Despite recent advances in the understanding of pain management, patients continue to suffer needlessly, primarily because of improper management and inadequate pain medication. Physicians often are concerned about iatrogenic addiction to opioids, even though the risk is low. They lack knowledge about the pharmacotherapeutic properties of opioids, including the inability to convert equianalgesic dosages from one medication to another. In addition, physicians often confuse physical dependence, tolerance and psychologic dependence. Physicians are concerned that their prescribing practices are scrutinized by state and federal agencies and that their medical license is at stake. Deficiencies in providing adequate pain management have persisted, despite multiple attempts to educate the medical community. Weinstein and associates examined the barriers to providing adequate pain management.

A 59-item questionnaire about pain management practices was sent to a random sample of practicing physicians in Texas. The survey measured three aspects of physician attitudes and knowledge concerning pain control, including overall reluctance to prescribe opioids, fear of patient addiction and fear of investigation by a drug regulatory agency (DRA). In addition, the questionnaire included items that explored psychologic factors that contributed to the way in which the physicians practiced pain management.

A total of 386 physicians responded to the survey. Approximately 40 percent of the respondents practiced in urban areas with populations of more than 1 million, 32 percent in communities of less than 100,000 and the remainder in areas that fell somewhere between. Overall, 30 percent of the respondents believed that the use of opioids should be limited to patients with severe, intractable pain. Ten percent stated that they would provide opioids for pain only when the patient was expected to live less than one year. More than 25 percent were concerned that the use of opioids for pain management carried a substantial addiction risk. In addition, a significant number of physicians stated that they were concerned about DRA scrutiny. Attitudes also appeared to be a function of community size. Physicians practicing in small communities (less than 100,000) had less accepting attitudes toward patients with chronic pain than physicians in urban areas. Specialty area also affected attitudes, with psychiatrists being more accepting of pain control measures than surgeons or internists.

The authors conclude that new educational strategies are needed to improve pain management practices. The negative attitude toward prescribing opioids and the fear of DRA scrutiny must be corrected to reduce unnecessary suffering.

editor's note: Treating pain produces a conundrum for physicians: we want to help our patients but we are concerned about addiction and DRA review of our prescribing habits. Despite previous efforts to help physicians understand the addiction potential of opioids and how to manage pain syndromes, Weinstein and associates demonstrate a continuing struggle with these issues. In a companion article, these authors also found that a significant number of medical school seniors had the same concerns. To change these attitudes, creative educational programs are needed for practicing and future physicians.—k.e.m.