PAINFUL REMEDY?

Patients, advocates and government spar over tighter controls on painkillers

A furious battle is being waged over whether new restrictions should be
placed on powerful prescription drugs used for everything from back pain to
cancer.

Federal health officials say the popular medications are triggering a new
drug crisis across America. More people are now addicted to painkillers and
antidepressants than to cocaine, while deaths related to prescription drugs
are increasing in alarming numbers.

"While we are making progress in dealing with heroin and cocaine,
(prescription drug abuse) is an area that has gone the wrong way," said
Rogene Waite, a spokeswoman for the Drug Enforcement Administration.

DEA officials point to a 48 percent increase in emergency-room visits
linked to just one of the powerful medications - the painkiller hydrocodone
- - between 1998 and 2001.

To stop this trend, the DEA says, tougher controls are needed on some drugs.

But groups that campaign for more liberal use of pain medications
vehemently oppose new restrictions, which they say would make doctors less
likely to prescribe medications patients need. They say the drugs "make
life worth living" for millions of people dealing with debilitating pain.

"What you are seeing is the clash of the war on drugs conflicting with the
war on pain," said Dr. Scott Fishman, chief of the division of pain
medicine at the University of California Davis. "It has a chilling effect
for health care in the future."

Both sides worry about the increasing number of people who become addicted
while taking pills for legitimate reasons and about drug addicts who add
prescription drugs to their stashes. They also acknowledge that some
doctors over-prescribe because they are careless, incompetent or greedy.

Pain control advocates say these problems can be solved by educating
doctors and patients about the drugs' potential for addiction, rather than
making the drugs more difficult to get.

"No one wants addicted citizens, but there are people suffering
mind-bending pain, and they have no way to live their lives in a normal
way," said Kathryn A. Padgett, executive director of the American Academy
of Pain Management, a nonprofit patients rights group based in Sonora. It
is partly funded by pharmaceutical companies such as Purdue Pharma, maker
of the painkiller OxyContin.

Padgett and her husband, Richard Weiner, started their organization in 1988
at a time when doctors and patients were beginning to rethink the idea that
potentially addictive drugs should be given only to dying patients. Weiner
had spotted the need for a patients rights group when he worked as a
counselor at a pain clinic.

In 2001, Weiner experienced firsthand the frustration and helplessness of
needing pain relief - and not being able to get it - when he found out he
had pancreatic cancer.

The pain was so intense that "literally, he was writhing on the floor,"
Padgett said. But it was months before the couple found doctors who would
prescribe medication that made the remaining months of Weiner's life
bearable. He died in 2002.

Opponents of a crackdown on painkillers say doctors are already so fearful
of prescribing powerful drugs that they limit their prescriptions to doses
small enough to escape the scrutiny of state and federal officials - and so
small they don't ease their patients' pain.

'Lit on Fire'

It was at least 10 years before doctors finally gave Cynthia Toussaint
sufficient amounts of drugs to relieve her agony.

Two decades ago, Toussaint was a 23-year-old dancer and actress in Los
Angeles when she pulled a hamstring during a ballet class. The pain spread
through her body until she felt she had been "doused in gasoline and lit on
fire."

Doctors told Toussaint the pain was imaginary and refused to prescribe
drugs powerful enough to relieve her suffering. It wasn't until 1995, when
she was finally diagnosed with reflex sympathetic dystrophy, a neurological
disease that causes severe pain, that she finally got the dosage of
painkillers she needed.

Toussaint, who often uses a wheelchair because of the pain, now takes at
least eight medications daily, including Vicodin, an opioid, or opiate-like
drug. She and her longtime companion, John Garrett, operate For Grace, a
nonprofit organization that helps patients and doctors manage the pain
associated with her disease, which afflicts at least 1.5 million Americans.

"The medication saved my life," she said. "If it wasn't for the opioids . .
. ."

Dr. Harvey L. Rose, a Carmichael physician, has fought hard for people like
Toussaint. But Rose also has had to fight for himself, spending $140,000 in
legal fees to defend himself against charges he prescribed too many pain
pills for his patients.

In 1981, Rose began prescribing morphine for elderly people who were
incapacitated by chronic pain. After reviewing Rose's records, Medical
Board of California authorities decided he was providing too many drugs and
accused him of prescribing medication without proper diagnosis.

The accusation was upheld, and in 1985 Rose was ordered to surrender his
medical license. He appealed, and a Superior Court judge dismissed the
charges after the state lost his transcript. A second attempt by the
Medical Board to file charges against him failed after a state senator
intervened.

Rose was so outraged by the accusations that he helped create California's
Intractable Pain Act in 1992 and helped write the state's Pain Patient's
Bill of Rights in 1997.

The two measures broadened the rights of patients to obtain medication,
particularly opioids such as oxycodone and hydrocodone.

Rose fears the DEA's current campaign to restrict certain drugs will make
more doctors withhold medication their patients need. Already, some of his
elderly patients say other doctors have refused their requests for pain
medication.

Doctors are caught in a bind when it comes to medications. It's either "too
much (or) too little," Rose said.

