PAINKILLERS GET NEW LEASE ON LIFE GUIDELINES EASE DOCTORS' PRESCRIPTIVE
CONCERNS

Tennessee is poised to adopt new regulations designed to ease
physicians' concerns about prescribing adequate doses of pain medication.

The measures, patterned after rules in Texas, have been approved by
the Tennessee Board of Medical Examiners and are being reviewed by the
state attorney general.

"There is confusion now. Some physicians are afraid to use large
amounts of (pain-relieving) drugs for fear of (state) board action or
civil suits," said Yarnell Beatty, director of Tennessee's physician
licensing board.

"Physicians have been crying for some guidelines so they can treat the
patients who really need the medication without getting into trouble."

No one has to convince Rhonda Kennedy, 31, of Tylertown, Miss., that
some doctors are restrained by fear. That fear, she says, hampered her
treatment for painful bladder inflammation.

"They all agreed I was in pain. They said it was something I was going
to have to live with. I think the doctors feared having the government
come down on them," said Kennedy, whose interstitial cystitis was
diagnosed four years ago.

The pending regulations outline how physicians should treat the pain
that may accompany ailments such as cancer, arthritis, and back and
neck problems.

Treating pain with "dangerous drugs and controlled substances" (as the
rules call them) would not result in disciplinary action if the
medication has a legitimate medical purpose and if the state
guidelines are followed.

The proposed measures reflect medicine's new appreciation of the
importance and complications of pain control, said Dr. Daniel Brookoff
of Methodist Healthcare's Comprehensive Pain Institute. Licensing
boards have traditionally emphasized the addictive potential of
certain pain medications rather than the need to ease suffering, he
said.

"I think these guidelines will have an enormous impact if they become
widely known," Brookoff said.

Sandra Taylor, a 23-year-old West Memphis wife and mother, knows
severe pain. She is sometimes able to withstand pain from her sickle
cell disease that would knock most people out cold.

"(I'm) wide awake, hollering and crying. It seems unbelievable, but
that's the way it is," said Taylor, who is rarely pain-free.

She takes nothing for the dull aches in her back and joints. When the
pain climbs or explodes in a sudden sharp burst, she uses the narcotic
Percocet. When it fails, she heads to her doctor's office or the
emergency room for Demerol or morphine injections.

"You cry and moan. You just can't be still. You just can't find a
comfortable place to lie," Taylor said. She recently spent a week in
the Regional Medical Center at Memphis while doctors tried to relieve
her discomfort.

Dr. Patricia Adams-Graves, Taylor's doctor, said fear of addiction has
long hindered pain treatment. Tennessee's proposed changes probably
won't have much impact on physicians who rarely treat patients with
chronically painful conditions like sickle cell disease, she said.

"With some painful syndromes, you have to prescribe above the maximum
dose. That's where doctors have fear," said Adams-Graves, a University
of Tennessee, Memphis, assistant professor and director of The Med's
Diggs-Kraus Sickle Cell Center.

At high doses, doctors worry that pain medication will inadvertently
kill the patient by suppressing breathing.

Taylor said the staffs of emergency rooms are often
suspicious.

"That really hurts. They look at you funny. If all I wanted was the
drugs, I wouldn't have waited for hours in pain," she said. "I wish
more doctors had a better understanding of sickle cell pain."

Under the new guidelines, doctors would have to document a patient's
medical history and examine the patient.

They would also have to develop a written treatment plan, explain the
possible risks and benefits of the treatment, document that the
treatment is regularly re-evaluated and that plan is being updated.
Such plans could require some patients to undergo additional tests or
referrals to other physicians.

Beatty couldn't recall the board having taken action against any
physicians treating terminal cancer patients. But he said there have
been cases in which the intractability of a patient's pain was
debated. "Some old problems still manifest themselves in physicians
who fail to document (medical care) and fail to make referrals," he
said.

The Tennessee Medical Association (TMA) and the American Cancer
Society both argue for the revisions.

Dr. Alvin Mauer, a UT-Memphis professor emeritus, referred to a 1998
federal proposal that would have expanded the authority of the Drug
Enforcement Agency (DEA). Although the bill, which died in Congress,
targeted physician- assisted suicide, Mauer said, it would have had a
chilling effect on improving pain control.

"Sometimes patients may be getting doses of morphine that would seem
absolutely obscene to someone who is not familiar with cancer pain
control," said Mauer, who has directed both St. Jude Children's
Research Hospital and the UT-Memphis Cancer Center.

He said about 90 percent of cancer pain can be controlled.

A longtime cancer society volunteer, Mauer helped develop the
proposal.

Marc Overlock, TMA senior vice president, said doctors need the safety
net the plan would provide. "This will give doctors confidence no
one's going to be looking over their shoulder inappropriately."

Kennedy consulted with four or five doctors after her bladder
condition was diagnosed. All believed that she was in pain. For two
years, she found some relief from a procedure in which her bladder was
distended.

She was as worried about addiction as some of the physicians
were.

"Being a Christian and a teacher, I wanted to stay away from pain
medication. I had heard stories of people being addicted."

Eventually, pain came to rule her life. On good days, it felt as if
she had broken glass in her stomach. On bad days, it felt as if a
knife were slicing into her back.

Pain kept her away from the classroom five or 10 days each month. She
spent evenings and weekends in bed. Her husband did the cooking and
cleaning. Her family went to church without her.

"The pain was extreme, and it was there 24 hours a day," she said.
Finally, she took a friend's advice and made the seven-hour trip to
Brookoff's Memphis office.

A month after treatment with medications targeting the bladder
inflammation and the pain, Kennedy was back in church. She could go
fishing with her children and went shopping for the first time in
three years.

"It has made a drastic change in my life. Before, the only thing that
was keeping me alive were my children. Now I'm excited. I can do
things. I can go places."

Brookoff said patients are often so concerned about addiction they are
reluctant to take pain medication. He tells them that addicts use
drugs to escape from their lives.

"Addiction isn't a big issue for folks who use drugs to live. Their
pain has excluded them from their lives."

To reach reporter Mary Powers, call 529-2383 or E-mail
powers@gomemphis.com