STATE'S PLEA TO DOCTORS: LIMIT OPIATE PRESCRIPTIONS

Alarmed by a sharp increase in the use of narcotic painkillers by
injured workers, the state Department of Labor and Industries is
urging doctors to curtail their prescriptions for powerful opiates
such as OxyContin and methadone.

In a letter mailed yesterday to 10,000 doctors in the Northwest, the
department warns of "potentially serious problems that may arise" when
noncancer patients take long-acting opiates for chronic pain.

The agency said it has identified 40 to 60 accidental-overdose deaths
between 1995 and 2003 among injured Washington workers who took too
many narcotic painkillers or painkillers mixed with other drugs. Most
of the deaths occurred since 1999, after Labor and Industries began
paying for opiates for chronic-pain patients who were hurt on the job.

Dr. Gary Franklin, the department's medical director, said the letter
was spurred by a "dramatic shift" in prescription volume toward more
potent classes of painkillers - such as OxyContin instead of aspirin
with codeine - and a 60 percent increase in the average dosage for all
pain relievers.

The action comes at a time a growing number of Americans are abusing
prescription painkillers. OxyContin is often bought and sold illegally
for the high it can produce. Some abusers chew the drug to bypass the
pill's time-release coating.

Workers in pain

The most common on-the-job injuries are musculoskeletal, including
sprains, fractures and strains. Not surprisingly, narcotic painkillers
make up the largest category of prescription drugs for injured
workers. In 2003, the Washington Department of Labor and Industries
spent $7 million for 150,000 prescriptions for opiates and $3.3
million for 65,000 prescriptions for nonsteroidal anti-inflammatory
drugs, which also are used for pain.

"We felt that it was imperative to let people know to be careful,"
Franklin said.

Four months ago, state Medicaid officials stopped paying for OxyContin
and other expensive painkillers unless patients had medical
justification why they couldn't take cheaper alternatives such as
morphine and methadone. Thousands of patients and their doctors
flooded the state with appeals, forcing it to temporarily resume
paying for all narcotic painkillers without a waiver. The resumption
will end in May.

The high cost of OxyContin was the primary reason for the initial
Medicaid decision. The long-acting drug, which became available by
prescription in 1996, costs the state $5.06 for a dose equivalent to
60 milligrams of morphine, which costs $2.36. The equivalent dose of
methadone costs 25 cents.

Washington's workers'-compensation program, run by Labor and
Industries, spent $3 million on OxyContin in 2003, more than for any
other single drug. Narcotic painkillers are the most frequently
prescribed category of drugs for injured workers, followed by
nonsteroidal anti-inflammatory drugs, which are often used for pain.

Those two categories accounted for nearly 55 percent of the program's
400,000 prescriptions and 30 percent of the $26.1 million in drug
costs last year, said Jaymie Mai, pharmacy consultant for Labor and
Industries.

But Franklin said his agency's warning letters were prompted not by
drug costs, but by the potential for overprescription and misuse.
Franklin said much remains unknown about the potential for addiction
and whether patients who take opiates for long periods will need
increasingly higher doses to get the same relief.

Between 1997 and 2001, the average morphine-equivalent dose of opiates
such as OxyContin and methadone taken by injured workers in Washington
rose from 80 milligrams a day to 130 milligrams a day.

Franklin also said doctors must be especially careful in prescribing
long-acting opiates because many pain patients often take other drugs,
including antidepressants, muscle relaxants and sleeping pills.

Franklin cited a report published in the November 2003 edition of The
New England Journal of Medicine that concluded "prolonged high-dose
opioid therapy may be neither safe nor effective" and warned doctors
against "indiscriminate prescribing."

But Dennis Turk, professor of anesthesiology and pain research at the
University of Washington School of Medicine, said Franklin may be
using selective data to overstate the dangers of narcotic
painkillers.

Turk, a psychologist and the incoming president of the American Pain
Society, said advocates have worked for decades to get doctors to take
pain management seriously. Turk said researchers do not know the full
consequences of long-term opiate use. But he expressed concern that
legitimate pain patients might be penalized by a crackdown on
painkiller prescriptions.

"Any medication can be abused," Turk said. "But should the 10 percent
(who might abuse painkillers) be driving the treatment for the other
90 percent?"

Franklin's letter noted that the U.S. Drug Enforcement Agency reported
that a national survey of medical examiners in 2000 and 2001 turned up
146 deaths due to OxyContin and an additional 318 deaths where
OxyContin was the likely cause.

Turk said that might sound alarming if people didn't also know that
3,000 Americans die annually after taking ibuprofen.

Turk said Franklin's letter amounted to telling doctors not to
prescribe medication unless it benefits patients.

"I can't believe that you need to remind physicians of that," he
said.