Millions of people who have surgery or who sustain serious wounds suffer needlessly from prolonged, severe pain, federal health officials said yesterday -- often because doctors and nurses administer inadequate doses of pain killers out of an unjustified fear of causing addiction.
An expert panel convened by the government's newly created Agency for Health Care Policy and Research issued a set of national guidelines intended to encourage health care workers and their patients to be more aggressive in fighting pain. Following the guidelines, the group said, would not only relieve suffering, but would speed recovery and reduce the length of hospital stays, resulting in substantial savings.
As an example of the current problem, one co-chair of the expert panel that drew up the guidelines, Ada Jacox of Johns Hopkins University, said the conventional dose of pain medication given after surgery is less than half the amount needed to achieve proper pain control.
The panelists, who were joined at a news conference yesterday by leaders of the American Medical Association and other professional groups, said patients are often denied adequate doses of pain killers because many health care workers believe in certain "myths." One of the most pervasive myths, they said, was that powerful drugs such as morphine pose a significant risk of addiction. Other myths, they said, hold that infants and the elderly have higher pain tolerance, that pain is necessary and builds character and that pain in itself is not harmful.
The new guidelines, contained in a 145-page book and three "quick reference" pamphlets, are being distributed to doctors and other clinicians across the country as well as to patients.
The report covers all forms of surgery or other painful medical procedures such as lumbar punctures and biopsies, as well as treatment of diseases and injuries that are painful. They recommend methods of assessing degrees of pain, discuss the merits and dosages of 29 common pain medications and suggest several non-drug ways of controlling pain such as breathing exercises.
The guidelines are the first to be issued by the new agency, which was created within the Public Health Service by Congress and charged with raising the notoriously uneven quality of medical practice around the country to the highest standards. Guidelines on at least 15 other medical matters are to be issued over the next two years.
Health and Human Services Secretary Louis W. Sullivan said the new agency's efforts are "the beginning of a peaceful revolution in American medical care."
While the guidelines are not legally enforceable, Public Health Service director James O. Mason said he expects them to become as widely accepted as the government guidelines on immunization that, although not enforced, have been followed almost universally for decades.
The AMA is still reviewing the guidelines, but its executive vice president, James Todd, said that the government was not imposing "cookbook medicine" on doctors and that patients will be better off if the guidelines are followed. The American Nurses Association and at least five other professional societies have endorsed the guidelines.
The guidelines were needed, the report says, because in the estimated 23 million operations performed in the United States each year, about half the patients receive such low or infrequent doses of pain medication that they continue to suffer moderate to severe pain. The report said this rate has not changed much since first measured more than 40 years ago, despite research indicating the importance of aggressive pain management.
"When doctors do things the traditional way," Mason said, "simply calling for injections of such pain killers as morphine and codeine 'as needed,' the results are often undermedication and unnecessary pain. This occurs particularly in infants, children and the elderly, who often cannot express their needs."
The report emphasizes that the stress of pain can delay healing and prolong hospital stays. According to one estimate, the average hospital stay could be shortened by half a day with proper pain control. Multiplied by the 23 million surgeries per year, that amounts to billions of dollars in unneeded hospital costs.
One of the most insidious effects of prolonged pain, recent animal studies indicate, is that it may allow cancer to start growing in the body by suppressing the immune system.
This finding "argues against the popular misconception: 'Pain will never kill you,'" said John C. Liebeskind, who described the research Wednesday at a coincidentally scheduled symposium at the National Academy of Sciences.
He said prolonged pain suppresses the "natural killer" cells that normally circulate in the blood, search out cancer cells and kill them.
"Pain can be a dangerous disease whose management merits the full attention of the health care team," Liebeskind said.
Reluctance to give enough pain killers, especially morphine (which the guidelines call "the drug of choice") and other opioid drugs, the report indicates, often grows out of fear of hooking patients on the drug.
"That fear is just not supported by the evidence," said Arthur G. Lipman, a clinical pharmacologist at the University of Utah and member of the panel that drew up the guidelines. "Addiction is, in fact, incredibly rare when the drugs are used properly."
He said the best evidence comes from a study of 12,000 patients given opioids for acute pain in which only 0.04 percent (one in 2,500) became addicted. Lipman said many patients who would otherwise suffer severe long-term pain have been on morphine for months without developing tolerance or addiction.
A key recommendation of the guidelines is that patients be closely involved with doctors in pain control, especially through use of a 10-point scale on which patients rate their pain. Studies have shown doctors and nurses gain a better grasp of how patients are suffering by using this method instead of various words of complaint.
Copies of the guidelines, including a brochure for patients, are available free to anyone who calls 1-800-358-9295.