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The article on pain management in the February 6 issue discusses a number of important issues, but several of these need to be further elucidated.
I wholeheartedly agree with the views of former APA presidents Lawrence Hartmann, M.D., and Joseph English, M.D., that APA should be playing an active role in the field of pain management. Unfortunately, APA has yet to demonstrate that it wishes or intends to be so involved.
Despite efforts by me and others over several years to convince the APA leadership to establish a component on pain, this has not happened. The limited interest that APA has shown in pain is also highlighted by the paucity of presentations on this subject at the annual meeting.
A reader of the article may be left with the impression that the major obstacles to appropriate pain management for the terminally ill are laws regulating the use of opioid analgesics. This is a frequently repeated shibboleth, the falseness of which is easy to prove. If it were true, one would expect types of pain that respond better to treatment with nonopioids to be well managed. However, pain related to bone metastases (the most common cause of cancer-related pain), which responds far better to the nonsteroidal anti-inflationary drugs, and pain secondary to nerve involvement, which is better treated with antidepressants and anticonvulsants, are just as poorly managed as pain that responds to opioids.
The real reason physicians do such a poor job managing pain always has been and continues to be the inadequate education most physicians receive on the subject in medical school and residency. If APA wishes to benefit patients and advance the field of pain management, it should employ its resources to help rectify this.
Steven A. King, M.D., M.S.
Philadelphia, Pa.