How far should doctors go in treating chronic pain with potentially addictive drugs?
Ten years ago, neuropsychiatrist Frank Adams was working at a suburban Dallas cancer centre when agents of the U.S. Drug Enforcement Agency raided his office, seized files and subsequendy charged him with improperly prescribing drugs. A specialist in using powerful, potentially addictive drugs to ease pain in cancer cases, Adams ran into trouble— including two brief incarcerations in a Dallas jail—after he started using the same drugs to treat pain in non-cancer patients. In the end, the state medical board exonerated him and he worked there another two years. Now, Adams is again facing disciplinary action—this time in Ontario—and the story may not have a happy ending. Having judged him incompetent in April, a panel of the Torontobased College of Physicians and Surgeons of Ontario is expected this fall to impose a sentence that could limit Adams’s medical activities—or even strip him of his licence. Adams, who has practised in Kingston, Ont., since 1995, neatly sums up his dilemma in his own defiant credo. “The textbooks tell you to use the least amount of medication needed,” he says. “In treating pain, I say, use the maximum necessary that can be tolerated by the patient.”
The case, which centres on charges that Adams endangered patients with high doses of painkillers and allowed some to inject drugs themselves, is at the heart of a debate over how far physicians should go in prescribing the opium-derived drugs and synthetic alternatives known as opioids for chronic pain.
Practitioners who favour the drugs fear the college’s action could cast a chill over the treatment of chronic pain. “What is happening to Frank Adams sends a terrible message,” said a palliative-care specialist in Western Canada who requested anonymity for fear of antagonizing medical authorities. “I know some doctors who are thinking of giving up treatment of chronic pain because they fear disciplinary action.”
Others questioned the college’s motives in prosecuting Adams, a Hamilton native who spent 15 years in the United States—six of them at Houston’s M.D. Anderson Cancer Center, the world’s largest cancer hospital. “I work in the same way Adams does— and I’ve made that clear to the college,” says Dr. Ellen Thompson, an Ottawa pain specialist who has threatened to reconsider her position on the college’s governing council if it revokes Adams’s medical licence. “He’s the only Kingston doctor who prescribes large quantities of opioids. And it looks like influential members of the college want to stop him.”
The college’s final decision could leave several hundred of Adams’s patients in a pain-wracked limbo. One is Julie McKenzie, a diabetic who has suffered pain since injuring her neck 15 years ago. “Other doctors weren’t able to help me,” says McKenzie, 37, who lives in Kingston and injects herself with the opioid Dilaudid. “I don’t know if I could go back to living that way.”
Despite continuing resistance by many physicians, acceptance of narcotics to control pain has grown over the past 30 years. Palliative-care physicians in some Canadian hospitals routinely use opioids to treat pain from cancer and other terminal diseases. And increasingly, specialists and family physicians prescribe moderate opioid doses for patients with chronic non-cancer pain that does not respond to other therapies. A handful of Canadian specialists—Adams is one—go further, prescribing high doses, if necessary, of such opioids as Demerol, Dilaudid and morphine for chronic pain. Adams, for example, has treated patients with 500 mg a day of Dilaudid—at least 30 times higher than more cautious physicians would prescribe.
Underlying the debate over opioids is the fear that patients will become addicted. Dr. Raju Hajela, a Kingston family practitioner who is president of the Canadian Society of Addiction Medicine, says he has treated former patients of Adams for addiction. In some cases, Hajela told Macleans, Adams prescribed “outrageous amounts and combinations of medications.” But Adams says that to “the best of my knowledge I have never had an addicted patient. I have treated patients who were previously addicted to drugs—that does not disqualify them from receiving humane care.”
Adams and other specialists acknowledge that many pain patients treated with opioids do become drug dependent and experience withdrawal symptoms if treatment is stopped abruptly. But, they argue, most do not experience the eupho-
ria sought by recreational drug users, and therefore rarely become addicted. “When people with non-cancer pain are treated with opioids,” says Dr Harold Merskey, a London, Ont., pain specialist, “the rate of addiction appears to be remarkably small.” Adams’s ordeal in Ontario began in May, 1998, when inspectors from the college arrived at his Kingston office with a warrant demanding 25 patient files. During six days of hearings in August and September last year, a fourmember panel reviewed Adams’s case at the college’s Toronto headquarters. In its verdict, the panel cited lapses ranging from a failure to conduct physical examinations to endangering the health of patients by prescribing high doses of drugs with potentially dangerous side-effects. Adams’s most serious offence, in the panel’s view, was that he allowed some patients to take drugs home and inject themselves. Declaring that such a practice should be “strongly discouraged and abhorred,” the panel found him incompetent and guilty of professional misconduct.
Adams’s aggressive approach had made him a physician-oflast-resort for chronic pain victims referred by other doctors. His patients include accident victims and others with conditions ranging from diabetes to fibromyalgia, a mysterious malady with no clear physical cause. Adams says his methods of treating chronic pain grew out of his extensive experience in dealing with terminal patients, and learning that opioids “can be used effectively and safely in doses undreamed of in the past.” He insists that his techniques are supported by scientific research—and that the Ontario college is out of step with the times. Other experts agree. “I think the authorities should be better informed,” says Dr. Anneli Vainio, director of Montreal General Hospital’s pain centre. “There is ample evidence to support using whatever amounts of opioids are needed in treating chronic pain.”
Official attitudes on the use of opioids in chronic pain vary across the country. Pain specialists in British Columbia and Alberta report a generally permissive approach, while many pain experts in Ontario accuse their college for being out of touch with current medical thinking. The most liberal province is Nova Scotia, where the college of physicians and surgeons issued guidelines last year encouraging doctors to use opioids to treat chronic pain when necessary. “Wehe saying that we want physicians to treat pain effectively, using whatever drugs are required, including opioids,” said Dr. Cameron Little, registrar of the Nova Scotia college.
Adams thinks his problems ultimately stem from lingering resistance on the part of many doctors towards treating pain at all. “Physicians tend to think in concrete terms,” he says, “and human suffering is something many of them can’t comprehend. My goal has been to see pain become just as important a part of medicine as any other medical condition.” EZ!
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