DOCTORS CAUTIOUS WITH PAIN PRESCRIPTIONS

Managing pain puts doctors in the position of divining which patients are
telling the truth and which are lying about their pain.

There's a joke in the Roanoke Valley medical community these days that
goes, "write a prescription, go to jail."

Doctors feel like they're under a microscope for prescribing
painkillers such as OxyContin and methadone, said Roanoke
interventional pain specialist Dr. Cyrus Bakhit, who runs the Pain
Management Center with Dr. Marc Swanson at 2110 Carolina Ave. S.W.

They can get sued for overtreating pain. They can get sued for
undertreating pain. And they can get prosecuted for the overdoses of
their patients.

Roanoke pain specialist Cecil Byron Knox faces trial again in November
in part for what federal prosecutors say was the prescription of
medication outside the scope of legitimate medical practice that they
say led to the death or serious injury of three people. In October, a
jury failed to convict Knox or his office manager, Beverly Gale Boone,
on any charges they faced.

Knox is one of about 100 doctors around the United States who have
faced criminal charges in connection with their prescribing practices,
the San Francisco Chronicle reported.

A result of the threat of prosecution is that many doctors are
practicing "defensive medicine," staying away from prescribing
opiates, said Dr. Sydney Vail, director of the trauma and trauma
critical care unit at Carilion Roanoke Memorial Hospital. Some doctors
who still prescribe the painkiller worry they might get pegged as an
"OxyContin doctor," Vail said. One patient who drives hours to see
Swanson told him that her primary care doctor said he would treat her
diabetes, he would treat her high blood pressure, but he would not
treat her pain.

While Swanson, Vail and Bakhit say that patients trading or selling
painkillers such as OxyContin are a real problem, Vail said the abuse
of OxyContin has been blown out of proportion in relation to that of
other prescription drugs, such as the painkillers Lortab and Percocet,
which are more widely abused.

As a result, some doctors are choosing to prescribe medications that
may not be as effective in treating pain and could be more toxic to
patients than OxyContin, the doctors said.

But all three doctors said they are not going to stop prescribing
painkillers they describe as "essential" to the care of their patients.

"No case in America will stop me from doing the right thing for my
patients," Vail said. Outside of pain management doctors, Vail said
he's probably one of the doctors who prescribes the most OxyContin in
the area.

The people who suffer when doctors are afraid to prescribe pain
medicine are the majority of the legitimate patients, the doctors
said. Many patients are undertreated for their pain because of those
fears, Swanson said. And patients have a right to effective pain
management under medical guidelines for care, Vail said.

Managing pain puts doctors in the position of divining which patients
are telling the truth and which are lying about their pain.

In some ways, Vail has it easier because there's little doubt that
patients are in pain when they show up at the trauma center with
everything from severe head and brain injuries to pelvic fractures and
burns.

"We see it all, and we treat it all," said Vail. Vail generally sees a
patient for about three months, and his practice is mainly concerned
with the treatment of what is known as acute pain. He describes acute
pain as pain that lasts during the healing of a wound and generally
goes away within six to eight weeks.

Chronic pain, meanwhile, persists indefinitely and often comes from
back and nerve injuries, Vail said.

Some of Vail's patients have told him they don't want to be prescribed
OxyContin.

It took three days to convince a female patient - who worried what her
friends would say and that she might get addicted if she started
taking oxycodone - that it would help her, Vail said. Once she started
taking the medication, the patient was able to participate in physical
therapy, and her condition improved more quickly, Vail said.

For Bakhit and Swanson, who treat patients who suffer from chronic
pain, it can sometimes be tougher to gauge how much they are really
suffering. They are two of five pain doctors affiliated with Carilion.

Bakhit, Swanson and Vail all emphasized that prescribing medication is
only one facet of pain management. Bakhit and Swanson also treat or
refer patients with interventional therapies that address nutritional,
psychological, behavioral and other issues.

Swanson and Bakhit acknowledge that diversion of painkillers is a
problem, but they argue that it is not limited to OxyContin. They
support the establishment of central databases so doctors can see what
other doctors may have prescribed to the same patient. But they say
that they think doctors who have taken all the precautions they can to
make sure patients aren't selling their medication shouldn't be held
responsible for patients' wrongdoing.

"It is unfortunate, if not illogical, to hold a doctor responsible for
something that is the personal responsibility of the patient," Bakhit
said. "What it comes down to is a few individuals taking advantage of
a system."

Still, vigilance about trying to keep the handful of people who abuse
or sell their medication is undoubtedly part of the job. Swanson and
Bakhit screen patients extensively and make them sign contracts.

Vail said that doctors know the warning signs of people who are
selling their medication: running out of prescriptions early, calling
to say their medication got stolen or they got mugged, for example.

And Vail said some people are very creative about getting medications.
One night when he was on call, he got paged. He spoke with a man who
claimed that one of Vail's colleagues, whom he named, had operated on
his mother. The man detailed the procedure to some degree of medical
specificity. The man knew enough to find out that Vail was on call and
to ask on his mother's behalf for Lortab, a prescription that can be
called in. (Prescriptions for OxyContin, meanwhile, must be submitted
in writing.)

"It was a perfect story, perfectly believable," Vail said. But he
checked the Carilion computer for the name the man gave for his mother
and found no listing. Then he called police, told them what happened
and gave them the man's name and phone number.

Other situations are not so clear-cut. Vail told the story of a
Roanoke patient with a history of chronic back pain on whom he has
operated twice. The patient contacted Vail three months after the
second surgery and asked for oral morphine.

Vail agreed to prescribe him a week's supply, with the understanding
that the patient would schedule an appointment with his primary care
physician to deal with his chronic pain.

Eight days later, the patient called Vail again. He said he wasn't
able to make the appointment with his primary care doctor and wanted
more medication. Vail referred him back to his primary care doctor and
did not write another prescription.

Another consequence of the closer scrutiny of doctors' prescribing
practices has led in some cases to patients with nowhere to turn for
pain management.

When Knox and most of his office staff were indicted in February 2002,
hundreds of his patients had nowhere to go, Swanson said.

Many came to the pain clinic at Carilion, said Swanson, who worked
there. The clinic closed down later that year, but the hospital system
now has five doctors, including Swanson and Bakhit, who specialize in
pain management .

Ninety percent of Knox's patients were the 1 percent to 2 percent of
patients other doctors have that they don't know what to do with,
Swanson said. He described some as "devastated": patients with gunshot
wounds to the spine, numerous back operations, degenerative disk disease.

Knox provided an important service in the medical community, Swanson
said.

And when the former Knox patients came to the clinic, doctors had no
way of telling whether they were telling the truth about the
medications they were taking because federal authorities had seized
the patient files.

Bakhit said doctors don't talk much about the case, but he indicated
that most doctors he's talked to are sympathetic to Knox.