ISSUE OF DRUGS AND PAIN STRIKES A NERVE

Alex Four-Horns leans forward as far as his aching body will allow
while his pain nurse massages a mixture of castor oil, ginger and
lavender into his shoulder.

Castor oil has a soothing effect, giving Four-Horns some short-term
relief from chronic pain, the result of a life-threatening automobile
accident three years ago that left him in a coma for a month, broke
both his thigh bones and damaged his knees and hips.

Once a strong, athletic man, Four-Horns, 29, now moves slowly, and he
finds it difficult to keep up with his sons, ages 2 and 8. "My hip
went out when I was putting up the Christmas tree with my boys," he said.

Healing oils, a lot of ibuprofen and occasional electrical nerve
stimulation are the only pain management tools available to Four-Horns.

The state Medicaid program pays for occasional visits from nurse
Dionetta Hudzinski to his home not far from downtown Yakima.
Hudzinski, who has long been active in advocating for people with
chronic pain, wonders if he might benefit from a prescription
painkiller. But she can't find a doctor to treat him for pain.

Four-Horns' case illustrates what University of California pain
physician Dr. Scott Fishman calls a war between two urgent public
health problems - the need to address many patients' undertreated and
untreated chronic pain and the need to reduce the nation's alarming
rate of prescription drug abuse.

Washington state became a battlefront in the pain war earlier this
year when a group of state agency medical directors, led by Dr. Gary
Franklin of the Department of Labor and Industries and in
consultation with practicing pain specialists, issued voluntary
guidelines to physicians for prescribing opioids for noncancer pain.
Opioids such as OxyContin are powerful painkillers that mimic
morphine. Heroin is made from morphine.

The state's chief recommendation is that doctors limit the total
opioid dose to the equivalent of 120 milligrams of morphine a day. At
that level, the state urges doctors to seek a consultation with a
pain management specialist. No other state recommends a dosing limit,
although others are exploring the idea.

The dosing guideline is about half the maximum average daily dose of
250 milligrams taken in recent years by injured workers and Medicaid
clients with chronic, noncancer pain, according to Franklin. Doses in
some cases exceeded 1,000 milligrams, he said. In contrast, some
cancer specialists say their patients with chronic pain might require
more than 600 milligrams of morphine a day.

Since the guidelines were published in March, they have become a
flashpoint in the national debate over finding the balance between
treating pain and stopping the illegal diversion of prescription
painkillers into street drugs. The American Academy of Pain Medicine,
an association of pain physicians, recently came out strongly against
the guidelines, warning that they will scare doctors away from
legitimately treating chronic pain. They attack the 120 mg dosing
limit as unscientific and say there simply aren't enough pain
specialists to take referrals from family doctors.

"Doctors don't have anyone to send these patients to," said Fishman.
"They'll say, 'I'm just not going to prescribe.' It will drive down
the number of prescriptions and the government will look like it's
succeeded. But whether this helps the prescription abuse problem, who
will know?"

Fishman said the dosing guideline is motivated by cost savings. "This
will save the state a lot of money," he said. "These drugs are expensive."

Franklin said the guideline is about saving lives. "Nothing else."

Nevertheless, the state has been under pressure to curb its more than
$500 million annual expense for Medicaid prescription drugs. An
estimated 70 million Americans suffer chronic pain from a variety of
diseases, such as arthritis, headache, fibromyalgia, and diabetes.
Experts say people at lower income levels and members of ethnic
groups, particularly African Americans, suffer disproportionately
from chronic pain, often the result of discriminatory health care.

Franklin said it's too soon for the state to determine if the dosing
limit is cutting down on prescription drug abuse. But he said doctors
appreciate the standards. He said they have received more than 6,000
hits on the state medical directors' Web site, which offers a
calculator to help people figure out if they are exceeding the dosing
limit. This first year of the guidelines is "an educational pilot," he added.

Asked what's next, Franklin said it's too soon to know. "The state is
trying to do this without waving a big stick, and I think it's
exactly the right thing to do."

Abuse of prescription painkillers, particularly by minors who steal
them from their parents, has been a growing problem since the
mid-1990s. That's when the medical establishment overcame a
longstanding phobia about using opioids to treat people with chronic,
noncancer or end-of-life pain.

