Editor's Message  |   September 2007
Overcoming Obstacles to Effective Pain Control
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   |   September 2007
Overcoming Obstacles to Effective Pain Control
The Journal of the American Osteopathic Association, September 2007, Vol. 107, ES1-ES3. doi:
The Journal of the American Osteopathic Association, September 2007, Vol. 107, ES1-ES3. doi:

“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

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 supplement to JAOA—The Journal of the American Osteopathic Association is the second installment in a refreshed four-part series devoted to pain management and available only online. 
Like its predecessor in the original series published in 2005 in both print and online (, this issue looks at some of the controversies in pain management that pose barriers to complete—or even adequate—pain control for all patient populations. 
Progress has been made in several areas. There has been a substantial increase in physician training in chronic pain interventions and opioid management. More physicians have been trained in office-based opioid treatment, and more are prescribing opioids.1 
In the first article, Joseph Rasor, RPT, OMS IV, and Gerald Harris, DO, discuss the evaluation of patients who complain of 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. 
The Monitoring the Future2 and a national survey3 have reported an increase in opioid abuse. Opioid overdoses have also increased.4 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 2000 of the physicians in the United States for compliance with the DATA 2000 Drug Enforcement Administration (DEA) waiver. 
Currently, buprenorphine hydrochloride and the buprenorphine hydrochloride-naloxone hydrochloride combination are the only two products that the US Food and Drug Administration has approved for office-based treatment of patients addicted to opioids. James J. Manlandro, DO, therefore provides a still 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 are 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 past surgeon general of the US Public Health Service, have identified these disparities that must be corrected. The fourth article looks at the depth of this problem from both the physician's and the patient's perspective. Studies by Todd et al5,6 have shown that physicians must be cognizant of potential discrimination in assessment and treatment of pain in all populations. In the refreshed review of disparities in health, Sergio Aguilar-Gaxiola, MD, PhD, professor and chair of the Section on Reducing Health Disparities at the University of California—Davis, joins Margaret R. Paulson, DO, and me in emphasizing the need for physicians to be cognizant of contributions to disparities (ie, bias, uncertainty, and stereotyping).7,8 
The DEA has intensified its efforts to decrease diversion and abuse of controlled substances in the United States. The increased scrutiny of addressing patient needs and the use of controlled substances have put many physicians under the microscope of review. The article on the DEA's position on prescribing activities of physicians and other providers reviews the fine details of practicing medicine in 2007 with patients who carry a high burden of illness and the federal efforts to decrease the misuse of controlled substances. 
The final article reports on the recommendations of the 2006 White House Leadership Conference on Medical Education in Substance Abuse. The osteopathic medical profession was well represented at the conference by this updated report's authors Stephen A. Wyatt, DO, who served as a member of the planning committee and expert panelist for the undergraduate working group, and Michael A. Dekker, OMS III, who was a student representative selected by the national organization of Health Professional Students for Substance Abuse Training. Also, Douglas M. Leonard, DO, represented the Association of American Colleges of Osteopathic Medicine, and I represented the AOAAM. 
Although their philosophic approach to patients, their families, and communities distinguishes osteopathic physicians from their allopathic counterparts, both professions share in the need to do much to improve the depth and quality of education in the prevention, treatment, and aftercare of substance abuse. Inasmuch 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 “conquer the mountain” and surmount the socioeconomic, racial, and ethnic barriers and the stigma of possible addiction, drug diversion, and other obstacles to comprehensive evaluation and pain management for all patients. Otherwise, much pain will remain unrecognized and continue to be 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.”9 
September 2007 has been proclaimed as Pain Awareness Month. This observance stems from the idea for dedicating September to pain education by the Partners for Understanding Pain, a consortium of national organizations. We are therefore hopeful that greater awareness will be the stimulus for continuing advancements and improved education in pain management. Then, we may truly alleviate the suffering of all our patients and not be tormenters. 
 The opinions of Dr Dekker are not necessarily the opinions of the Indian Health Service or the US Public Health Service.
 This continuing medical education publication is supported by an educational grant from Purdue Pharma LP.
SAMHSA/CSAT Evaluation of the Buprenorphine Waiver Program. US Department of Health and Human Services, Substance Abuse and Mental Services Administration, Center for Substance Abuse Treatment. Available at: Accessed August 28, 2007.
Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Results on Adolescent Drug Use: Overview of Key Findings, 2006. Bethesda Md: National Institute on Drug Abuse NIH Publication No. [yet to be assigned]); 2007. [Summary available at: Accessed August 28, 2007.]
Substance Abuse and Mental Health Services Administration. Results from the 2002 National Survey on Drug Use and Health: National Findings Rockville, Md: Office of Applied Studies, NHSDA Series H-22, DHHS Publication No. SMA 03-3836; 2003. Available at: Accessed August 28, 2007.
Paulozzi LJ, Budnitz DX, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15:618 –627.
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.
Aguilar-Gaxiola S, Medina-Mora ME, Magaña CG, Vega WA, Alejo-Garcia C, Quintanar TR, et al. Illicit drug use research in Latin America: epidemiology, service use, and HIV. Drug Alcohol Depend. 2006;84(suppl 1): S85–S93.
Breslau J, Aguilar-Gaxiola S, Borges G, Kendler KS, Su M, Kessler RC. Risk for psychiatric disorder among immigrants and their US-born descendants: evidence from the National Comorbidity Survey Replication. J Nerv Ment Dis. 2007 Mar; 195 (3):189–195 Available at: Accessed August 20, 2007.
Levi P. Cited in Bennett DS. Breakthrough pain: treatment rationale with opioids. Available at: Accessed August 20, 2007.