LET'S GET SERIOUS ABOUT RELIEVING CHRONIC PAIN

Patients with debilitating pain from chronic illness, accidents,
surgery or advanced cancer have long had problems getting adequate
medication to control their pain and make life worth living.

Now the federal government, and especially the Drug Enforcement
Administration, is working overtime to make it even harder for
doctors to manage serious pain, including that of dying patients
trying to exit this world gracefully.

In an article in the current New England Journal of Medicine titled
"The Big Chill: Inserting the D.E.A. into End-of-Life Care," two
specialists in palliative care, Dr. Timothy E. Quill and Dr. Diane E.
Meier, state that despite some physicians' commitment to treat pain
and despite the effectiveness of opioid drugs like OxyContin and
morphine, "abundant evidence suggests that patients' fears of
undertreatment of distressing symptoms are justified."

They continue, "Although a lack of proper training and overblown
fears of addiction contribute to such undertreatment, physicians'
fears of regulatory oversight and disciplinary action remain a
central stumbling block."

Obstacles to Relief

In addition to a case before the United States Supreme Court,
Gonzales v. Oregon, that threatens to undermine Oregon's Death With
Dignity Act, the D.E.A. has recently increased raids on doctors'
offices, confiscating files and arresting doctors on charges of
overprescribing narcotics to patients who are addicts or drug dealers.

Most of these physicians are compassionate people trying to help
suffering patients but are sometimes fooled by clever addicts, drug
dealers or undercover agents who fake their pain.

Should the court rule against Oregon, the D.E.A. could turn to all
physicians whose patients die while getting prescribed opioids or
barbiturates, even if the drugs were administered only to relieve
intractable pain, not to hasten death.

Yes, there are bad apples among members of the medical profession.
There are some doctors who charge for medical exams that they never
do and provide phony patients with prescriptions for narcotics to
feed their habits or sell on the street.

But should all physicians be subject to intense scrutiny by the
D.E.A. and risk arrest and prosecution, leaving legitimate patients
to suffer intensely or scramble to find other doctors willing to risk
taking them on?

Doctors have no certain way to measure patients' pain other than to
ask them. Patients should be asked to rate their pain, say, on a
scale of 1 to 10, with 10 being the most intense they can imagine.
"Model Guidelines for the Use of Controlled Substances for the
Treatment of Pain" were established in 1998, and every physician who
prescribes narcotics should know them by now. These guidelines
emphasize that documentation is critical to proper pain management.

With patients who are prescribed strong painkillers, doctors first
are supposed to obtain a medical history, perform a physical
examination, ask about addictive behaviors and whether other
treatment options have been tried, and fully record what they find.

Prescriptions for controlled substances like narcotics cannot be
refilled automatically. When a patient asks for a new one, a
well-documented follow-up visit is necessary. The doctor should ask
about the kinds and amounts of painkillers being taking, side
effects, performance of daily activities and aberrant drug-related behaviors.

Dr. Jennifer P. Schneider, a pain management and addiction medicine
specialist in Tucson, gives this example: "Back pain today is 4/10,
walks the dog 15 minutes daily, constipation is controlled with
Senokot-S, patient is on schedule with his meds." She advises
physicians, "If a patient lies about his medical problems and turns
out to be a drug abuser, at least you've documented that you were
acting in good faith."

A Fear of Prosecution

The growing number of arrests of pain management specialists is
exacting high costs for patients, physicians and medical insurers.
Some doctors order costly but unnecessary diagnostic tests so they
can show the D.E.A. a reason for prescribing strong pain medication.

Many doctors are simply unwilling to prescribe narcotics, no matter
how much a patient suffers. Ignorance, as well as a fear of the
D.E.A., plays a role. For example, the surgeon who performed my
double-knee replacement a year ago told me, in reference to
OxyContin, a synthetic opioid: "I don't like to prescribe these
drugs. Patients have too hard a time getting off them."

Well, sir, if you never prescribe them, then chances are you never
learned how to help patients stop them. Many doctors and patients
fail to understand the difference between physical dependence and addiction.

An addict uses a drug to get high, becomes tolerant and needs
ever-increasing amounts to maintain that high. Patients taking
narcotics for pain don't get high; they get relief from their pain,
and when larger doses are needed, it is usually because their pain
has become more intense, as often happens in patients with advanced
cancer or degenerative diseases.

Physical dependence occurs in almost everyone who takes a narcotic
for two weeks or more. The body becomes adapted to the presence of
narcotics (that is, becomes physically dependent on them). A patient
cannot go off them abruptly without suffering serious withdrawal.

A Gentle Weaning Process

I asked Dr. Schneider how to go off narcotics safely. She suggested
cutting back 10 milligrams every three days (the exact amount would
depend on the dose a patient is on). If at any point in the weaning
process my pain became more intense, I was to go back to the last
dose, wait a week, then try to resume the weaning.

As I neared the end, the cutback was five milligrams every three
days. Then the dose was down to nothing, and no withdrawal symptoms, either.

Having heard only about those who, like Betty Ford, got hooked on
painkillers, many patients are afraid of becoming addicted if
narcotics are prescribed. But it is the rare patient who becomes
addicted, and it is nearly always someone with a history of
addiction, typically to alcohol.

Even with dying patients, the families and physicians often shy away
from narcotics for fear of addiction, as if it mattered whether
someone near the end of life - in desperate pain or extreme agitation
- - became addicted to the morphine that could provide almost instant relief.

Proper pain management for dying patients can facilitate important
communication between patients and their loved ones and provide what
most people would call "a good death."

"Pain is a common symptom in patients nearing the end of life," with
up to "77 percent of patients suffering unrelieved, pronounced pain
during the last year of life," Dr. Timothy J. Moynihan wrote in The
Mayo Clinic Proceedings in 2003.

In their current article, Dr. Quill of the University of Rochester
School of Medicine and Dr. Meier of Mount Sinai School of Medicine
stated, "Allowing D.E.A. agents, trained only to combat criminal
substance abuse and diversion, to dictate to physicians what
constitutes acceptable medical practice for seriously ill and dying
persons" may make doctors increasingly reluctant to prescribe needed
medications and "end up abandoning patients and their families in
their moment of greatest need."