TREATING PAIN NO LONGER A GAMBLE

Doctors Are Freer To Prescribe Narcotics, But Fears Linger

Twenty-four years ago, the Medical Board of California accused Dr.
Harvey Rose of overprescribing pain medicine, a disciplinary ordeal
that lasted four years and cost him $140,000 in legal fees.

Fast-forward to 2004 and you sometimes find the 72-year-old Carmichael
doctor teamed up with the medical board's enforcement chief, trying to
convince doctors that treating pain - even with high doses of
narcotics - can be safe for both patients and physicians.

Recently, he and Joan Jerzak, the medical board's enforcement chief,
met with a group of physicians at Scott's Seafood Grill & Bar in
Sacramento to discuss pain management. "If you are practicing medicine
appropriately, don't worry," Jerzak told the group. "We are not behind
every bush and tree."

A lot has changed since the days when doctors were disciplined because
they prescribed more than a modest amount of narcotics for pain.
Researchers' understanding of pain - and how to treat it - has evolved
to the point where many doctors believe that for some patients, relief
comes only with seemingly lethal doses of drugs.

Numerous new laws, regulations and guidelines aimed at educating and
protecting physicians reflect this evolution in thought about pain
management.

But that doesn't always translate to treatment.

Because pain cannot be measured with a blood test or pinpointed under
a microscope, doctors often regard patient complaints skeptically.
Some figure a patient seeking pain treatment could be an addict or
drug dealer. They worry that ongoing treatment with narcotics could be
dangerous and habit-forming, or that prescribing controlled substances
could get them into trouble.

Their concerns are legitimate. The federal Drug Enforcement Agency
estimates that 6.2 million Americans abuse prescription drugs,
particularly painkillers in the opioid family. In March, the
president's Office of National Drug Control Policy announced plans to
step up investigations and enforcement actions against the illegal
sale, use or diversion of controlled substances such as the painkiller
OxyContin.

Complicating matters is the fact that many doctors still know little
about the nature of pain and its treatment, and there are too few
specialists to meet the demand.

"Most doctors today have had no training in pain management, and yet
most people come to the doctor for pain," said Dr. Scott Fishman, a
pain specialist at UC Davis Medical Center and president-elect of the
American Academy of Pain Medicine. "Most doctors want to do the right
thing, but they aren't sure what that is."

Fishman advises doctors to start by trusting the patient. "Our motto
is, 'Pain is what the patient says it is.' When someone complains of
pain, they are suffering from something."

Those on the forefront of pain medicine have tried to clearly
differentiate painkiller dependence from addiction. A chronic-pain
patient who requires massive doses of narcotics on an ongoing basis to
function is considered dependent but not addicted to the medication -
even though that patient ultimately may suffer withdrawal without the
drug and become tolerant, requiring higher doses for the same effect.

An addict, on the other hand, has no control over his drug use and
continues to use the substance despite the harm it causes. In essence,
an addict does not get better when medicated.

But even addicts can be prescribed opioid drugs safely, Fishman
argues, as long as they are monitored.

"Addiction is a huge public health problem, but it pales in comparison
to the problem of under-treated pain," Fishman said. "We have to deal
with both at once."

Fishman describes the body's pain system as a complex system of neural
pathways. Some transmit quickly, resulting in sharp or stinging pain,
while others move the information more slowly and result in a dull
pain or ache.

While pain can trigger the flow of natural chemicals called endorphins
that alleviate pain, it also can prompt a release of prostaglandins
that intensify pain sensation. How one person responds to pain can be
very different from another.

Chronic pain results when neural pathways become hypersensitive to the
signals and resistant to the body's pain-relieving mechanisms, often
as the result of an injury, according to specialist Dr. Jennifer Schneider.

Opioids, such as morphine, codeine and oxycodone, act on the brain and
spinal cord to alleviate pain. They also act on the limbic system,
which plays a role in both pain and pleasure, raising the specter of
addiction.

Bill Sandberg, executive director of the Sierra Sacramento Valley
Medical Society, said fear and uncertainty among doctors are the
greatest obstacles to appropriate pain treatment. The prospect of
getting arrested or losing their medical license leads many physicians
to simply say no.

DEA data indicate that less than one-tenth of one percent of the
nearly 1 million physicians registered with the agency were sanctioned
for alleged diversion of controlled substances between 1999 and 2003.

Still, these cases quickly gain notoriety and strike fear in the
hearts of doctors. The case of Dr. Frank Fisher of Redding, who faced
murder charges related to his prescription of narcotics, for example,
drew national media attention.

"You don't have to see very many of your colleagues burned at the
stake to fear that you might be next," said Fisher, now living with
his parents in the Bay Area. "What I am hearing from pain patients
from all over the country is that doctors who will treat pain
aggressively are getting scarcer and scarcer."

All charges against Fisher have been dropped and his medical license
reinstated. But he has not resumed his medical practice and said he
won't be prescribing controlled drugs.

Highly publicized doctor discipline cases help explain why physicians
such as Rose, well past typical retirement age, still see patients
from as far away as Indiana for pain treatment, and why the
cutting-edge Division of Pain Medicine at UC Davis Medical Center gets
500 referrals every month.

