PHYSICIANS GUIDED ON PAINKILLERS

Specialists, Drug Agency Hope Outline Will Ease Prescription Fears

WASHINGTON - New guidelines seek to improve treatment for millions of
Americans with unrelieved pain by spelling out exactly how powerful
painkillers like Oxycontin and morphine can be prescribed without
attracting the wrath of the Drug Enforcement Administration.

Many doctors hesitate to prescribe narcotics, which are heavily regulated
because they can be abused by addicts.

The guidelines issued last week, written by leading pain specialists
together with the DEA, stress that the drugs are safe for the proper
patients - and pledge that doctors won't be arrested for providing
legitimate therapy.

There is "unwarranted fear that doctors who treat pain aggressively are
singled out," says Patricia Good, DEA's drug-diversion chief. The
guidelines should help eliminate this "aura of fear," she says.

They come at a crucial time, says co-author David Joranson, pain policy
director at the University of Wisconsin-Madison Medical School. Fewer
doctors are willing to prescribe narcotic painkillers, known as opioids,
partly because of the government's high-profile crackdown on
prescription-drug abuse. Some pharmacies won't stock them for fear of
burglaries.

"In some ways, pain management and the use of pain medications has become a
crime story when it really should be a health-care story," Mr. Joranson says.

The key message: "These are legitimate treatments. They're essential for
good medical care," says Dr. Russell Portenoy, pain chief at New York's
Beth Israel Medical Center and a well-known pain specialist.

With the guidelines, the DEA sanctions that view - and is distributing the
document to agents and prosecutors to help them distinguish aggressive pain
management from drug diversion. A lot of opioid-taking patients in a
practice shouldn't by itself signal suspicion, the guidelines advise, while
long-distance prescribing and lots of premature refills might.

Fear of the DEA isn't the only obstacle. Many nonspecialists simply don't
know much about opioids.

Consider Cynthia C. Hildt, 65, a retired New York teacher who hunted relief
for disabling back pain for 20 years before Dr. Portenoy prescribed
morphine. Recently another doctor asked her if she wasn't afraid of addiction.

"I said, 'I seem to have the choice of living with this unconscionable pain
or taking a pill that will help, and I don't believe that addiction is a
worry under those circumstances,"' Ms. Hildt recalls.

The new guidelines stress that when prescribed properly for serious pain,
opioids hardly ever lead to addiction.

About 30 percent of Americans suffer chronic pain; for as many as a third,
it can be disabling, Dr. Portenoy says.

How many need opioids but are undertreated? About 40 percent of cancer and
AIDS patients and the terminally ill, populations where opioids are
considered optimal care, he says. Opioids also are useful for other types
of pain, such as back or nerve pain, although there's less consensus on how
often to use them.

The DEA regulates doctors who prescribe controlled substances including
opioid painkillers such as morphine, codeine, fentanyl and Oxycontin - to
ensure they're not diverted for illegal use.

Last year, just 50 doctors nationwide were arrested on charges that they
prescribed or otherwise distributed controlled substances beyond the scope
of medical practice, somewhat fewer than in recent years, Ms.Good says.

On the other hand, opioid abuse is on the rise, a trend illustrated by
Oxycontin, blamed for more than 100 deaths. The long-acting pill is crucial
for severe cancer pain, but it can produce a quick, potentially lethal high
if crushed, snorted or injected.

The guidelines spell out how physicians can balance aggressive pain control
with the need to spot doctor-shopping abusers.

Among the recommendations:

Document a medical history, physical exam, pain assessment and treatment
plan in first-time patients' charts, with re-evaluations at follow-up visits.

Records should show evidence that the doctor evaluated the nature and
impact of the pain, earlier treatments, and alcohol and drug history.
Measuring pain intensity and extent of relief over time "is important
evidence of the appropriateness of therapy."

Watch for abuse warning signs, such as a patient unwilling to allow
contact with previous doctors, escalating doses, seeking early refills or
requesting specific medications. These require careful evaluations they
might merely signal unrelieved pain.

More worrisome signs include deterioration in functioning at home or
work, illegal activities such as stealing or forging prescriptions, and
repeatedly "losing" prescriptions.