Pubdate: Sun, 20 Mar 2016
Source: Philadelphia Inquirer, The (PA)
Copyright: 2016 Philadelphia Newspapers Inc
Author: Don Sapatkin


Guidelines Aim to Halt Steep Rise in Addiction. but Some Patients Are Worried.

As a teen growing up in Lansdale, Pat Allan may have experimented 
with painkillers.

But what put him in serious trouble, his family believes, was the 
Vicodin prescribed after his wisdom teeth were removed in high 
school. He escalated into abusing prescription opioids bought on the 
street and their cheaper cousin, heroin.

He was 30 years old when New York City police called to say he had 
been found dead of an overdose. His little sister Kay listened on her 
dad's speakerphone.

When her own wisdom teeth came out the next month, she declined the Vicodin.

"My whole family does," said Kay, now a 20-year-old nursing student 
at Penn State.

Last week, the federal government made its biggest move yet to 
educate Americans on the dangers of prescription painkillers, issuing 
detailed recommendations on their use.

The Centers for Disease Control and Prevention's "Guideline for 
Prescribing Opioids for Chronic Pain" unrelated to cancer is aimed at 
primary-care doctors. The 12 points range from trying nonaddictive 
therapies first to testing patients' urine to offering the 
overdose-reversal medication naloxone for families of high-risk 
patients to have at hand in case of disaster.

They say initial prescriptions should be for limited amounts. 
Research shows that many unused pills wind up in the hands of a child 
or sold on the street.

The guidelines largely agree with existing recommendations from other 
medical groups. But how they were announced guaranteed attention, 
especially from doctors: publication in the prestigious Journal of 
the American Medical Association, which also ran five related pieces. 
A sixth was published in the New England Journal of Medicine.

"They give us a lot more visibility," said Michael Ashburn, an 
anesthesiology professor at the Hospital of the University of 
Pennsylvania and director of the Penn Pain Medicine Center.

More than 20,000 deaths

More than 20,000 Americans a year die from prescription 
pain-medication overdoses. Thousands more die of heroin use, which 
some seek to avoid withdrawal sickness.

"That's a small city each year that's dying from these things," 
Ashburn said. In the 1980s and ' 90s, physicians realized that pain 
was generally undertreated. Many worried about giving patients 
addictive painkillers, but pharmaceutical marketing reassured that 
their pain medications were safe. The government allowed 
direct-to-consumer prescription drug advertising for the first time, 
fueling demand.

Opioid prescriptions skyrocketed, reaching 259 million - more than a 
bottle for every adult - in 2012, and then declining slightly. Many 
were long-term scripts for drugs like Percocet that were intended for 
short-term use.

There still are no gold-standard randomized trials of these drugs' 
effectiveness for chronic pain. Other studies have shown little 
benefit, and even harm for most, but not all, patients.

"Every day I have had new caution, new concern about prescribing 
narcotics," said Charles Cutler, a family physician in Norristown and 
president-elect of the Pennsylvania Medical Society.

For decades, doctors "focused on pain when we should have focused on 
function," said Chris Echterling, medical director for vulnerable 
populations for WellSpan Health, a central Pennsylvania hospital group.

"If your goal is to go biking, then we can get you biking with a 
little back pain," he said, using other therapies without overdose 
risk. "If you solely track the pain out of context of function you 
may not be improving things."

Charles P. O'Brien, founding director of Penn's Center for Studies of 
Addiction, said most doctors have little or no training in addiction, 
let alone prescription opioids.

O'Brien said the first thing he teaches medical residents is to 
respect the addiction potential of opioids. That doesn't mean not to 
use them, he said, but to understand when they are appropriate and 
what to expect, like withdrawal.

"Physical dependence is a normal adaptation; you take a drug and your 
body adapts to it and changes. When the drug stops, your body reacts 
to that change," O'Brien said.

"Addiction is getting a high, doctor-shopping, doing all those 
things. It's pathological." Genetic differences, he added, influence 
who goes from the first to the second.

State guidelines

In the absence of federal guidelines, many state medical societies 
created their own. Massachusetts Gov. Charlie Baker last week signed 
a law limiting initial opioid prescriptions to a seven-day supply.

New Jersey has voluntary guidelines in the works. Pennsylvania, where 
death rates from prescription-drug overdoses are lower - but rising 
faster - than the national average, released a series of 
recommendations for different specialties over the last year. They 
are posted at

Pennsylvania's guidelines make no mention of federal recommendation 
No. 9 - checking the Prescription Drug Monitoring Program, a database 
designed to detect doctor-shopping - because it is one of only two 
states that doesn't have one. (That should change in August.)

Patients adjusting

But patients who fear losing the drugs they need are worried about 
the new guidelines. "Three days or less will often be sufficient" is 
one example of a recommendation that some say could make doctors cut 
off needed medication.

Julie Odell says the nerve condition brought on by walking into a 
steel beam four years ago causes her so much pain - "as if somebody 
stabbed you with a screwdriver in the back of your head and the tip 
came out your eye" - that she'd have to give up her job teaching 
college writing without Vicodin tamping it down.

The 51-year-old from Roxborough has tried numerous alternatives: 
Botox, nerve ablations, acupuncture, yoga, Alexander technique, 
massage, physical therapists, chiropractors, IV lidocaine, and nearly 
20 medications. That would more than satisfy the guidelines, so she's 
not worried about losing her access to Vicodin.

But she worries about people who can't try so many options, like some 
of the people in her chronic pain support group on Facebook. "These 
are people in tiny towns, no specialist for 200 miles," Odell said.

"I think she has reasonable fears," said Echterling, the WellSpan 
physician based in York, Pa., who nevertheless strongly supports the 

Ashburn, the pain doctor at Penn, frames the question of whether and 
how much to prescribe this way: "Being liberal likely increases the 
risk of death, which of course is irreversible. ... If you end up 
prescribing a little bit too low," he said, "you have an opportunity 
to adjust the prescription and make it right."
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