OPIOIDS HELP PATIENTS, BUT ARE A CONFLICT FOR DOCTORS

Wife, mother, photographer and community activist Hope Proper disappeared in
the late 1980s. She was replaced by Hope Proper, woman in pain. Nerve damage
from an old injury kept her in unremitting agony. "It becomes your
identity," says Proper, 58, of Moorestown, N.J. "You're not you anymore. You
are the pain."

Today, Proper has reclaimed some of her former identities and added a few
new ones. Like art museum curator. Like methadone user.

Proper, who has been taking methadone since 1999, considers herself lucky to
have found a physician who wasn't afraid to prescribe whatever it took to
manage her pain.

Doctors often are reluctant to try opioids -- methadone, morphine and other
narcotic painkillers -- for patients who have chronic pain unrelated to
cancer. They're afraid that their patients will become hooked, and that they
themselves will be slapped with professional sanctions or criminal charges.
Even when physicians are willing to treat chronic pain with opioids, they
may hesitate to prescribe enough pills.

"We are deeply suspicious of patients who report pain when they are not
bleeding, when they are not dying," says Sandra Johnson, health law and
ethics professor at Saint Louis University in St. Louis. So millions of
adults in the USA are left with inadequately controlled pain that interferes
with their ability to sleep, to work, to walk, to enjoy life.

The situation has become more complicated in recent months with reports of
widespread abuse of OxyContin, the country's top-selling opioid. OxyContin
is a timed-release version of oxycodone, the same opioid as in Percocet and
Percodan.

Swallowed whole as directed, an OxyContin pill gradually releases oxycodone
over a 12-hour period. But chewed or crushed and snorted or injected, the
pill releases its entire dose of oxycodone at once, giving an immediate
high.

That discovery, and some indiscriminate prescribing, has led to a rash of
illegal sales, drugstore robberies and reports of homemakers and
grandmothers becoming junkies. Pain specialists fear that a resulting
backlash might further restrict patients' access to opioids.

An estimated 9% of adults suffer from moderate to severe chronic pain caused
by back injuries, arthritis and other non-cancer conditions, according to
the American Pain Society. Like Proper, two-thirds of them have lived with
pain for more than five years.

"The public health problem represented by misuse of prescription opioids is
minuscule in comparison with that of untreated and unrelenting pain," says a
statement released by the American Academy of Pain Medicine at its annual
meeting this year.

How Opioids Work

Opioids block transmission of pain messages to the brain by attaching
themselves to special proteins in the brain, spinal cord and
gastrointestinal tract. Some, like morphine, are derived from opium, while
others, like methadone, are synthetic.

In some ways, opioids are safer than other popular painkillers called
non-steroidal anti-inflammatory drugs, or NSAIDs, says James Campbell,
director of the Blaustein Pain Treatment Program at Johns Hopkins Hospital
in Baltimore. NSAIDs such as ibuprofen can damage the liver.

Opioids have no such track record, Campbell says, although they can cause
nausea and constipation. But because in the wrong hands they have the
potential for abuse, they are controlled substances under the jurisdiction
of the U.S. Drug Enforcement Administration.

Proper understands why people might equate opioids with drug abusers. She
used to think of them that way herself. Even in the depths of her pain,
Proper bridled at the thought of going on opioids. For years, she tried
everything but.

"Like everyone else, I assumed I would develop an addiction," Proper says.
In her first few years on Dilaudid, her initial opioid, she tried to
minimize her chance of becoming addicted by taking a pill only when her pain
became unbearable.

Proper says that she now knows better, but that society's misconceptions
about opioids continue to dog her. When she applied for long-term-care
insurance recently, she was rejected, even though she performed well on
memory tests administered by the company.

"It wasn't the chronicity of the pain that disturbed them," Proper says. "It
was the opiates. Because I'm on opioid medications, (the company thought)
I'm both cognitively and functionally impaired."

She filed a lengthy appeal, referring to numerous articles in scientific
journals. She convinced company officials that she was not living in some
methadone-induced fog, and they reversed their earlier decision. "It's one
little step for us," Proper says.

Long-term opioid users develop a powerful tolerance for the drugs' sedating
effects, Campbell says. They tend to score better on tests of thinking
ability because their pain is under control.

When a specialist first suggested opioids for pain resulting from abdominal
surgeries in 1993, images of strung-out junkies came to Diane Keybida's
mind. She thought she would never be able to return to work as a dental
hygienist. It took several sessions with a psychologist before she could
accept the thought of taking the drugs.

