Feds working on guidelines for painkiller prescriptions

WASHINGTON -- New guidelines seek to improve treatment for millions of Americans with unrelieved pain by spelling out exactly how to prescribe powerful painkillers like Oxycontin and morphine without attracting the wrath of the Drug Enforcement Administration.

Many doctors hesitate to prescribe narcotics, which are heavily regulated because they can be abused by addicts.

The guidelines issued Wednesday, written by leading pain specialists together with the DEA, stress that the drugs are safe for the proper patient -- and pledge that doctors won't be arrested for providing legitimate therapy.

There is "unwarranted fear that doctors who treat pain aggressively are singled out," said Patricia Good, DEA's drug-diversion chief.

The guidelines should help eliminate this "aura of fear," she said.

They come at a crucial time, said co-author David Joranson, pain policy director at the University of Wisconsin-Madison Medical School. Fewer doctors are willing to prescribe narcotic painkillers, known as opioids, partly because of the government's high-profile crackdown on prescription-drug abuse. Some pharmacies won't stock them for fear of burglaries.

"In some ways, pain management and the use of pain medications has become a crime story when it really should be a health-care story," Joranson said.

The key message: "These are legitimate treatments. They're essential for good medical care," said Dr. Russell Portenoy, pain chief at New York's Beth Israel Medical Center and a well-known pain specialist.

With the guidelines, the DEA sanctions that view -- and is distributing the document to agents and prosecutors to help them distinguish aggressive pain management from drug diversion. A lot of opioid-taking patients in a practice shouldn't by itself signal suspicion, the guidelines advise, while long-distance prescribing and lots of premature refills might.

Fear of DEA isn't the only obstacle. Many nonspecialists simply don't know much about opioids.

Consider Cynthia C. Hildt, 65, a retired New York teacher who hunted relief for disabling back pain for 20 years before Portenoy prescribed morphine. Recently another doctor asked if she wasn't afraid of addiction.

"I said, 'I seem to have the choice of living with this unconscionable pain or taking a pill that will help, and I don't believe that addiction is a worry under those circumstances,"' the outraged Hildt recalled.

Indeed, the new guidelines stress that when prescribed properly for serious pain, opioids hardly ever lead to addiction.

About 30 percent of Americans suffer chronic pain; for as many as a third, it can be disabling, Portenoy said.

How many need opioids but are undertreated? About 40 percent of cancer and AIDS patients and the terminally ill, populations where opioids are considered optimal care, he said. Opioids also are useful for other types of pain, such as back or nerve pain, although there's less consensus on how often to use them.

The DEA regulates doctors who prescribe controlled substances -- including opioid painkillers such as morphine, codeine, fentanyl, Oxycontin -- to ensure they're not diverted for illegal use.

Last year, just 50 doctors nationwide were arrested on charges that they prescribed or otherwise distributed controlled substances beyond the scope of medical practice, somewhat fewer than in recent years, Good said.

On the other hand, opioid abuse is on the rise, a trend illustrated by Oxycontin, blamed for more than 100 deaths. The long-acting pill is crucial for severe cancer pain, but it can produce a quick, potentially lethal high if crushed, snorted or injected.

The guidelines spell out how physicians can balance aggressive pain control with the need to spot doctor-shopping abusers. Among the recommendations:

--Document a medical history, physical exam, pain assessment and treatment plan in first-time patients' charts, with re-evaluations at follow-up visits.

--Records should show evidence that the doctor evaluated the nature and impact of the pain, earlier treatments, and alcohol and drug history. Measuring pain intensity and extent of relief over time "is important evidence of the appropriateness of therapy."

--Watch for abuse warning signs, such as a patient unwilling to allow contact with previous doctors, escalating doses, seeking early refills or requesting specific medications. These require careful evaluations -- they might merely signal unrelieved pain.

--More worrisome signs include deterioration in functioning at home or work, illegal activities such as stealing or forging prescriptions, and repeatedly "losing" prescriptions.