NEW STATE LAW LEAVES PATIENTS IN PAIN

It was meant to curb rising overdose deaths. But Washington's new
pain-management law makes it so difficult for doctors to treat pain
that many have stopped trying, leaving legions of patients without
life-enabling medication.

Charles Passantino stared at his doctor in disbelief.

A 64-year-old patient with a crippling liver disease, Passantino had
received treatment for eight years for chronic pain. He took small
doses of oxycodone, a generic painkiller, to free his muscles from
stiffness and swelling.

With the pills, he got by. Without them, just walking from bedroom to
living room proved unbearable.

Now, with little explanation and no warning, he was being dumped.

In March, Passantino's doctor told him that his Pierce County clinic,
part of the Community Health Care network, was no longer treating
chronic-pain patients. The doctor wrote one last oxycodone
prescription - 25 pills, 5 milligrams each, good for maybe a week -
and suggested that Passantino cut the tablets into pieces, to make
them last longer.

Good luck finding another doctor, the physician said.

What happened to Passantino is a scene that has played out in medical
offices across Washington, thanks to new state rules governing the
prescribing of painkillers. Those rules - which, among other things,
impose restrictions upon doctors once certain dosage levels are
reached - have driven so many health-care providers from the field
that many pain patients now struggle to find care.

State officials say Washington's new pain-management law will help
reverse a rising tide of overdose deaths.

But the law does nothing to specifically address the risks of
methadone - by far, the state's number-one killer among long-acting pain drugs.

What's more, hundreds if not thousands of patients have been denied
life-enabling medications, cut off or turned away by doctors leery of
the burdens and expense imposed by lawmakers, according to hospital
representatives and consumer advocates.

At least 84 clinics and hospitals now refuse new pain patients, and
some have booted existing patients, The Times found.

The growing legion of untreated pain patients has become so
troublesome that some clinics, like one in Everett, post signs that
ward off walk-ins: "We do not treat pain patients."

Across the nation, the annual death toll from prescription
painkillers continues to escalate, more than tripling from 1999 to
2008, according to statistics that federal health officials released
last month.

Confronted with this epidemic, health officials in other parts of the
country have been eying Washington's groundbreaking law with special
interest, says Dr. Lynn R. Webster, medical director of a Utah
pain-research center and a national expert on preventing abuse of
narcotic painkillers.

But Washington's approach, he says, is not a model worth emulating.
He told The Times: "If other states follow suit, many patients could
suffer needlessly."

Unanswered pleas

Desperate to ration what pills he had left, Passantino quartered his
oxycodone tablets into tiny, chalky nuggets, each one good for just a
single milligram of relief.

But by April, his supply ran out.

Most days he curled up in bed. Even simple pleasures - watching
television or reading a book - became unbearable.

His wife, Jennifer, hunted down a list of 60 physicians and clinics
that work with Medicaid patients. With help from a relative she
called every provider on the list, pleading for someone to treat her
husband. She tallied the answers in a journal. Every answer was no.

They once could have afforded good care and expensive medication.
Jennifer earned a six-figure income as an executive for a consumer
health company. Charles home-schooled their two daughters.

But in his 40s, Charles was diagnosed with diabetes. By his 50s, he
developed end-stage liver disease - the kind associated with
non-alcoholics - linked to fatty deposits that cause inflammation and scarring.

Struggles at work pushed Jennifer into unemployment. She later landed
two part-time jobs - neither with health insurance - at a local
department store and an accounting firm.

Today, they are poor by every state standard. Charles is enrolled in
Medicaid to cover his $2,700 to $3,200 monthly prescription costs. To
stay in the program, the couple's annual income cannot exceed $35,000.

In May, a month after Charles finished his last pill, Jennifer wrote
to Gov. Chris Gregoire. Though not yet in effect, the state's
pain-management law was creating a devastating impact, her letter said.

"Please help me get the care my husband needs," she wrote.

Charles had never felt more depressed or hopeless, the letter said,
and his condition was "continuing to deteriorate."

Then, after months of closed doors, Charles secured an appointment at
Seattle's Swedish Medical System.

But the examination came to an abrupt halt when a nurse practitioner
refused to write a prescription for oxycodone. Instead, she suggested
methadone, Passantino says.

With Medicaid patients, the state saves money by restricting their
access to costlier drugs. Washington designates methadone, which
costs less than a dollar a dose, as a preferred painkiller.
Oxycodone, three to four times more expensive, isn't on the list.

