29 November 1996

Pain Management and Chemical Dependency - New York - Nov 1996

Pain Management and Chemical Dependency - Evolving Perpectives: New York Conference

November 21-23, 1996

Speakers from several disciplines agreed that chronic pain is often under-treated. Many patients suffer needlessly due to 'opiophobia' on the part of the medical profession. Evidence was presented that the risk of dependence in those prescribed narcotics for pain was virtually zero. One large study of over a thousand cases could not find one patient who developed addiction behaviour. Another criticised concept was the use of 'PRN' ('when necessary') orders for both cancer and non-cancer pain. One delegate re-defined 'PRN' as 'please restrict narcotics' (!) which is a common result of this type of order. The success of 'on-demand' morphine in post-operative pain may well have lessons in the treatment of chronic pain.

Two large groups which delegates considered to be under-treated were those with HIV/AIDS or those with previous histories of drug abuse. Chronic methadone maintenance has no analgesic effect, such patients often needing substantially higher analgesic doses to obtain adequate pain relief. The WHO 'ladder' system of pain management was questioned by some speakers, especially when questionable invasive (and irreversible) procedures were sometimes used prior to a trial of long-acting morphine such as Kapanol or MS Contin. Some doctors still seem to believe that almost anything would be better than a life taking narcotics. Many patients would argue the reverse, when their lives have been changed for the better with the judicious use of opioids.

Innovative treatments also discussed included the 3 day transdermal fentanyl patch, 'long acting' methadone (LAAM) as well as the controversial ultra-rapid detoxification under anaesthetic. Further research is awaited in these interesting areas.

The conference was held at the Crowne Plaza Hotel on Broadway and 48th Street, New York, NY, 10036. November 21-23, 1996. Convenor: Dr Hermon Joseph.

1 March 1996

Problem drug users

[Letter in Br J Gen Pract. 1996 Mar;46(404):200.]
I read with interest the editorial on problem drug users by Wilson et al (September Journal, p. 454).

I agree with the general theme of the authors, but would take exception to two related assertions.

While adding psycho-social supports certainly improves treatment outcomes, the provision of methadone alone with virtually no additional support has also been shown to yield significant benefits to patients. Even doctors with little experience in the area, given some guidelines based on simple pharmacology and therapeutics, would be doing much good and little harm in prescribing to addicts who are otherwise denied appropriate treatment.

Though respecting Scottish GPs' claims for increased funding for the treatment of addictions, it is my belief that most drug and alcohol treatment lies directly within the scope of general medical services.

Over the past 10 years in New South Wales, the number of GP methadone prescribers has risen from a handful to over 200. Most treat their patients using their nursing, pathology and pharmacy staff, as they would for patients with other conditions. Most GPs have found it a very rewarding experience and there have been no 'horror stories' reported. One of the accompaniments has been a drug-user HIV incidence below 1%, compared with up to 50% in some foreign studies.

I was shocked to read that some British GPs are so busy that others must write their prescriptions. In addition, may I suggest that there is evidence for the benefit of other prescribed drugs in chemical dependence. Naltrexone, buprenorphine, disulfiram and even heroin itself have all shown some promise.

Andrew Byrne