DOCTORS GET GUIDANCE ON PAINKILLERS

Many Doctors Fear Government Action If They Prescribe Drugs Like Morphine,
Oxycontin.

New guidelines seek to improve treatment for millions of Americans with
unrelieved pain by spelling out exactly how to prescribe powerful
painkillers like Oxycontin and morphine without attracting the wrath of the
Drug Enforcement Administration.

Many doctors hesitate to prescribe narcotics, which are heavily regulated
because they can be abused by addicts.

The guidelines issued Wednesday, written by leading pain specialists
together with the DEA, stress that the drugs are safe for the proper patient
- -- and pledge that doctors won't be arrested for providing legitimate
therapy.

There is "unwarranted fear that doctors who treat pain aggressively are
singled out," said Patricia Good, DEA's drug-diversion chief.

The guidelines should help eliminate this "aura of fear," she said.

They come at a crucial time, said co-author David Joranson, pain policy
director at the UW Medical School. Fewer doctors are willing to prescribe
narcotic painkillers, known as opioids, partly because of the government's
high-profile crackdown on prescription-drug abuse. Some pharmacies won't
stock them for fear of burglaries.

"In some ways, pain management and the use of pain medications has become a
crime story when it really should be a health-care story," Joranson said.

The key message from the guidelines: "These are legitimate treatments.
They're essential for good medical care," said Dr. Russell Portenoy, pain
chief at New York's Beth Israel Medical Center and a well-known pain
specialist.

June Dahl, a UW-Madison professor of pharmacology, called the guidelines "a
great step toward reducing the barriers" to the treatment of severe pain.

She added that doctors have been reluctant to give adequate doses because of
"excessive fear" they might be investigated. "It's amazing how much
confusion there still is. There is a reluctance to give adequate doses. It
kind of seems unbelievable that there is a reluctance to treat people who
are dying, especially since there's no evidence that you can get addicted."

The DEA is distributing the guidelines to agents and prosecutors to help
them distinguish aggressive pain management from drug diversion. A lot of
opioid-taking patients in a practice shouldn't by itself signal suspicion,
the guidelines advise, while long-distance prescribing and lots of premature
refills might.

Fear of the DEA isn't the only obstacle. Many nonspecialists simply don't
know much about opioids.

Consider Cynthia C. Hildt, 65, a retired New York teacher who hunted relief
for disabling back pain for 20 years before Portenoy prescribed morphine.
Recently another doctor asked if she wasn't afraid of addiction.

"I said, I seem to have the choice of living with this unconscionable pain
or taking a pill that will help, and I don't believe that addiction is a
worry under those circumstances,' " Hildt said.

Indeed, the new guidelines stress that when prescribed properly for serious
pain, opioids hardly ever lead to addiction.

"Clearly, the risk is small unless someone has a history of substance
abuse," Dahl said.

About 30 percent of Americans suffer chronic pain; for as many as a third,
it can be disabling, Portenoy said.

How many need opioids but are undertreated? About 40 percent of cancer and
AIDS patients and the terminally ill, populations where opioids are
considered optimal care, he said.

"There are a lot of people with pain who need their pain controlled to
restore function and quality of life," Dahl said. "That must be balanced
with the need to protect the public from these drugs that can be diverted
and abused."

The DEA regulates doctors who prescribe controlled substances -- including
opioid painkillers such as morphine, codeine, fentanyl and Oxycontin -- to
ensure they're not diverted for illegal use.

Last year, 50 doctors nationwide were arrested on charges that they
prescribed or otherwise distributed controlled substances beyond the scope
of medical practice, somewhat fewer than in recent years, Good said.

On the other hand, opioid abuse is on the rise, a trend illustrated by
Oxycontin, blamed for more than 100 deaths. The long-acting pill is crucial
for severe cancer pain, but it can produce a quick, potentially lethal high
if crushed, snorted or injected.

Pain medication guidelines

The guidelines spell out how physicians can balance aggressive pain control
with the need to spot doctor-shopping abusers. Among the recommendations:

* Document a medical history, physical exam, pain assessment and treatment
plan in first-time patients' charts, with re-evaluations at follow-up
visits.

* Records should show evidence that the doctor evaluated the nature and
impact of the pain, earlier treatments, and alcohol and drug history.
Measuring pain intensity and extent of relief over time "is important
evidence of the appropriateness of therapy."

* Watch for abuse warning signs, such as a patient unwilling to allow
contact with previous doctors, escalating doses, seeking early refills or
requesting specific medications. These require careful evaluations -- they
might merely signal unrelieved pain.

* More worrisome signs include deterioration in functioning at home or work,
illegal activities such as stealing or forging prescriptions, and repeatedly
"losing" prescriptions.