A SHIFT IN THE TREATMENT OF CHRONIC PAIN

With Laws as Shield, Doctors Are More Willing to Prescribe Drugs

After 40 years of debate among doctors, medical and law-enforcement
officials, state legislatures have begun passing laws to shield
doctors from being prosecuted for prescribing powerful medications
against intractable pain.

At the same time, leaders of major medical institutions said, a
fundamental change has been occurring among doctors, who are now more
willing to proscribe narcotics and other such medication to treat pain.

Last week, the agency that accred its most of the nation's
health-care organizations adopted standards under which the
organizations must "recognize the right of patients to appropriate
assessment and management of pain." The agency, the Joint Commission
on Accreditation of Healthcare Organizations, accredits about 20,000
hospitals, nursing homes and home-care agencies, which together
provide some 96 per-cent of the nation's in-patient care.

"Unrelieved pain has enormous psychological effects on patients," said
Dr. Dennis S. O'Leary, president of the joint commission, "and
research shows that unrelieved pain can slow recovery, create burdens
on patients and their families and increase costs of the health-care
system. And we believe patients have an explicit right to effective
assessment and management of existing pain."

In addition, half of the state medical boards in the nation have in
recent years adopted model guidelines, written by the Federation of
State Medical Boards to protect doctors from losing their licenses for
prescribing morphine and other narcotics, so long as they are given
strictly for relieving pain.

For decades, doctors have been caught between complaints of
under-treating pain and concern about being disciplined or prosecuted
for being too aggressive.

Law-enforement officials have been watchful for doctors who may supply
narcotics to addicts for profit, or overprescribe drugs as a form of
mercy killing or assisted suicide. At the same time, patients or their
families have complained bitterly that they or their loved ones have
often been left without relief to suffer needlessly for long periods.

In the early 80's, for example, Dr. Harvey Rose, a pain specialist in
Sacramento, Calif., was accused by the California Medical Board of
overprescribing pain medication. He succeeded in fighting the charge,
but only after spending four years and $140,000. He then helped lead
the efforts to make California one of the first states to enact the
protective laws, in 1990, for doctors who use narcotic Medications to
treat chronic and intractable pain.

Relatively few criminal cases of overprescribing narcotics have been
brought against doctors, "but the ones that were had a tremendously
chilling effect," said Dr. Allen S. Licher, past president of the
American Society of Clinical Oncology. "Doctors just did not want to
take the chance of getting caught up in that."

But the pendulum has swung. "Doctors and policy-makers both have
finally come to see that treating chronic, intractable pain is one of
the essential tasks of caring for a patient, Dr.Licher said.

Nineteen states now have laws that protect doctors from prosecution by
state and local law-enforcement agencies for overprescribing
painkillers so long as the medications are needed to treat pain caused
by medical disorders. The states, according to the National Conference
of State Legislatures, are California, Colorado, Florida,, Minnesota,
Missouri, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Oklahoma,
Oregon, Pennsylvania, Rhode Island, Texas, Virginia, Washington, West
Virginia and Wisconsin. A decade ago, no states had such protection.

Most of the changes have come in the last three years, and a dozen
more states, along with the United States Senate, are considering
similar legislation.

Besides the new legal protections, medical advances in recent years
and broad cultural changes have also been factors in the change, said
Dr. Kathleen Foley, a pain-management specialist at Memorial
Sloan-Kettering Cancer Center in New York.

"There has been such an explosion in science in the understanding of
pain systems," Dr. Foley said, "and because of this, along with the
efforts of many brave people to persuade their colleagues to change
their attitudes toward treating pain, the great barriers that have
existed to proper pain control are finally coming down."

One barrier used to be the fear of creating narcotics addicts, noted
Dr. June L. Dahl, a professor of medicine at the University of
Wisconsin Medical School who was on panel of the Federation of State
Medical Boards that adopted the pain guidelines. But, Dr. Dahl said,
"There is absolutely no data that show patients properly treated for
severe pain with painkillers becoming addicted except for those with a
history of drug abuse, and they have to be screened out."

Medication for severe, long-term pain usually includes opiates or a
narcotic that in the correct dosage dulls pain and induces steep but
in overdoses can cause convulsions and death. "What one must know is
that when the medication is built up slowly over time, when the doses
are gradually increased, a patient can tolerate levels high enough to
relieve very severe pain," Dr. Dahl said, although she cautioned that
the doctor, the patient or a relative of the patient must have some
expertise in pain control.

Officials, doctors and researchers at cancer treatment centers, the
National Institutes of Health, the American Medical Association,
patient-support groups and researchers at several universities have
been at the forefront to bring about the changes. They have built on
the efforts of people like Dr. Elizabeth KFCbler-Ross who as a
professor of medicine at the University of Chicago Medical School in
the 1960's was virtually ostracized by fellow doctors for complaining
that they routinely neglected patients once they became terminally ill
and left them to die in pain.

But the medical establishment has been slow to change. Dr. Melvin H.
Konner, an anthropologist at Emory University in Atlanta who is also a
graduate of Harvard Medical School, said that as recently as the
1980's interns in university hospitals were routinely told to ignore
the pain of sick or injured newborn babies because their brains were
too undeveloped to experience It. "We now know that this is not so,"
Dr. Konner said.

Just last year, the Journal of the American Medical Association
reported a Brown University study of 13,635 cancer patients in nursing
homes, age 65 or older, showing that only 26 percent of those in pain
were given any medication. And in 1995, the journal published a survey
in which family members of one group of 4,301 conscious patients who
died in hospitals reported that 50 percent of them were in moderate to
severe pain in the last eight days of their life. Though some patients
refuse medication, the percentage was regarded as far lower than the
number of patients who want pain relief given the choice.

Despite the changes in law and medical board guidelines, pain
treatment remains controversial. In Sacramento, Dr. Rose said he had
to argue vigorously to get the right amount of medicine for his wife
to relieve her pain as she was dying of cancer in 1994 -- and then
again last year for himself when he was recuperating from a quadruple
bypass.

Last February, another Californian, Dr. Frank Fisher, was charged with
three counts of murder in the deaths of three patients treated at his
clinic in Redding. Dr. Fisher was jailed, unable to post the bail set
at $15 million, to await trial. He said he treated a large number of
patients, many of them poor people who had chronic, intractable pain
but had been snubbed by other doctors. "I feel like I'm being punished
for behaving in good conscience and for doing the right thing," he
said.

But a spokesman for the California Attorney General's Office insisted
that enough evidence had been presented at a preliminary hearing by
other doctors who said "an inordinate amount of painkillers" had been
prescribed to justify a trial. The prosecutor's concern was that
rather than treating real pain, the doctor was simply supplying drugs
to those who abused them and who had medical need.

A group of Dr. Fisher's patients came to his defense, including the
husband of one of the alleged vlctims, who said she had had grave
health problems and did not die from her medications. The head of the
local county health center called Dr. Fisher's arrest "a disaster,
like a natural disaster, like an earth quake," and said the county was
suddenly left with hundreds of people who were unable to get the
medication they needed.

On July 16 the murder charges were dropped and Dr. Fisher was released
after four months in jail, on the ground that there was insufficient
evidence of an intent to kill. But the doctor is not free and clear:
the three murder indictments were reduced to manslaughter.