Rose, 72, said he won't stop prescribing painkillers for patients who need
them.

"I'm very respectful of the DEA, but I know the rules of the game," he
said. "Many doctors are fearful, scared to death. But if I refuse
(patients), who is going to take care of them?"

Regulatory Hassles

The DEA is focusing much of its attention on the nation's most abused
prescription drug, hydrocodone, which it is considering reclassifying as a
highly addictive drug. The agency is expected to make its decision by the
end of the year.

The DEA schedules, or ranks, controlled substances according to their
potential for abuse, their acceptable medical use and their safety under
medical supervision.

Schedule I drugs, including heroin and LSD, have the highest potential for
abuse and the most stringent controls. Schedule V drugs, which include
cough suppressants, have the fewest controls.

The DEA is considering moving hydrocodone from Schedule III to Schedule II,
which includes oxycodone-based drugs and morphine. If the change is made,
people will have to take their prescriptions to the pharmacy in person.
Refills won't be allowed, so a new prescription will be required each time
a patient needs more medication.

Those who oppose hydrocodone's reclassification say the number of
addictions is relatively low compared with the number of people who take
hydrocodone-based drugs. They also say most patients find a dosage level
that enables them to use the drugs safely.

Dr. Robert Hertzka, president of the California Medical Association and a
San Diego anesthesiologist, said the hassle of dealing with Schedule II
drugs makes many physicians reluctant to prescribe them, even if they are
clearly needed.

Hertzka's concern is backed up by the Federation of State Medical Boards, a
group that researches medical issues. In a recent report, the federation
found a "significant body of evidence suggesting that both acute and
chronic pain continue to be undertreated."

Part of the problem is that doctors don't want to deal with the paperwork
involved.

They must file records to state and federal regulators every time they
prescribe a Schedule II or III drug. The state forms, submitted monthly,
include the patient's name, address and birth date, the physician's medical
license number and controlled substance registration number, and the amount
of drugs the doctor dispenses every day.

Doctors who prescribe restricted drugs talk about frightening encounters
with law enforcement agents, Hertzka said.

"Investigators ask for records (while) in some cases, these doctors have
waiting rooms filled with patients," he said. "The whole thing is
worrisome, whether it's the Medical Board or the DEA or federal law
enforcement."

The American Medical Association has written to federal authorities
expressing its concern about the "harassment of physicians by DEA agents."

So far, no physicians have filed reports of harassment with the AMA,
according to Rebecca Patchin, a California-based trustee of the
association, but she said the organization is just beginning to look into
the matter.

"There is physicians' fear (of the DEA) similar to the public's fear of the
IRS," Patchin said. "They say it is just an investigation, but it is
frightening just to receive a letter from any regulatory body."

'War on Drugs'

The most telling description of these debates is one word: war.

"The war on drugs has turned into a war on doctors and the legal drugs they
prescribe and the suffering patients who need the drugs to attempt anything
approaching a normal life," said Kathryn Serkes, public affairs counsel for
the Association of American Physicians and Surgeons.

"Physicians are being threatened, de-licensed and imprisoned for
prescribing in good faith with the intention of relieving pain," Serkes
said. "Their patients have become collateral damage in this trumped-up war."

The association is so concerned about the potential harm to doctors that it
e-mailed the following warning to its members this year:

"If you're thinking about getting into pain management using opioids as
appropriate . . . DON'T. Forget what you learned in medical school. . . .
Drug agents now set medical standards. Or if you do, first discuss the
risks with your family."

The DEA and pain specialists called a truce last month and are working
together on guidelines to help doctors understand their responsibility to
make sure their patients aren't abusing prescription medications.

DEA officials say they want to reassure doctors that they won't be
prosecuted for properly prescribing medication, even when high dosages are
involved.

Of the 732 doctors investigated last year by the DEA, 50 lost their
licenses for improperly prescribing drugs, said Pat Good, chief of the
liaison and policy section in the DEA's Office of Diversion Control. The
charges ranged from fraudulently filing too many prescriptions to murder
linked to overdose deaths.

Good said that considering there are 700,000 physicians in the United
States, the number of prosecutions is low and shouldn't be generating such
a storm of protest.

That doesn't comfort doctors who say they must balance the possibility of
facing criminal charges with their patients' need for pain medication.

Question of Balance

Marilyn Townsend straddles the drug debate.

The 59-year-old Corona homemaker knows firsthand the tragedy drugs can
bring. But she knows, too, the miracle of drugs and how they can ease
debilitating pain.

She knows there is a delicate balance.

Townsend's two stepsons died within six months of each other after they
accidentally overdosed on prescription painkillers mixed with illegal
drugs. Cameron died in July 2001 at age 25. Robert, 22, died the following
January.

Even as Townsend laments their deaths, she relies on prescription drugs to
ease back pain caused by severe scoliosis.

"For me, taking the drugs is a matter of surviving the day-to-day,"
Townsend said.

But for those who become addicted, like her stepsons, she says: "There is
no happy medium. They have to go all the way."