale at North York’s Rothbart Pain Management Clinic have also been investigated by the CPSO for overuse of opioids, and their cases are still ongoing.

Reached at his North York clinic, Rothbart (who also heads up the Ontario Medical Association’s section on chronic pain) says the committee “is doing what a lot of bureaucratic bodies do — they have made up their minds they are going to find this guy guilty regardless.”

But the CPSO’s Hefley insists, “It’s not an ideological disagreement when a physician doesn’t perform physical examinations or take proper histories of patients. You have to look at this in its totality. There were a number of concerns about the way his practice was conducted besides the pain medication issue.”

Adams counters that he is a pain specialist and doesn’t need to do all the traditional physical tests the referring physicians have already performed.

“I’m working with a drug that primarily affects brain function, so every time a patient comes, a mental status exam is reported,” he says.

In one case, the CPSO takes Adams to task for prescribing large amounts of acetaminophen to a car-accident victim with chronic headaches, but Rothbart notes that this was done because the patient in question had become suicidal.

“Weighing the pros and cons,” he explains, “Adams felt it was better to let the patient continue with those large amounts — even when there was risk to his liver and kidneys in the long run — than to kill himself in the short run.”

To a number of high-placed observers contacted by NOW, the CPSO’s actions against doctors like Adams are only fuelling the existing crisis in palliative care.

Margaret Somerville, a leading ethicist at the McGill Centre for Medicine, Ethics and Law in Montreal and chairperson of the World Health Organization’s committee on pain management, which sets international standards, says, “Just because someone is prescribing opioids for chronic pain of non-malignant origin doesn’t mean they are justified in doing so, but to have a blanket rule that that is always unjustified is really unacceptable.

“When people are in long-term chronic pain,” she stresses, ” I think it’s medical negligence not to treat them with the treatment of choice. Pain is a medical condition that has to be treated.”


Opioid phobia

Somerville notes that traditionally doctors have been phobic about using opioids, their attitudes strongly influenced by efforts going back to the 1930s to solve the problem of drug addiction.

“Our attitude to narcotics for pain is very dependent on our attitude to pain,” Somerville also suggests, “and we grossly underestimate pain. Because of that, we think these treatments are not justified.”

Senator Sharon Carstairs, who last month issued a five-year update on her 1995 special Senate committee report on euthanasia and assisted suicide, finds the state of pain management in Canada disgraceful.

“There’s very little training in medical schools, or indeed in nursing schools, in this country on pain management,” Carstairs notes. “Doctors are fearful of using adequate amounts of pain medication because they feel they may be exposed to lawsuits.”

Indeed, Adams fears that the College’s actions may have profound repercussions for doctors facing similar challenges in their practices.

“This is a public health issue,” he says, “and the College has created an enormous problem that could set back the treatment of pain in this province for many, many years. My conviction is going to result, I would imagine, in a hell of a lot of doctors never picking up another prescription pad.

“But the College doesn’t want to talk about how we can work with our patients safely, with the best therapeutic index and outcome possible. They start with the gun pulled out and already aimed.”

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