PRESCRIPTION FOR PAIN

'PAIN-KILLER" is one of medicine's overblown promises. The pain is
often eased and delayed, not killed. In chronic cases, it always
comes back. The last thing that patients and doctors should be
worrying about as they use these imperfect medications is an arrest
for substance abuse by overzealous police.

But there are places in this country where patients and physicians do
have to worry. The CBS program "60 Minutes" and New York Times
columnist John Tierney have recently focused on the plight of a
47-year-old father of three and law school graduate serving a 25-year
drug-trafficking sentence in Florida.

Richard Paey has had to use a wheelchair since an auto accident 21
years ago left him with screws in his spine and persistent pain. He
also has multiple sclerosis. Despite three months of surveillance,
police found no evidence he was selling any of his drugs, but a
prosecutor still succeeded in convicting him on the grounds that he
could not himself have used the 25 pills a day he was getting. Paey
said he took that many pills, each of low dosage, to avoid higher-
strength pills that could tempt drug abusers and draw the attention
of the Drug Enforcement Administration. He is appealing his conviction.

Historically, doctors in the United States tended to under-medicate
patients with chronic pain for fear they would become addicted.
Improvements in medications and the development of the hospice model
for treating terminal patients have led to better pain management.
But doctors and patients in chronic but not terminal cases face
increasing scrutiny when patients need repeated prescriptions for
large quantities of controlled substances.

CBS interviewed Dr. Russell Portnoy, chairman of the department of
pain medicine at Beth Israel Hospital in New York, who said, "There
is a very deep concern on the part of the medical profession that the
authorities don't know anything about pain medicine and are so afraid
of prescription drug abuse that they tend to investigate or go after
prescribers on the basis of very weak evidence."

In Boston, Dr. Carol Warfield, chairwoman of the department of
anesthesia, critical care and pain medicine at Beth Israel Deaconess,
and a professor at Harvard Medical School, said that to her knowledge
there had been no recent cases in this state like Paey's. But she
said that here, too, doctors work in fear of patients becoming
addicted and of themselves suffering legal sanctions for their
prescribing practices.

Martha Coakley, district attorney for Middlesex County, said she does
not think that overzealous prosecution of prescription drug abuse is
a problem in this state. Speaking of her own office, she said, "We
would stop short of micro-managing" pain treatment. But she said
there is a problem of prescription drug users becoming addicted to
substances like OxyContin. Coakley is right that prescription drug
abuse is a problem, just as the use of methamphetamines, heroin, and
cocaine is. But patients will suffer needlessly if prosecutors and
the DEA do not fine-tune their investigations of suspected prescription abuse.