Editor's Message  |   March 2005
Osteopathic Medicine: Providing “Rest From Pain” at End of Life
Author Notes
  • Dr Nichols, chair of the AOA End-of-Life Care Committee, an AOA trustee, and member of the JAOA Editorial Advisory Board, is dean of Midwestern University's Chicago College of Osteopathic Medicine in Downers Grove, Ill. 
Article Information
Pain Management/Palliative Care / Palliative Care
Editor's Message   |   March 2005
Osteopathic Medicine: Providing “Rest From Pain” at End of Life
The Journal of the American Osteopathic Association, March 2005, Vol. 105, 1S. doi:
The Journal of the American Osteopathic Association, March 2005, Vol. 105, 1S. doi:

“For all the happiness mankind can gain Is not in pleasure, but in rest from pain.”

John Dryden (1631–1700) English poet, dramatist, and critic from The Indian Emperor

Pain management and end-of-life care—I would submit that these two terms call out the best that osteopathic medicine has to offer. Our profession was begun to address the treatment of patients to provide them “rest from pain” in new and innovative ways. Further, there is probably no occasion when all the aspects of osteopathic medicine come into play more than when osteopathic physicians provide care at the end of life. In this, the first of a series of four supplements on pain management, we focus on the context of the elderly and end-of-life care. 
Our first article is the initial publication of an excellent paper stating the position of the American Osteopathic Association (AOA) against the use of placebos in pain management in end-of-life care, deeming such use as unacceptable, unjustified, and unethical. In July 2004, the AOA House of Delegates approved the policy statement drafted by the AOA End-of-Life Care Committee. 
The four articles that follow are packed with pearls. Two are more global, and the others focus on more specific aspects of our topic. 
The article by Jimmie P. Leleszi, DO, and Jeanne G. Lewandowski, MD, provides excellent insight into what is “pain.” The totality of the pain experience includes the physical noxious stimuli, the emotional discomfort, interpersonal conflict, and nonacceptance of one's own dying. Further, the authors thoroughly outline the physiology of pain in the context of the whole person. In summary, the “gold standard” of the assessment of pain in pain management is that pain is whatever the patient says it is. 
In his article titled “Management of Pain in Older Adults,” Thomas A. Cavalieri, DO, points out that physicians are hampered by a lack of training, inappropriate pain assessment methods, and reluctance to use opioids. He beautifully details the proper approaches to pain from pharmacologic and nonpharmacologic points of view. His article culminates in the 10 principles for effective pain management that every physician should have well in mind. 
Bringing methadone hydrochloride, an old medication, back to the forefront for consideration in pain management is the focus of the article by John F. Manfredonia, DO. He aptly points out that while we physicians must nurture the physical and psychological well-being of our patients, we must also be the stewards of society's financial resources. For such reasons, use of methadone is having a resurgence in the management of pain and is particularly well suited for use in the elderly. 
Finally, Tracy L. Marx, DO, writes from a perspective of a physician partnering with hospice in a nursing home. She also references one of the few studies that has identified predictors of short-term mortality in nursing home residents. It is crucial that all physicians understand these points. She gives an excellent insight into the issues in hospice, making the important point that different disease states have different patterns of dying. 
In conclusion, we want to be sure all osteopathic physicians are aware of the continuing controversy surrounding the Drug Enforcement Administration's (DEA) August 2004 unofficial document titled, “Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel.” The DEA subsequently withdrew the document because it contained misstatements. After withdrawal of that document, an Interim Policy Statement was published in the Federal Register on November 16, 2004, indicating that the DEA would address in greater detail the subject of dispensing controlled substances for the treatment of pain in a future Federal Register document, taking into consideration the views of the medical community. The announcement of that pending document was published in the Federal Register inviting comment from the medical community. 
The following two statements from the DEA are very important: 
  • “DEA recognizes that the overwhelming majority of physicians dispense controlled substances lawfully for legitimate medical reasons, including the treatment of pain.”
  • “The purpose of this recitation (of the relevant provisions of the Controlled Substances Act and DEA regulations relating to the dispensing of controlled substances for the treatment of pain) will be to provide guidance and reassurance to the overwhelming majority of physicians who engage in legitimate pain treatment while deterring unlawful prescribing and dispensing of pharmaceutical controlled substances.”
The AOA staff and the End-of-Life Care Committee will continue to monitor this crucial issue to be sure those two points are honored. On March 18, President George Thomas, DO, submitted comments to the DEA on dispensing controlled substances for the management of pain. The AOA recommended that the DEA include a thorough explanation of its interpretation of physician responsibilities when preparing the policy statement, including administrative history and relevant court proceedings. The AOA also recommended that physicians experienced in the management of pain should be involved in drafting practice guidelines regarding medical use of pain medications. 
The remaining three supplements in this series on pain management will continue to provide updates on forthcoming documents related to policy statements and guidelines from the DEA. The next supplement focuses on issues in pain therapy including addiction. We hope that this supplement proves to be a valuable resource to osteopathic physicians providing their patients rest from pain at end of life. 
About the JAOA's Pain Management Supplement Series Coordinating Editor
Frederick J. Goldstein, PhD, FCP, brings expertise, experience, enthusiasm, and a dedicated interest in pain management to his role as coordinating editor of the current series of four JAOA supplements on pain management. A member of the JAOA's Editorial Advisory Board since 1998, Dr Goldstein is a professor of clinical pharmacology and coordinator of pharmacology in the Department of Neuroscience, Physiology and Pharmacology at the Philadelphia College of Osteopathic Medicine (PCOM). He is also a clinical research associate in the Department of Anesthesiology at Albert Einstein Medical Center in Philadelphia and a lecturer in pharmacology at the University of Pennsylvania School of Dental Medicine. 
Dr Goldstein frequently lectures on drug abuse to community, social, and religious organizations and medical schools and staffs of medical centers. 
Dr Goldstein has served as consultant to the Philadelphia Field Office of the Drug Enforcement Administration, the Eastern District of the US Attorney's Office, and the Pennsylvania Board of Probation and Parole, among other agencies. He is a member of the editorial boards of the Journal of Clinical Pharmacology and the new Journal of Opioid Management. He is a reviewer for those publications as well as for the JAOA. Dr Goldstein is a Fellow of the American College of Clinical Pharmacology, and his other societal memberships include the American Society for Pharmacology and Experimental Therapeutics, the International Association for the Study of Pain, and the American Pain Society. 
In 1990, Dr Goldstein received the Lindback Award for Distinguished Teaching, Philadelphia College of Pharmacy and Science, now the University of the Sciences. 
Dr Goldstein has no conflicts of interest to disclose. 
 Dr Nichols has no conflicts of interest.
 This continuing medical education publication supported by an unrestricted educational grant from Purdue Pharma LP