Research at the time showed that carefully managed treatment with
opioids brought patients sustained relief from pain and improved
function. Addiction rates appeared low.

Dr. Gary Bos, an orthopedic oncologist in Yakima, remembers the push
to use the narcotics by medical associations and pharmaceutical
manufacturers. At the time, he was practicing in North Carolina.
"Doctors were walking around with little buttons that said 'pain'
with a big red slash through the word," he said.

Bos said he and a lot of his colleagues were skeptical. "Many of us
stood back and thought it was wrong. And sure enough, we got a whole
bunch of addicts."

In the United States, office visits for potent prescription opioids
increased nearly fivefold between 1980 and 2000. In the state of
Washington, the rate increased 2.5 times. According to national
figures, 9.5 percent of high school seniors in 2005 used hydrocodone,
often marketed as Vicodin.

Franklin and his colleagues began studying the issue through the lens
of the state workers' compensation system. In 2005, they published a
paper showing that prescriptions for the most potent opioids as a
percentage of all opioids jumped from 19 percent in 1996 - when the
medical standards were relaxed - to 37 percent, or 57,000
prescriptions, in 2002. Daily dosages of the long-acting narcotics
increased 50 percent, from 88 mg a day to 132 mg.

The most controversial finding in the Franklin study was that 32
people died in the six-year study period either "definitely or
probably" from an accidental overdose of prescribed opioids. Another
12 deaths were "possibly" related to an overdose.

The Franklin study didn't draw any definite conclusions about why
prescription narcotic rates rose in that time. But it suggested that
people taking the drugs for chronic pain developed either a tolerance
to them or an abnormal sensitivity to pain because of them. Deaths
could be prevented, the study said, with "prudent" guidelines on the
use of the narcotics for chronic pain.

Judith Paice, who directs the cancer pain program at Northwestern
University medical school in Chicago, said the data used in the
Franklin study were flawed because they didn't document the actual
dosage taken by the 44 patients who definitely or probably died of an overdose.

Paice, a registered nurse with a Ph.D, objected to Washington state's
guidelines on behalf of the American Pain Society, an association of
scientists, clinicians and other medical professionals that tries to
change public policy and clinical practice to reduce pain-related suffering.

More than half of her patients in Chicago take more than the
equivalent of 120 mg of morphine a day. She said some are cancer
survivors dealing with chronic pain from nerve damage. "I have
survivors who can't bend over and tie their shoe laces," Paice said.

It's not practical, she contends, for doctors to refer patients at
the maximum dosage to the kind of pain specialist the state is
recommending. Such physicians are in short supply, mainly because
they have to spend a lot of time with patients and aren't reimbursed
very well. "That's the dirty truth," Paice said.

On its Web site for doctors, the state medical directors group lists
only seven physicians certified in pain medicine or recognized as
experienced in management of chronic pain. The closest to Yakima is a
Richland doctor, who only takes patients by referral from other doctors.

Franklin stands by the state's guidelines. Still, he said he's
"taking some heat" on the specialty consultation. "There really is an
access issue," he acknowledged. One possible solution, he said, is
having specialists conduct consultations by phone or even via the Internet.

While the medical experts debate, Alex Four-Horns keeps the heat on
high in his small house. The cold weather, he said, accentuates the
pain in his thighs, where metal rods hold his bones together. "I
literally don't move when it gets this cold," he said.

Four-Horns has never raised the subject of narcotic painkillers when
he has had occasion to see a doctor. He's wary of being labeled a
drug-seeker or drug abuser because he's American Indian. "I don't
know if it was stereotyping but it was not a topic I felt comfortable
bringing up," he explained.

For his pain, he takes 800 mg of ibuprofen two or three times a day,
putting him two times above the recommended dosage for moderate pain.
It's been three years since the accident landed him in Seattle's
Harborview Medical Center, the region's trauma center. So he worries
about the cumulative effect of the ibuprofen on his heart and liver.
So does Hudzinski, his nurse.

Hudzinski said when she sees patients like Four-Horns, her goal is to
assure them their pain and their need for pain relief is real. She
believes that has helped Four-Horns over the two years she's been
seeing him. "We haven't cured his pain, but his perception of his
pain has changed," Hudzinski said.