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Pain care guidelines created for doctors
Physicians often fear facing prosecution for prescribing needed drugs
By CZERNE M. REID

Posted: Aug. 11, 2004

National pain experts and the government have issued new guidelines to help physicians avoid contributing to societal drug abuse and at the same time educate law enforcement officers about basic pain management.

Often, doctors are reluctant to prescribe potentially addictive drugs for fear that they will be scrutinized and prosecuted by the Drug Enforcement Administration.

The document - in the form of answers to 30 frequently asked questions - will help keep drug enforcement officers from interfering with doctors who legitimately treat pain, according to the DEA and pain experts.

"It is important that the two groups come together so that the mystique and misconceptions about the medications can be cleared up," said Raymond Gaeta, director of Stanford University's Pain Management Center.

"The FAQ is a first step toward reversing what appears to be an increasingly unfriendly environment for pain management," said David Joranson, director of the Pain and Policy Studies Group at University of Wisconsin-Madison and one of the paper's authors.

"We're not trying to push drugs," Joranson said, "but when drugs are necessary, there are some issues that must be addressed."

About 40% of people with severe pain as a result of cancer or AIDS, and those who have end-of-life pain, are undertreated, said Russell Portenoy, chairman of the pain medicine and palliative care department at Beth Israel Medical Center in New York. Among those likely to be undertreated are pain patients who have a history of abuse or addiction, Portenoy said.

The new document specifically addresses pain relievers called opioids.

The class includes drugs such as morphine, codeine, methadone and oxycodone. Also in that class is hydrocodone, which may face tighter restrictions by the DEA.

"Opioids appear to be underused and stigmatized," Portenoy said.

The DEA ranks drugs according to their potential for addiction and sets prescription guidelines.

Many prescribers view the DEA as "scary" and at odds with the goals of good patient care, said Patricia Good, chief of the liaison and policy section in the DEA's Office of Diversion Control. She said this is because some providers hold misconceptions about the administration's role or beliefs in terms of prescribing potentially addictive drugs.

"The goal is not to eradicate them," Good said, "but to prevent their illicit use."

The document comes after the recent case of Milwaukee psychiatrist Richard I.H. Wang, who is under investigation in the prescription of dangerous levels of addictive painkillers.

It also follows up on a 2001 statement the DEA issued in collaboration with 21 professional societies calling for balanced policy that addressed both pain undertreatment and prescription drug abuse.

The group decided to put together an educational document that could be easily understood, frequently updated and widely disseminated, Portenoy said.

The DEA plans to include the document in the registration process for physicians, and widely distribute it to regulatory and law enforcement personnel. Gaeta suggested that the information be sent to individual physicians and - as an incentive - incorporated into continuing medical education seminars for credit.

The release of the document begins a long process of breaking down many barriers, which are a consequence of the myths people hold about pain, addiction and the effects of pain medication, said June Dahl, professor of pharmacology at UW Medical School and director of the American Alliance of Cancer Pain Initiatives.

Much of the confusion and fear about opioids stems from the use of incorrect terminology and the associated stigma, Dahl said.

After using opioids for a long time, patients often become physically dependent and suffer uncomfortable withdrawal symptoms if they stop taking the medications. The severity of the symptoms may drive patients to questionable behavior, such as stealing or forging prescriptions. But it should not be confused with addiction, Joranson said, which is accompanied by compulsive behavior and continued use of the medications despite harm.

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