By Virginia Baldwin Gilbert
Of the Post-Dispatch

April 18, 2000

Sandra Johnson and her colleagues headed to Tinseltown on a mission.

The small group of nationally recognized researchers in law and medicine weren't looking for their big break in Hollywood -- just a plot line or two.

The researchers' method of presenting their findings on pain management in a panel was familiar. Their audience -- a group of TV screenwriters -- was not.

"One of the goals of the study is to change practices," explained Johnson, director of the Center for Health Law Studies at St. Louis University.

"The question is, 'How do we change the minds of people generally to understand that pain relief is possible?' With all these lawyer and medical shows, if they can raise the level of coverage of the issue there, it could have an important impact."

In fact, the executive story editor for "ER," the nation's favorite TV doctor show, moderated the panel last month.

Does that mean that viewers next season might see Dr. Mark Green lecturing an intern about the necessity of giving enough pain reliever to a dying patient?

Not exactly.

"Stories from the show never start from the medicine," said Dr. Joe Sachs, the "ER" story editor and also a board-certified emergency medicine physician.

"It's important, as a writer on 'ER,' to keep up with what's new in the medical literature," Sachs said in a telephone interview. "But if it was just about medicine, we'd be on The Learning Channel. Medicine is the backdrop. Our stories start from character."

Still, the panel was enlightening, Sachs said, particularly in highlighting and debunking the myths that patients and even many doctors believe. "Such as, when the end of life is near, that sometimes you can't control pain. That's a myth. You can always control pain," he said.

The researchers -- Leora Kuttner of the University of British Columbia, Dr. Scott M. Fishman of the University of California at Davis, Dr. Russell K. Portenoy of Beth Israel Hospital in New York -- also wanted scriptwriters to know that giving enough powerful pain medication to be effective will not hasten a patient's death, that pills can work as well as shots and that using narcotics to ease chronic pain will not turn sufferers into addicts.

For Dr. John Visconti, an oncologist at St. Louis University Hospital, pain is not a plot device in a TV show. Treating patients in pain is part of his job every day.

But he liked the idea of his colleagues taking their research to the people who make TV shows.

"Studies in the 1990s showed we do a poor job of pain management in this country," Visconti said. "I think it could be very exciting to promote (better pain relief methods) in a different medium. It could give education to patients as well as give physicians more prompting to treat pain seriously."

Visconti learned his own lesson about treating pain when, as a young resident, he prescribed a mild pain killer to a woman suffering severe pain with arthritis. Her pain continued, and she wound up in the hospital, where another doctor finally prescribed stronger medication to relieve her pain.

"It prompted me to rethink my pain management," Visconti said. "Pain is a very important symptom with a patient. When you're suffering, pain prioritizes your day."

If doctors and patients could learn from a fictional TV show, so much the better.

"There's a gap between what we can do and what we do" to ease patients' pain, said Johnson, the researcher.

Johnson and several colleagues around the country have been studying non-medical obstacles to pain relief. The research is funded by the Mayday Fund of New York, a non-profit foundation dedicated to the reduction of physical pain.

Johnson, whose specialty is law, and other researchers in medicine have been looking into why doctors sometimes don't prescribe enough painkillers to stop their patients' pain.

The first difficulty is defining the problem. Pain is not easily measured in a way you can describe with numbers on a chart, like temperature or blood pressure.

"In a scientifically driven and evidence-driven medical practice, having pain be so subjective is unnerving to some professionals and insurance people," Johnson said.

Johnson's group found a more recent cause for U.S. patients not getting the pain relief they need.

Many physicians fear if they prescribe painkillers in high enough doses and for a period of time long enough to be effective, they will come to the attention of drug-enforcement authorities.

"We found a problem in licensure and discipline," Johnson said. "The number of physicians who lost licenses were few, but a lot got caught up in investigations, and that's a devastating event. There's a huge shame factor, an attack on their professional integrity. It disrupts their relationship with patients and costs them legal fees."

The Mayday Fund held its first conference on the drug investigation issue in 1996 and invited state regulators, state attorneys general, state medical boards, physicians, nurses, lawyers, pharmacists and patients.

Last year, the federation of state medical boards recommended new guidelines for evaluating doctors' use of pain relievers. Instead of considering just the amount of pain medicine and the length of time a patient is on the drug, the new guidelines suggest evaluators look at whether the doctor has examined the patient, whether there is a treatment plan, and whether the treatment is effective, Johnson said.

Missouri has been at the forefront in changing the climate for doctors to prescribe painkillers, Johnson said. In 1996, Missouri's medical board asked for, and got, a law that offers pain-prescribing doctors some prote ction from inappropriate investigation.

"The challenge here is to make sure that enforcement is in line with the law," Johnson said.

Sometimes a doctor or nurse's inability to understand a patient's pain or their fear of investigation may combine with other attitudes to cause unnecessary suffering for particular groups.

Researchers in Michigan are studying the experience of people suffering from sickle cell disease who go to hospital emergency rooms in pain.

Sickle cell disease is genetically based and strikes people of African descent. Sufferers may face the additional barrier of racial stereotypes.

"The situation presents a lot of problems of the emergency room," Johnson said. "The staff has little history and no personal relationship with the patient. The patient comes in reporting pain and knowing what drug he needs, because he's had these pain bouts before."

From the medical staff's point of view, the patient "could be a pain-relief-seeking patient or a druggie," Johnson said.

That type of dilemma could make for dramatic TV - a point not lost on either the experts or the screenwriters.

Sachs, of "ER," makes no promises about whether viewers will learn more about pain management in the 22 new episodes planned for next season. "ER" writers will put the pain research in with their "big bag of tricks of the latest in medicine," he said.

"The story comes out if it serves the dramatic need."