WHEN GOOD INTENTIONS HURT

The job of the federal Drug Enforcement Agency is to bust drug crooks, not
encourage drug use.

But this month, the DEA gave narcotic painkillers an unusually glowing
review, saying they are "accepted around the world as the most important
approach" to managing severe, acute, chronic and even moderate pain from
surgery, cancer, AIDS and other suffering.

The un-DEA-like message is included in an unprecedented set of painkiller
guidelines issued by the agency after it teamed up with 17 pain-management
experts from around the country.

It comes after years of complaints that DEA investigators and other law
enforcers have been so determined to go after prescription drug abusers
that they are inadvertently hurting patients who really need the drugs.

Other unlikely national groups are jumping on the "painkillers can be a
good thing" bandwagon, too - including the National Association of
Attorneys General and the Federation of State Medical Boards. In so many
words, the groups are assuring both doctors and patients that if narcotic
drugs are being used properly, investigators won't come knocking at the door.

The trend, applauded by pain doctors and pain patients, represents a
pendulum swing away from years of bad publicity about abuse of prescription
drugs, particularly Purdue Pharma's OxyContin.

OxyContin - a time-release opioid valuable to cancer patients - has gotten
a bad reputation as "Oxy," a drug injected or snorted by adult addicts and
teens, dozens of whom have died as a result. Cephalon's Actiq, a lozenge on
a stick designed to deal with spikes of uncontrolled cancer pain, has
earned the street name perc-o-pop among abusers.

While the abuse of prescription drugs is widespread and growing, pain
patients say they are the real victims when they are denied desperately
needed medications by doctors who fear being investigated or causing their
patients to become addicted.

"Every time something becomes more popular in the drug world, I'm the one
who has to deal with the extra regulations and fear," said Lynn Repetto,
54, a Philadelphian who has suffered from chronic pain caused by
degenerating spinal discs and surgery.

Repetto, a registered nurse, spent 10 years worrying that her doctors would
stop giving her prescriptions for narcotic painkillers or that she wouldn't
find pharmacies willing to stock them. The investigatory zeal that greeted
OxyContin's abuse, she observes, probably didn't make it harder for abusers
to get the drug "but it made it harder for me to get it. And I was getting
it legally."

Until Repetto finally found more consistent relief when she had a morphine
pump implanted last year, her life illustrated the devastating consequences
of severe, chronic pain - consequences arguably worse than those caused by
painkiller addiction.

The pain was so bad at times that Repetto, who cannot work, thought about
suicide. "I would never have done that," she said, "but I couldn't close my
eyes for a second to sleep peacefully... . I'd pace, walk around the
kitchen, back and forth, back and forth. I'd think about all the things I
couldn't do."

The new DEA guidelines on prescription painkiller use, issued Aug. 11, are
meant to achieve a "better balance" between the opposing camps of pain
treatment and abuse prevention. The concept of balance is attracting new
support on both law enforcement and treatment sides.

"I think we have a special obligation to reassure the medical community
that we are not talking about [investigating] appropriate pain management,"
said Oklahoma's attorney general, W. A. Drew Edmondson.

As recent president of the National Association of Attorneys General,
Edmondson launched an initiative encouraging attorneys general nationwide
to be more active in end-of-life care issues - including making sure that
dying patients are able to get the pain relief they need.

The national Federation of State Medical Boards, representing the boards
that license and sanction the nation's doctors, has taken its own
progressive stand, recently approving updated painkiller-use guidelines.

They inform doctors that treatment of pain is a public health priority;
doctors won't lose their licenses if they dispense painkillers in
legitimate ways. In fact, says the federation, medical boards in two
states, Oregon and California, have disciplined physicians for not giving
patients enough pain medication.

Could undertreatment of pain become a hot new medical malpractice issue?
Three years ago, an Alameda County, Calif., jury found that a physician had
been reckless and committed "elder abuse" by denying adequate pain
treatment to an 85-year-old lung-cancer patient dying in agony as his
family watched helplessly.

But for all the progressive national moves toward a balanced approach on
painkillers, many doctors and law enforcers remain in a tug of war, with
patients "see-sawed between the two," said Willard Andrews, an oncologist
at Abington Memorial Hospital.

Figures from the two camps can conflict.

Pain doctors and experts, including those at the respected Pain & Policy
Studies Group at the University of Wisconsin, point to surveys showing that
specific patient groups suffer needlessly from under-prescription of
narcotic medications.

Widely accepted figures indicate that 40 percent of cancer patients are not
getting the pain relief they need, and that 50 percent of hospice patients
die in moderate to severe pain.

But there are no good figures on the total number of Americans in
unrelieved pain. "What I've heard is anywhere between 10 million and 100
million," said Will Rowe, executive director of the American Pain
Foundation, which is seeking funding for a nationwide pain survey.

On the law-enforcement side, investigators point to figures showing that
prescription painkiller abuse is rising. Newly released federal statistics
say admissions for narcotic painkiller abuse more than doubled between 1992
and 2002 - the latter year recording 84,000 admissions involving painkillers.

And investigators also pose this tough question: If so many people are not
getting the pain meds they need, then why is the painkiller drug market
booming? OxyContin sales alone totaled $1.9 billion for the 12 months
ending in June this year, up 11 percent from 2003, according to new data
from IMS Health, a leading pharmaceutical information and consulting company.

Painkillers "have been marketed by companies and used by doctors for
reasons they weren't meant to address," said Pennsylvania's attorney
general, Jerry Pappert. "Sprained ankle? I don't think so."

Meanwhile, new painkiller restrictions may assist the law-enforcement side
but at the expense of pain patients.

The same DEA that issued progressive guidelines on painkiller use is also
considering moving hydrocodones - a narcotics class that includes the
popular painkiller Vicodin - into a more restricted prescription category.
That could mean more problems for pain patients, including those who now
depend on Vicodin because their doctors are reluctant to prescribe already
highly restricted drugs such as Percocet.

Locally, in a move meant to discourage pain medication abuse, Independence
Blue Cross recently began requiring that doctors file a preauthorization
form before a patient is allowed to fill a prescription for more than 60
tablets of any controlled painkiller.

Doctors say the new requirement will give them more paperwork and could
discourage legitimate painkiller use. "For legitimate patients, it's
absolutely a headache to do this," complained King of Prussia internist
Frederic Becker.

Although she applauds the new DEA guidelines, Pam Kedziera, nurse manager
of the pain management team at the Fox Chase Cancer Center in Philadelphia,
thinks there are many hurdles ahead before America truly achieves a
balanced approach on the use-abuse of pain medications.

Patients themselves, she says, have been so stigmatized by the bad
publicity over painkillers that they are hesitant to ask for the relief
they know they need. "People are so afraid of being labeled" as addicts,
Kedziera said. "Patients have to learn to say to doctors, 'The pain is no
better than when I started this, so what do we do next?' "

Abington oncologist Andrews understands that stigma on a personal level. As
he went to a pharmacy to pick up painkillers for his mother, dying of
cancer, Andrews recalled feeling "like you're a narcotics abuser. Even as a
physician, you feel the negative stigma of narcotics use."