"I realized if I'm going to have any life, I have to take these pills," says
Keybida, 47, of Califon, N.J.

Before she went on opioids, Keybida says, she could barely walk, let alone
bale hay and repair heavy machinery, as she used to on her family's small
farm. She planned her life so that she would have to descend the stairs of
her two-story home only once a day.

For the past four years, Keybida has been taking sustained-release morphine
pills three times a day. If necessary, she'll take a "rescue dose" whenever
the pain gets too severe. She still isn't up to seeing as many patients at
her husband's dental practice as she did before the pain hit. And she hasn't
resumed her strenuous farm chores.

"It's still good days, bad days," she says. Although the pain is still
there, "it's not bringing me to tears."

Even doctors who want to specialize in treating pain share patients' and
society's misconceptions about opioids, says Russell Portenoy, Keybida's and
Proper's doctor. When doctors enter Portenoy's training program at Beth
Israel Medical Center in New York, where he chairs the department of pain
medicine and palliative care, "it's a huge eye-opener."

From 30 to 200 Tablets

The first shock, he says, is the size of a prescription. For pain expected
to last only a few weeks or so, doctors are used to writing a non-refillable
prescription for, say, 30 tablets. For patients with chronic pain, who
measure their suffering in years, he's likely to write a prescription for
200 tablets. Patients sometimes develop a tolerance for opioids'
pain-killing effects and require larger doses.

Joseph Saccomanno of Patterson, N.Y., has had firsthand experience with
physicians' fears about opioids. After Saccomanno suffered a herniated disc
while lifting computer monitors nine years ago, one doctor never prescribed
quite enough medication to control his searing back pain. So he started
taking five OxyContin pills a day instead of the prescribed four. That fifth
dose, he says, enabled him to go to the mall with his kids.

Suspected Of Being A Junkie

When Saccomanno, 44, ran out of pills several days early and sought more,
his doctor suspected him of being a junkie and ordered him into detox.
Saccomanno says that while most of his fellow detox patients were taking
methadone to break their addictions to illicit drugs, he was discovering how
much the drug helped relieve his back pain.

Doctors as well as patients confuse addiction with physical dependence,
Portenoy says. Like most people who take an opioid regularly for a few days
or more, Saccomanno is physically dependent on methadone. If he were to stop
taking it, he would experience withdrawal.

But it's not the withdrawal depicted in movies, with victims bouncing off
walls in distress, Portenoy says. "It looks like the flu," he says. "In some
people, very mild, in some people, not so mild."

Addiction, with its powerful psychological component, is different. "You're
exhibiting drug-seeking behavior, and you're acting irrationally," says
Terry Woodworth, deputy director of the DEA's diversion control office.

To help enlighten doctors, the Federation of State Medical Boards three
years ago adopted model guidelines for the use of controlled substances in
treating pain.

The guidelines recommend that doctors complete a thorough medical history
and physical examination before drawing up a written treatment plan. In
addition, doctors should periodically review the treatment course, paying
special attention to patients who are at risk for misusing their
medications, such as those with a history of substance abuse or a
psychiatric disorder along with pain.

Dale Austin, the group's interim chief executive director, says 48 of 69
member boards have adopted the guidelines. "If physicians are embracing
those guidelines in their practice, that will keep them out of trouble from
a regulatory standpoint," Austin says.

But it's too early to tell whether the guidelines have led to improved
treatment of chronic pain, says Johnson of Saint Louis University. "The
boards are mentally committed to use these guidelines," she says. "I'm
hopeful, but right now it is just on paper."

Doctors who have been trained in treating pain say they can recognize the
signs of opioid abuse and nip it before it escalates.

"I think of one patient out of maybe 300 or 400 patients where we were
pretty suspicious that there was an abuse issue," Campbell says. "There was
a pattern of lost prescriptions. Inconsistent stories. Claiming to be very
disabled, but you call up, and the patient's never at home."

Portenoy says he won't even necessarily stop prescribing opioids to a
patient who is abusing them. There are ways to control addictive behaviors,
he says, such as writing prescriptions for small amounts of pills and doing
drug screens on patients' urine samples.

In all his years of treating pain, Portenoy says, he has had to take only a
few patients off opioids because of abuse. "But you know, I'm very prepared
for that."