But Passantino recognized the danger placed before him. He knew
methadone could kill him.

Unlike other narcotic pain drugs, or opioids, which dissipate from
the body within hours, methadone lingers in the bloodstream for days,
potentially building to toxic levels. The drug can paralyze
respiratory muscles; victims fall asleep and stop breathing.

Doctors had warned Passantino that his damaged liver couldn't process
drugs with such extended duration. That was why the state had allowed
him to get oxycodone in the first place.

The nurse practitioner apologized, said there was nothing more to be
done, and sent Passantino home with no relief.

Lawmakers argue from experience

When the state Legislature deliberated over the pain-management bill
in 2010, the most striking voice of opposition belonged to Sen.
Darlene Fairley, D-Lake Forest Park, a paraplegic whose spine had
been crushed in the 1970s in an accident with a drunken driver.

"I worry that this legislation gets in the way of longtime patients
and their doctors," Fairley warned her fellow lawmakers.

Fairley feared her medication - 5 milligrams of oxycodone daily -
would become difficult to obtain. Supporting herself on a crutch, she
said, "It worries me because obviously I take pain medications - and
I can tell what may happen in later years as the pain gets worse."

But the bill's supporters assured the public that longtime patients -
like Fairley, like Charles Passantino - would not be turned away and
made to suffer.

Lawmakers heard testimony about patients' growing reliance on
narcotic pain drugs, which contributed to addiction and diversion.
Other medical experts cited a steep climb in prescription-drug
deaths, surpassing the state's annual toll of traffic fatalities.

The law's co-sponsor, Rep. Jim Moeller, D-Vancouver, recounted his
experience as a chemical-dependency counselor helping people hooked
on prescription drugs.

Sen. Karen Keiser, D-Kent, rallied support with her account of
receiving a prescription for vast amounts of OxyContin, a powerful
narcotic painkiller, after she slipped and broke a knee.

"I didn't need that much medication," she said of her 2009 accident.
"Doctors pass out pain medications almost without thinking. What
we're trying to do is put guidelines in place and give doctors pause."

For lawmakers, there was also a financial incentive. The Department
of Labor & Industries, which oversees medical compensation for
injured workers, predicted the new law would result in fewer
prescriptions for opioid medications, saving the state an estimated
$13 million a year, according to legislative fiscal notes.

The law passed with minimal opposition, 96-1 in the House and 36-12
in the Senate.

Coupled with new rules passed by medical licensing boards, the law
requires practitioners to document patient backgrounds and track
behavior; conduct random urine screenings; and - most important of
all - consult with a pain specialist if daily doses exceed the
equivalent of 120 milligrams of morphine. Cancer and hospice patients
are exempt, as are post-surgical patients and those with pain from
sudden injury.

The law already applies to all medical providers except for doctors
and physician assistants. The two remaining groups will be covered as
of next month, although many doctors have already begun reacting to the law.

The requirement to consult a specialist whenever daily doses climb
above 120 milligrams has caused the most anxiety among medical providers.

Washington has at least 1.5 million people who struggle with chronic
or acute pain, the American Academy of Pain Management estimates. The
state has thousands of practitioners with prescribing privileges. But
as of last month, the state's sanctioned list of pain specialists
numbered just 13.

Moeller told The Times that he's heard from frustrated patients,
mostly on Medicaid or Medicare, who have been denied pain medications
since the law's passage. Most had been taking doses below the
120-milligram threshold. "We're kind of scratching our heads,
thinking, 'Why are they being denied then?' We don't understand," Moeller said.

At the same time, he's heard from medical providers grateful for
being able to point to the new rules as a basis for refusing large
amounts of painkillers. Moeller said he thinks patients are being
turned away not because of the law, but because prescribers have
become frustrated with trying to distinguish patients in legitimate
pain from addicts or scammers. "I think this is a change in the right
direction, not the wrong one," he said of the law.

Moeller called it "unfortunate" that Medicaid covers narcotic
painkillers but not such alternative treatments as acupuncture,
physical therapy and massage.

Lawmakers plan to hold a work-study session on the state's new
pain-management framework in the coming months, hearing from patients
and from providers who helped write the rules. "With the rules,"
Moeller said, "I think you'd have to live under them for a while
before you'd know exactly what to change."

Warnings about methadone

While lawmakers embraced anecdotes of patient abuse and provider
excess, the state's new rules sidestepped any special measures to
account for methadone's complexity and risk.

