INTRODUCTION
The original Texas Cancer Councilšs Workgroup On Pain Control In Cancer
Patients was composed of C. Stratton Hill, Jr., M.D., Chairman, Houston,
Everett G. Heinze, M.D., Austin, R. Wayne Hurt, M.D., Houston, R. Prithvi
Raj, M.D., Lubbock, Becky O'Shea, R.N., M.S., Dallas, Raul Rodriquez,
M.D., McAllen, and William Willis, M.D., Ph.D., Galveston. The results of
their efforts produced Guidelines for the Treatment of Cancer Pain in two
formats, a comprehensive volume containing a wide variety of pain
treatment approaches, including invasive techniques, and this pocket
edition, limited primarily to the pharmacological approach to pain
treatment. The pocket edition proved by far to be the more popular format.
For this reason this format is being brought up to date. This updated
version was done by members of The Texas Cancer Pain Initiative and once
again funded by the Texas Cancer Council. Members responsible for this
version are Sharon Weinstein, M.D., Debbie Thorpe, Ph.D, RN, Mary
Cunningham, MS, RN, and C. Stratton Hill, Jr., M.D.
Although the principles of assessing and treating pain have not changed
since the first edition of this book, technological advances with oral,
transdermal and other delivery systems using different formulations of
drugs are now available. Additionally, some of the old sections have been
expanded to include more details. Legislative and regulatory changes have
been accomplished. The Intractable Pain Treatment Act has been amended to
permit the prescribing of opioids to patients who are currently substance
abusers or have a history of substance abuse if they develop acute or
chronic painful medical conditions. The two most common conditions
encountered in this setting are cancer and AIDS. The Texas State Board of
Medical Examiners has adopted rules that serve as guidelines for the
standard of practice for prescribing opioids. Last, but not least, the
75th Texas Legislature passed a law that will substitute electronic
monitoring of Schedule II prescriptions for the current triplicate
prescription program! Eventually Schedule II drugs can be written on
ordinary prescriptions used for any other type drug.
Our premise continues to be that all cancer pain can be controlled with
means currently available to the general medical community. Control does
not always mean the complete absence of pain. Endurance of some pain may
be preferable to complete relief if undesirable side effects of pain
treatment are incapacitating and cannot be ameliorated by appropriate
treatment or do not spontaneously disappear. However our goal is to
strive to achieve, by using these guidelines, complete pain relief and
return to a normal, or near normal, functional state, with limitations
imposed only by the disease process itself. The emphasis in selecting
treatment modalities is on simplicity and cost effectiveness. Improved
technological advances in drug delivery, which often are expensive, should
be used if there is a specific indication for them, however the majority
of patients can be managed with simple methods.
Despite increased educational efforts, particularly at the post-graduate
level, to make all health care professionals aware of the under treatment
of all types of pain, and provide lectures, seminars, and conferences
outlining proper treatment methods, a significant number of Texans
continue to experience needless pain. This problem will increase as a
public health issue because a higher percentage of the population (both
Texas and the U.S.) is living into an older age group where the prevalence
of chronic painful medical conditions is highest. This population is very
concerned about the quality of life they will have. If pain, and other
distressing symptoms, deprive them of an acceptable quality of life and
they are denied access to drugs and other treatment modalities that can
relieve these symptoms they will seek means to end their plight. The US
Supreme Court has ruled that there is no constitutional right to
physician-assisted suicide. This will put pressure on state legislators
to make physician-assisted suicide legal. There is therefore an urgent
need to improve pain treatment in Texas.
A major cause of physicians reluctance to prescribe strong opioids
(narcotics) continues to be fear of sanctions against them by the Texas
State Board of Medical Examiners (TSBME) and the state and federal drug
enforcement agencies. Any physician who is charged with violating the
Medical Practice Act, and his/her attorney, should be aware of Chapter
170, Authority of a Physician to Prescribe for the Treatment of Pain, of
the TSBME rules. These provide guidelines for the standard of practice
for the use of these drugs. They also describe the conditions the TSBME
will use to judge the physicians conduct. No agreed settlement with the
TSBME should be entered into until these rules are reviewed.
