Pubdate: Mon, 16 Jan 2006
Source: St. Louis Post-Dispatch (MO)
Copyright: 2006 St. Louis Post-Dispatch
Contact:  http://www.stltoday.com/
Details: http://www.mapinc.org/media/418
Author: Jane Brody
Bookmark: http://www.mapinc.org/find?232 (Chronic Pain)
Note: Jane Brody is a New York Times columnist.

TREATING CHRONIC PAIN SHOULDN'T BE THIS HARD

Patients with debilitating pain from chronic illness, accidents,
surgery or advanced cancer have long had problems getting adequate
medication to control their pain and make life worth living.

Now the federal government, and especially the Drug Enforcement
Administration, are working overtime to make it even harder for
doctors to manage serious pain, including that of dying patients
trying to exit this world gracefully.

In an article in the current New England Journal of Medicine titled "The Big
Chill: Inserting the DEA Into End-of-Life Care," two specialists in palliative
care, Dr. Timothy E. Quill and Dr. Diane E. Meier, state that despite some
physicians' commitment to treat pain and despite the effectiveness of opioid
drugs such as OxyContin and morphine, "abundant evidence suggests that
patients' fears of undertreatment of distressing symptoms are justified."

They continue, "Although a lack of proper training and overblown fears
of addiction contribute to such undertreatment, physicians' fears of
regulatory oversight and disciplinary action remain a central
stumbling block."

In addition to a case before the United States Supreme Court, Gonzales
v. Oregon, that threatens to undermine Oregon's Death With Dignity
Act, the DEA has recently increased raids on doctors' offices,
confiscating files and arresting doctors on charges of overprescribing
narcotics to patients who are addicts or drug dealers.

Most of these physicians are compassionate people trying to help
suffering patients but are sometimes fooled by clever addicts, drug
dealers or undercover agents who fake their pain.

Should the court rule against Oregon, the DEA could turn to all
physicians whose patients die while getting prescribed opioids or
barbiturates, even if the drugs were administered only to relieve
intractable pain, not to hasten death.

Yes, there are bad apples among members of the medical profession.
There are some doctors who charge for medical exams that they never do
and provide phony patients with prescriptions for narcotics to feed
their habits or sell on the street.

But should all physicians be subject to intense scrutiny by the DEA
and risk arrest and prosecution, leaving legitimate patients to suffer
intensely or scramble to find other doctors willing to risk taking
them on?

Doctors have no certain way to measure patients' pain other than to
ask them. Patients should be asked to rate their pain, say, on a scale
of 1 to 10, with 10 being the most intense they can imagine. "Model
Guidelines for the Use of Controlled Substances for the Treatment of
Pain" were established in 1998, and every physician who prescribes
narcotics should know them by now. These guidelines emphasize that
documentation is critical to proper pain management.

With patients who are prescribed strong painkillers, doctors first are
supposed to obtain a medical history, perform a physical examination,
ask about addictive behaviors and whether other treatment options have
been tried, and fully record what they find.

Prescriptions for controlled substances such as narcotics cannot be
refilled automatically. When a patient asks for a new one, a
well-documented follow-up visit is necessary. The doctor should ask
about the kinds and amounts of painkillers being taken, side effects,
performance of daily activities and aberrant drug-related behaviors.

Dr. Jennifer P. Schneider, a pain management and addiction medicine
specialist in Tucson, gives this example: "Back pain today is 4 (out
of 10), walks the dog 15 minutes daily, constipation is controlled
with Senokot-S, patient is on schedule with his meds."

She advises physicians, "If a patient lies about his medical problems
and turns out to be a drug abuser, at least you've documented that you
were acting in good faith."

The growing number of arrests of pain management specialists is
exacting high costs for patients, physicians and medical insurers.
Some doctors order costly but unnecessary diagnostic tests so they can
show the DEA a reason for prescribing strong pain medication.

Many doctors are simply unwilling to prescribe narcotics, no matter
how much a patient suffers. Ignorance, as well as a fear of the DEA,
plays a role. For example, the surgeon who performed my double-knee
replacement a year ago told me, in reference to OxyContin, a synthetic
opioid: "I don't like to prescribe these drugs. Patients have too hard
a time getting off them."

Well, sir, if you never prescribe them, then chances are you never
learned how to help patients stop them. Many doctors and patients fail
to understand the difference between physical dependence and addiction.

A critical difference

An addict uses a drug to get high, becomes tolerant and needs
ever-increasing amounts to maintain that high. Patients taking
narcotics for pain don't get high; they get relief from their pain,
and when larger doses are needed, it is usually because their pain has
become more intense, as often happens in patients with advanced cancer
or degenerative diseases.

Physical dependence occurs in almost everyone who takes a narcotic for
two weeks or more. The body adapts to the presence of narcotics, so a
patient cannot go off them abruptly without suffering serious withdrawal.

I asked Schneider how to go off narcotics safely. She suggested
cutting back 10 milligrams every three days (the exact amount would
depend on the dose a patient is on). If at any point in the weaning
process my pain became more intense, I was to go back to the last
dose, wait a week, then try to resume the weaning.

As I neared the end, the cutback was 5 milligrams every three days.
Then the dose was down to nothing, and no withdrawal symptoms, either.

Having heard only about those who, like Betty Ford, got hooked on
painkillers, many patients are afraid of becoming addicted if
narcotics are prescribed. But it is the rare patient who becomes
addicted, and it is nearly always someone with a history of addiction,
typically to alcohol.

Even with dying patients, the families and physicians often shy away
from narcotics for fear of addiction, as if it mattered whether
someone near the end of life - in desperate pain or extreme agitation
- - became addicted to the morphine that could provide almost instant
relief.

Proper pain management for dying patients can facilitate important
communication between patients and their loved ones and provide what
most people would call "a good death."

"Pain is a common symptom in patients nearing the end of life," with
up to "77 percent of patients suffering unrelieved, pronounced pain
during the last year of life," Dr. Timothy J. Moynihan wrote in Mayo
Clinic Proceedings in 2003.

In their current article, Quill of the University of Rochester School
of Medicine and Meier of Mount Sinai School of Medicine stated,
"Allowing DEA agents, trained only to combat criminal substance abuse
and diversion, to dictate to physicians what constitutes acceptable
medical practice for seriously ill and dying persons" may make doctors
increasingly reluctant to prescribe needed medications and "end up
abandoning patients and their families in their moment of greatest
need."

Jane Brody is a New York Times columnist.
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