VoL 1 No. 2 spring 1986 77

Editorial

Narcotic Analgesics: Fears and Responsibilities

Few areas of medicine or pharmacy have sparked stronger legal, political and emotional reaction than the use of narcotic analgesics for pain man- agement. "I won't stock a Schedule II narcotic because my pharmacy might be r ipped off"; " I f Congress would only legalize heroin, cancer pain would be eliminated"; "I don't want my father to die a junkie: ' At one time or another, most of us have heard statements like these.

National and international laws relating to narcotics affect the percep- tions that practitioners and patients alike have on their use for pain man- agement. Treatment providers must cut through existing legal and psycho- logical barriers to ensure that patients receive needed analgesics, and they must also work toward the goal of achieving a more rational approach to using these drugs. This will be no easy task.

The "politics o f pain" became clear to me in 1978 when I se~'ed as White House representative to the National Institutes of Health Interagency Com- mittee on New Therapies for Pain and Discomfort. Much like today, the federal government was more or less forced to look at tile entire pain issue because o f demands to legalize heroin for the treatment o f cancer patients in pain. It immediately became apparent to all members of the Pain and Discomfort Committee that heroin per se should not be the focus of atten- tion. If that substance were available tomorrow in every pharmacy in the United States, millions still would needlessly be suffering. The heroin issue was clearly only one small facet of a much broader problem facing health care providers and patients, ie, how to improve access to existing pain medications and therapies.

The Pain Committee met for 18 months and was fortunate to receive support and advice from the preeminent experts in the field, many of whom are on the Editorial Advisory Board of this journal . It issued a repor t con ta in ing many recommenda t ions , which, if implemented , would .improve pain management. Unfortunately (or fortunately, depending on )'our perspective), government reports by themselves do little to change tile practice of medicine. The participants on the committee recognized that to have any real impact in this area, tim word would have to reach the people who, on a daily basis, treated those in pain. Recent developments towards this end have been encouraging.

The American Medical Association has devoted substantial resources to highlighting .mearls of improving pain management. Congressional hear- ings on legalizing heroin for limited treatment purposes have focused public and political attention on the issue. The Depar tment o f Health and Human Services has reinstituted a government-wide committee to look at pain management. Some states, notably Wisconsin, are planning confer- ences on the subject. Tim World Health Organization is taking an interna- tional perspective in trying to improve pain relief, particularly in cancer patients. The pharmaceutical industry is developing new analgesics and new forms of existing medications to better relieve pain. Publications such

78 Editorial Journal of Pain and Symptom Management

as this journal , are helping to inform physicians, nurses and other health care providers that something can and must be done to alleviate suffering. Yet there is a long way to go.

At the outset I noted that the pain management issue, in addit ion to obvious medical implications, has legal, political and emot ional aspects. Much o f this is due to the fear engendered by federal and state laws and policies which, necessarily, strictly limit access to the most effective pain medications, many of which are abusable substances. Control led sub- stances laws and similar statutes in other countries have been adopted in large measure to meet international treaty obligations to reduce drug abuse; for over 70 years these agreements have required governments to control the use of narcotics and other drugs with abuse potential. Yet these restrictive laws have at times affected physicians' willingness to prescribe pain medications, and-patients ' willingness to take them. (As a fo rmer legal adviser to the United Nations Internat ional Narcotics Control Board, I recognize that the aim of these treaties is to ensure that these substances are only used for medical and scientific purposes, and not to ban them from the legitimate market. I also recognize that the administrative and regula. tory structures in many countries greatly reduce or virtually eliminate access to controlled substances needed for pain treatment.) The impact o f these laws is too little Understood today.

What is to be done? Clearly, the educational effort a imed at both treat- men t providers and patients, has to continue; the irrational fear o f using analgesics, particularly narcotics, must be overcome. Beyond that, there should be an in-depth study of how state, federal and international laws affect access to pain medication. More important , that study must lead to political action to change statutes and policies that are too restrictive. This would give a clear signal to health care providers in the US and elsewhere that their governments suppor t appropr ia te medical t reatment o f pain, even if that t reatment entails the use ofabusab le substances. This would not in any way encourage drug abuse. Rather, it would encourage p rope r drug use.

Expanded educational activites, sound medical practice and political action can combine to improve the use of analgesics here and abroad and help those in need o f pain relief. The t ime has come for all c o n c e r n e d - - physicians, nurses, pharmacists, professional societies, industry, govern- men t and o thers - - to take action. There is plenty to do.

Robert T. Angarola is a partner in the Washington, DC law firm of Hyman, Phelps and McNamara. He served on the White House domestic policy staff from 1977 to 1981, and was White House liaison to the NIH Interagency Committee for New Therapies for Pain and Discomfort. Before that he ~ s legal advisor to the UN International Narcotics Control Board.