PILL STOPPERS

The DEA Acknowledges Yet Denies the Conflict Between Drug Control And Pain
Control

In a new pamphlet ( http://www.stoppain.org/faq.pdf ) offering advice to
doctors, pharmacists, and regulators about the appropriate use of
narcotics, the Drug Enforcement Administration acknowledges that people who
behave like addicts may simply be patients desperate for pain relief.

It notes that "drug-seeking behaviors" such as visits to several doctors,
requests for specific narcotics, demands for more medication, and
unilateral dose escalation "cannot immediately be ascribed to addiction"
and may instead be due to unrelieved pain. From the perspective of doctors
anxious to avoid prescriptions that attract the government's attention (
http://www.reason.com/0408/fe.ms.dr.shtml ), the DEA's discussion of this
phenomenon, known as "pseudoaddiction," is both welcome and worrisome.

On the one hand, the DEA admits that distinguishing between legitimate
patients and people looking to get high can be tricky.

On the other hand, even while calling uncontrolled pain "an enormous public
health problem," the DEA denies there is any conflict between preventing
nonmedical use of opioids and making sure that people who need painkillers
can get them in adequate doses.

Announcing (
http://www.medsch.wisc.edu/painpolicy/press_kit/8.11.04_transcript.pdf )
the publication of the pain medication pamphlet, which was prepared in
consultation with leading pain experts, the DEA's Patricia Good said the
government's goal is "ensuring both the ready access to prescription
opioids and the elimination of their abuse and diversion." Since pain
cannot be objectively verified-as the pamphlet notes, "self-report is the
'gold standard' for pain measurement"-this mission is plainly impossible,
and insisting on it is a mark of delusion or bad faith.

The pamphlet itself is less grandiose, implicitly conceding that the
complete elimination of nonmedical use is unrealistic, but it still does
not come to terms with the unavoidable conflict between drug control and
pain control. "These two goals are not in conflict," it says. "They coexist
and must be balanced." Yet the very idea of balancing these goals means
there is a tradeoff between them. A less skeptical attitude toward
patients, for instance, means fewer people in pain will be turned away, but
it also means some fakers will slip through. Although the DEA generously
allows that "any physician can be duped," its proposed solution-watching
for the tell-tale signs of drug abuse-hardly seems adequate in light of
pseudoaddiction, which it says "greatly complicates the assessment of
drug-related problems." Likewise, the pamphlet tells pharmacists to watch
for "red flags" in prescription patterns and customer behavior but cautions
that they do not necessarily mean anything illegal is going on. "The
parameters of acceptable medical practice include patterns of drug
prescription...that may raise a 'red flag' for both clinicians and
regulators," the DEA admits.

It also notes that misconceptions about addiction-in particular, the idea
that "simple exposure to opioids" is enough to produce it, or that
tolerance and withdrawal symptoms are its essence- "can lead to
inappropriate targeting of practitioners and patients for investigation and
prosecution." In case of such targeting, physicians are advised not only to
keep careful, detailed patient records (a good idea anyway) but to consult
pain specialists even when their guidance is not needed, because a record
of having done so "would be reassuring to a regulator should the therapy
ever be questioned." Such defensive maneuvers do not seem to jibe with the
DEA's aspiration that "law enforcement and regulatory authorities should
avoid interfering in pain management."

The DEA says there's no need for law-abiding doctors to worry, because "the
arrest and indictment of a physician cannot occur unless he or she can be
shown to have knowingly and intentionally distributed or prescribed
controlled substances to a person outside the scope of legitimate
practice." In reality, of course, this determination does not happen until
trial (assuming there is one), and by then the damage to a doctor's
reputation and livelihood may be irreparable.

Even conscientious doctors worry that state or federal regulators might
suspect them of operating "outside the scope of legitimate practice." This
pamphlet, though presumably intended to be reassuring, demonstrates there
are ample grounds for such concern.

During the same press briefing (
http://www.medsch.wisc.edu/painpolicy/press_kit/8.11.04_transcript.pdf ) in
which the DEA's Patricia Good denied that drug law enforcement has a
chilling effect on pain treatment, David Joranson, one of the experts who
helped produce the pamphlet, noted that "the medical and regulatory
environment for pain management seems to be worsening," with physicians
increasingly fearful of investigation and reluctant to prescribe opioids.
"In some ways," he said, "the use of pain medications has become a crime
story when it really should be a health care story."