Mary Montri, a 66-year-old retired group home operator from
Indianapolis,recently flew to Sacramento to see Rose for a checkup and
prescription refill. She takes a combination of methadone and Dilaudid
to alleviate pain resulting from an unsuccessful back surgery.

Montri said she sought out Rose after Virginia doctor William Hurwitz
was arrested last year on drug trafficking charges. Hurwitz's trial in
a Virginia federal court is now under way.

Montri had seen Hurwitz, she said, because every other doctor she
consulted refused to prescribe the medication she needs. She said she
makes the trip to Sacramento every five months because without her
medicine she couldn't get out of bed.

"It makes you feel pretty bad when you have to leave your home state
to get help," she said. "But that's the way it is."

Although no studies have been done to determine the extent of chronic
pain affliction in the United States, one survey estimated that 9
percent of the adult population suffers from moderate to severe pain.
Chronic pain can result from diseases such as arthritis and
fibromyalgia, from traumatic injuries or even limb amputations that
lead to what is called "phantom" pain.

Depending on the patients, their pain and their tolerance of
medicines, doctors on the forefront of pain medicine say appropriate
treatment may require prescribing large doses of habit-forming drugs
at regular intervals.

Numerous guidelines and regulations have emerged over the past two
decades based on this principle, with California on the forefront of
the movement.

Among the key provisions is the Intractable Pain Treatment Act, passed
in 1990, which gives doctors wide latitude in prescribing controlled
substances.

The state Legislature in 1997 adopted the Pain Patient's Bill of
Rights, allowing a patient to request or reject any and all kinds of
treatment to relieve pain, including opioids.

California doctors now are required to get 12 hours of pain treatment
training, and Gov. Arnold Schwarzenegger has signed into law a measure
requiring law enforcement and medical experts to jointly develop
protocols for investigating cases of under-and over-treatment.

Some law enforcement officials contend the regulations have gone too
far, hampering efforts to prosecute negligent doctors who over-
prescribe medication or provide narcotics to an addict.

"If a doctor is doing something and the patient dies, I can't touch
them because the law said you have a right to ask (for drugs) and you
have the right to prescribe them," said Shasta County Deputy District
Attorney Dan Flynn.

But Jerzak, with the medical board, is among those who argue that
under-treatment is by far the greater problem.

"We are still aggressive in pursuing doctors who don't practice to the
standard of care," Jerzak said. "We still file charges against doctors
who violate our guidelines. But it is a not a large number of
physicians who violate them."

Jerzak acknowledges that this is a shift from the days when physicians
were disciplined based solely on the volume of narcotic prescriptions
they wrote.

"We did too good a job, and we put such fear into the medical
community that their fear of oversight caused them to under-medicate
patients in pain," she said.

In an effort to educate doctors, the medical board has issued pain
treatment guidelines, and Jerzak frequently travels the state
presenting her seminar: "How to Arrest Pain Without Getting Arrested."

Patients such as 63-year-old Darlene Rodni of Roseville hope it makes
a difference.

Her ailments include spinal stenosis, degenerative disc disease,
scoliosis, arthritis and residual pain from a hip replacement surgery
and a serious auto accident.

Dr. Rose gives her just enough medicine to keep her from becoming an
invalid, she said. That includes periodic injections of cortisone and
Xylocaine, a muscle relaxant, a painkilling patch and a drug that
combines hydrocodone, an opioid, with acetaminophen.

Rodni said that last year Rose put her on Dilaudid, a stronger opioid,
but it made her feel woozy. With her current regimen, she said, she's
never without some pain but she's coherent.

"It definitely keeps me going," she said. "Without it, I don't know
what I would do."

Her greatest concern, she said, is losing the doctor who has treated
her through years of suffering. "He's there 100 percent for his
patients," Rodni said of Rose. "I worry; who am I going to get to help
me when he decides to retire?"

Path of pain Key developments in the war on pain in California:

1985: California Medical Association and the Medical Board of
California develop guidelines for prescription of controlled substances.

1990: State Legislature passes Intractable Pain Treatment Act, which
defines lawful and prohibited uses of controlled substances in the
treatment of pain.

1994: Medical Board of California issues statement acknowledging that
pain is often under-treated and that some patients need large doses of
pain drugs for relief.

1997: State Legislature passes Pain Patient's Bill of Rights, which
gives patients the right to request or reject any or all modalities to
relieve severe, chronic, intractable pain.

1999: California doctors can prescribe controlled substances for
terminally ill patients without using a Department of Justice
"triplicate" prescription form.

2001: State Legislature passes law requiring health facilities to
assess pain as a vital sign.

2001: A California jury finds an internist guilty of elder abuse for
under-treating a dying man's pain. The doctor was ordered to pay $1.5
million to surviving family members.

2001: State Legislature requires physicians to complete 12 hours of
medical education in pain management.

2002: Medical board issues expanded pain management guidelines for
physicians.

2004: State Legislature revamps triplicate prescription system for
controlled substances.

2004: State Legislature passes law requiring representatives from law
enforcement and medicine to jointly develop protocols for
investigating suspicious prescribing practices.