Dr. Sean Emami of the American Academy of Pain Management urged
legislators to consider additional restrictions or public warnings
when methadone was prescribed for pain.

"Methadone deserves special attention here," he testified.

At least 2,173 people died in Washington by accidentally overdosing
on methadone between 2003 and 2010, a Seattle Times analysis of death
certificates shows. Among long-acting painkillers - a group that
includes OxyContin, fentanyl and morphine - methadone accounts for
less than 10 percent of the drugs prescribed but more than half the
deaths, The Times found.

The drug has taken a particularly dramatic toll among the poor, who
account for about half of the fatalities. To save money, the state
steers Medicaid patients and recipients of workers' compensation to
methadone, one of only two long-acting painkillers on the state's
list of preferred drugs.

Emami detailed a federal study that found for every 1,000 pain
patients given methadone, two died within the first two weeks.

Methadone victims often die within the first days of use - sometimes
after just one 5-milligram dose - and at levels far below the new
law's 120-milligram threshold, according to autopsy findings by the
King County Medical Examiner's Office.

Other physicians submitted research that showed many patients - even
family practitioners - were unaware of methadone's unique risks, such
as how it lingered in the body for days or its volatility when
combined with other common medications.

The state's new rules, passed by licensing boards, give a nod to
methadone - but in an odd way that suggests the drug is different
without treating it as so. The rules say "long-acting opioids,
including methadone, should only be prescribed" by medical providers
"familiar with its risk and use." Anyone prescribing long-acting
opioids "should" complete at least four continuing-education hours
relating to the topic, the rules say.

The rules single out methadone by name but do nothing to demand
additional warnings or training when the drug is prescribed. And the
rule's language - using "should," not "shall" - turns the rule's
elements into a suggestion rather than a requirement. Doctors and
other medical providers should pursue continuing education about
prescribing long-acting opioids - but they don't have to.

Hopes raised and dashed

Charles Passantino's wife, Jennifer, continued to work the phone,
determined to find a way to relieve her husband's pain.

She enlisted the American Pain Foundation, which provided a contact
to Dr. Jeff Thompson, who oversees Medicaid prescription programs for
the state.

Informed of Passantino's plight, Thompson was stunned and
sympathetic, Jennifer says. He became an advocate for the family and
reported back with good news: He'd convinced Community Health Care to
reinstate Passantino as a pain patient.

"After talking to both parties, I got them hooked back into the
system," Thompson told The Times.

Passantino, hopes raised, showed up for an appointment at Community
Health - only to have a practitioner refuse to provide oxycodone or
any other opioid. The state couldn't order otherwise; Community
Health is a private clinic. Once again, Passantino was turned away.

"There was no light in my life, no happiness," Passantino says. He
thought of suicide, but his faith sustained him. A plaque over his
front door was a talisman: "Jesus is The Head of this House."

Desperation led to one more option: medical marijuana. Without
hesitation, a doctor authorized a state-required patient card.

"The irony did not escape us," Jennifer says. "We can't get a legal
pain drug anywhere in the state of Washington. But we can have all
the pot we want."

'They saw a responsible patient'

Passantino's quest for care became a crusade for Elin Bjorling, who
oversees the Washington office of the American Pain Foundation, a
nonprofit group that serves as an advocate for patients.

This fall, Bjorling released a survey that found dozens of health
clinics have adopted new policies refusing to treat chronic-pain patients.

"This is a crisis that is causing widespread and needless suffering," she says.

In Passantino's case, Bjorling canvassed dozens of doctors and
marshaled her organization's forces to alert the Governor's Office
and lawmakers to Passantino's situation. In September, she broke
through: A University of Washington clinic agreed to examine Passantino.

"They took a look at me and saw a responsible patient who had taken
small doses of pain pills - no more than what they give infants - for
more than eight years without problems," Passantino says.

The clinic agreed to treat Passantino - and put him back on
oxycodone, six months after he'd been cut off.

Once more, with each dose, Passantino is temporarily freed from pain.
He enjoys short walks with his wife along their tree-lined neighborhood.

"As happy as I am," Jennifer says, "I know that we had extraordinary
help in finding care. We're an exception. Others won't be able to
follow in our footsteps.

"There are many other people suffering in pain out there, and there's
nobody to help them."

News researchers Gene Balk and David Turim contributed to this report.