Editor's Message  |   June 2005
Controversies in Pain Management
Author Notes
  • Dr Dekker is on the speakers bureau of the American Osteopathic Academy of Addiction Medicine, which has received educational grants from Reckitt Benckiser Pharmaceuticals and Purdue Pharma LP. 
  • Address correspondence to Anthony H. Dekker, DO, Administration, Phoenix Indian Medical Center, Indian Health Service, US Public Health Service, 4212 N 16th St, Phoenix, AZ 85016-5319.E-mail: 
Article Information
Pain Management/Palliative Care
Editor's Message   |   June 2005
Controversies in Pain Management
The Journal of the American Osteopathic Association, June 2005, Vol. 105, S1. doi:
The Journal of the American Osteopathic Association, June 2005, Vol. 105, S1. doi:
Since 1995, evaluation, treatment, and regular assessment of pain has become the community standard in the United States. Regulatory agencies such as the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) have facilitated this process. Quality and peer reviews now include pain measurement and care as high priority items. The JCAHO, AHRQ, American Academy of Pain Management, American Pain Society, American Geriatrics Society, and American Society of Addiction Medicine currently include such professional activities in their physician profiles, and patient satisfaction is now a top priority for many healthcare systems. 
This JAOA supplement, the second installment in a series of four parts devoted to pain management, looks at some of the controversies in pain management that pose barriers to complete—or even adequate—pain control for all patient populations. 
In the first article, Joseph Rasor, RPT, OMS III, and Gerald Harris, DO, discuss the evaluation of patients in pain and their treatment with opioids. They review the indications and contraindications. Judicious use of opioids with appropriate documentation has become mandatory in today's medicolegal climate. 
An increase in abuse of opioids has been observed. To assist physicians, the Drug Abuse Treatment Act (DATA) of 2000 authorized the training and waiver qualification of physicians to use approved Schedule III, IV, and V medications for managing opioid abuse and withdrawal processes. The American Osteopathic Academy of Addiction Medicine (AOAAM) ( has trained more than 20% of the physicians in the United States for compliance with the DATA 2000 Drug Enforcement Administration waiver. 
Currently, buprenorphine hydrochloride and the buprenorphine hydrochloride–naloxone hydrochloride combination are the only two products approved by the US Food and Drug Administration for office-based treatment of patients addicted to opioids. James J. Manlandro, DO, therefore provides a timely and appropriate overview of the use of buprenorphine in office-based treatment of patients with opioid addiction. Dr Manlandro was a major contributor to the Treatment Improvement Protocol (TIP) 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, which served as the source for his overview. The portable document file of the full guidelines is available at: TIP 40 is also availabe at 
Healthcare disparities in the United States have become a critical issue and another barrier to effective pain management in special populations. The Institute of Medicine and Vice Adm Richard H. Carmona, MD, MPH, USPHS, the surgeon general of the US Public Health Service, have identified these disparities that must be corrected. Margaret Paulson, OMS III, and I look at the depth of this problem from both the physician's and the patient's perspective. Studies by Todd et al1,2 have revealed that physicians must be cognizant of potential discrimination in assessment and treatment of pain in all populations. 
The final article reports on the recommendations of the 2004 Leadership Conference on Medical Education in Substance Abuse. The osteopathic medical profession was well represented at the conference by the report's authors Stephen A. Wyatt, DO, William Vilensky, RPh, DO, James J. Manlandro, Jr, DO, and Michael A. Dekker, OMS II. 
Osteopathic physicians differ from their allopathic counterparts in the philosophic approach to patients, their families, and communities. But, both professions have in common that they need to do much to improve the depth and quality of education in the prevention, treatment, and aftercare of substance abuse. In as much as treatment of patients in pain is intricately woven in the recognition and treatment of substance abuse, the osteopathic medical profession along with the allopathic medical profession must invest in ongoing education in these challenging areas to meet head on and break down the barriers to comprehensive pain management for all patients. Otherwise, much pain will remain unrecognized and undertreated. And thus, in the words of Auschwitz survivor Primo Levi, a chemist, philosopher, and writer, “If we know that pain and suffering can be alleviated and we do nothing about it, we, ourselves, are tormentors.”3 
 “Substance use disorders are medical illnesses and may not be ignored or go untreated. We do not choose the illnesses we treat.”—Vice Adm Richard H. Carmona, MD, MPH, Surgeon General of the US Public Health Service
 This continuing medical education publication supported by an unrestricted educational grant from Purdue Pharma LP
Todd KH, Lee T, Hoffman JR. The effect of ethnicity on physician estimates of pain severity in patients with isolated extremity trauma. JAMA. 1994;271:925 –928.
Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA.. (1993). ;269:1537 –1539.
Levi P. Cited in Bennett DS. Breakthrough pain: treatment rationale with opioids. Available at: Accessed June 24, 2005.