"No patient should ever wish for death because of his physician's reluctance to use adequate amounts of potent narcotics." So said the psychiatrist Jerome Jaffe, later Richard Nixon's drug czar, in a 1966 pharmacology textbook. He put the admonition in italics.
The situation Jaffe had in mind was observed several years later by Richard Marks and Edward Sachar, psychiatrists at New York's Montefiore Hospital and Medical Center. Assigned to deal with "difficult" patients, Marks and Sachar discovered a very good reason why so many continued to complain even after being treated with narcotics: They were still in pain.
"To our surprise," they later wrote in the Annals of Internal Medicine, "instead of the primary issue being personality problems in the patient, in virtually every case it was found that the patient was not being adequately treated and, further, the house staff for various reasons was reluctant to prescribe more."
Three decades later, the problem that surprised Marks and Sachar persists, as reflected in the headline over a recent A.P. story: "Hospitals Told to Treat Pain." The article describes standards that the Joint Commission on Accreditation of Healthcare Organizations will begin enforcing on Jan. 1.
The standards require hospitals, nursing homes, and other health care facilities to "recognize the right of patients to appropriate assessment and management of pain." Among other things, that entails regularly asking patients how much pain they are feeling and prescribing medication to control it.
It is startling to realize, at the dawn of the 21st century, that physicians and nurses need to be told they have a duty to relieve patients' pain to the best of their ability. But one study after another has shown that such care cannot be taken for granted.
In a 1994 study published by The New England Journal of Medicine, researchers interviewed 1,308 outpatients with cancer that had spread beyond its original site. Of the two-thirds who reported pain, 42 percent had not received adequate treatment.
A 1998 study reported in The Journal of the American Medical Association identified 4,000 cancer patients in nursing homes who were in daily pain. Only 26 percent were receiving strong narcotics such as morphine, while 32 percent were getting weak opioids such as codeine and 16 percent were taking over-the-counter pain relievers. More than a quarter of the patients in daily pain were not getting any analgesic at all.
A study published last year in The New England Journal of Medicine, based on interviews with the parents of 103 children who had died of cancer, found that 89 percent of the kids suffered "a lot" or "a great deal" in their last month of life. Less than 30 percent were successfully treated for pain.
The Department of Health and Human Services estimates that cancer pain can be controlled about 90 percent of the time. It has also urged more aggressive treatment of postoperative pain, which a 1992 report said could be better relieved in one out of two cases.
Various factors contribute to the undertreatment of pain, including patients' reluctance to complain and medical workers' reluctance to believe them when they do. On both sides, there may be a tendency to see pain as a distraction from the more important task of treating the underlying condition.
That attitude is shortsighted not just because it leads to needless suffering but also because there is substantial evidence that pain can slow a patient's recovery. Research also shows that prompt and regular medication, administered before the patient is in agony, makes it possible to keep pain under control at a lower dose.
But the biggest obstacle to adequate pain treatment is probably "opiophobia," an irrational fear of narcotics fostered by the war on drugs. Despite studies indicating that people treated with painkillers rarely become addicted, doctors (and patients) worry that the fabled allure of these drugs will prove irresistible.
Such anxieties are reinforced by the possibility of disciplinary action against doctors whom regulators consider too generous with narcotics. In a 1991 survey of 90 physicians published by the Wisconsin Medical Journal, most said regulatory concerns had affected their prescriptions, leading them to choose lower doses, smaller amounts, fewer refills, or different drugs.
By forcing health care facilities to pay more attention to pain, the new accreditation standards may help counteract opiophobia. Bitter experience has shown that compassion alone is not up to the task.