America is seriously divided about controlling chronic pain, which afflicts more than 50 million people and costs the country $100 billion a year.
On the one hand, we grossly under-treat it. Management of chronic pain and the pain of dying patients is arguably the most egregiously neglected field of medicine.
On the other hand, as a society, we have become obsessed with the war on drugs - and the fear of addiction to opioids (narcotics). Pain patients who were functioning well on morphine-like drugs such as oxycodone (OxyContin) are now fearful of them - or can't get them.
Some drug stores, wary of robberies of OxyContin, are afraid to stock it. Some unscrupulous doctors have written excessive prescriptions for it. Some patients, like talk show host Rush Limbaugh, abuse it.
The problem is obvious: Some of the drugs that most effectively treat pain are the ones commonly abused. In one survey of New York doctors, 30 percent said they were prescribing fewer opioids or switching patients to less-effective drugs for fear that the Drug Enforcement Administration will investigate.
"Every bit of evidence suggests that we have been under-treating pain," said Dr. Kathleen Foley, an attending neurologist at the Memorial Sloan-Kettering Cancer Center and head of the Project on Death in America.
In the past five years alone, three major reports from the Institute of Medicine, an arm of the National Academy of Sciences, have concluded that pain control in the United States is woefully inadequate. Also, the U.S. Supreme Court, in deciding in 1997 against a constitutional right to physician-assisted suicide, highlighted the need for better pain control.
Though the fear of addiction is great, in reality the risk is small when patients take drugs in the doses prescribed by physicians. "Addiction," to be sure, is a loaded word. It is psychological dependence - a compulsion to seek more and more of the drug - that laypeople usually mean.
A 1982 study on patients in 93 burn facilities found no evidence that any patients became addicted to opioids. More recent data from pain clinics suggest that the addiction rate might be around 10 percent, but people who attend pain clinics are not typical of all pain patients.
Once doses are adjusted correctly and monitored by a doctor, patients on opioids for chronic pain often function "at high levels," including taking care of families and even driving, Foley said.
Despite America's conflicted views, there are signs we're overcoming our phobia.
Last month, the American Academy of Pain Medicine and leading doctors announced a new initiative called Top Med that will provide a Web-based "virtual textbook" available free to medical students across the country. It is sorely needed. Only 3 percent of medical schools have a separate, required course on pain management, and only 4 percent require a course in end-of-life care.
There's other good news. In 2001, the group that accredits the vast majority of the nation's hospitals required that hospitals assess and manage pain for all patients.
Almost all states (including Maryland) have launched pain initiatives to reduce legislative barriers to effective pain control.
Many states are also establishing electronic systems to monitor the prescribing and dispensing of controlled substances - a tricky business because the idea is to forestall abuse but provide access for people who need opioids.
Nationally, a bill pending in Congress called the National All Schedules Prescription Electronic Reporting Act would do much the same thing.
Ultimately, says Dr. John Klippel, medical director of the Arthritis Foundation, the issues comes down to quality of life. Patients should realize, he said, that, when medicine is taken properly, "the potential for addiction is really minimal."
Judy Foreman is a lecturer on medicine at Harvard Medical School.