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When good intentions hurt;
Even government officials are beginning to concede that in their zeal to halt drug abuse, they have made it more difficult for sick people to get the painkillers they need.

by Fawn Vrazo; Inquirer Staff Writer; The Philadelphia Inquirer; August 23, 2004. Originally posted: 8/23/2004; [www.doctordeluca.com/Library/WOD/WhenGoodIntentionsHurt04.htm]. This document is also available at: [www.philly.com/mld/inquirer/9471208.htm?template=contentModules/printstory.jsp]

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The job of the federal Drug Enforcement Agency is to bust drug crooks, not encourage drug use.

But this month, the DEA gave narcotic painkillers an unusually glowing review, saying they are "accepted around the world as the most important approach" to managing severe, acute, chronic and even moderate pain from surgery, cancer, AIDS and other suffering.

The un-DEA-like message is included in an unprecedented set of painkiller guidelines issued by the agency after it teamed up with 17 pain-management experts from around the country.

It comes after years of complaints that DEA investigators and other law enforcers have been so determined to go after prescription drug abusers that they are inadvertently hurting patients who really need the drugs.

Other unlikely national groups are jumping on the "painkillers can be a good thing" bandwagon, too - including the National Association of Attorneys General and the Federation of State Medical Boards. In so many words, the groups are assuring both doctors and patients that if narcotic drugs are being used properly, investigators won't come knocking at the door.

The trend, applauded by pain doctors and pain patients, represents a pendulum swing away from years of bad publicity about abuse of prescription drugs, particularly Purdue Pharma's OxyContin.

OxyContin - a time-release opioid valuable to cancer patients - has gotten a bad reputation as "Oxy," a drug injected or snorted by adult addicts and teens, dozens of whom have died as a result. Cephalon's Actiq, a lozenge on a stick designed to deal with spikes of uncontrolled cancer pain, has earned the street name perc-o-pop among abusers.

While the abuse of prescription drugs is widespread and growing, pain patients say they are the real victims when they are denied desperately needed medications by doctors who fear being investigated or causing their patients to become addicted.

"Every time something becomes more popular in the drug world, I'm the one who has to deal with the extra regulations and fear," said Lynn Repetto, 54, a Philadelphian who has suffered from chronic pain caused by degenerating spinal discs and surgery.

Repetto, a registered nurse, spent 10 years worrying that her doctors would stop giving her prescriptions for narcotic painkillers or that she wouldn't find pharmacies willing to stock them. The investigatory zeal that greeted OxyContin's abuse, she observes, probably didn't make it harder for abusers to get the drug "but it made it harder for me to get it. And I was getting it legally."

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Until Repetto finally found more consistent relief when she had a morphine pump implanted last year, her life illustrated the devastating consequences of severe, chronic pain - consequences arguably worse than those caused by painkiller addiction.

The pain was so bad at times that Repetto, who cannot work, thought about suicide. "I would never have done that," she said, "but I couldn't close my eyes for a second to sleep peacefully... . I'd pace, walk around the kitchen, back and forth, back and forth. I'd think about all the things I couldn't do."

The new DEA guidelines on prescription painkiller use, issued Aug. 11, are meant to achieve a "better balance" between the opposing camps of pain treatment and abuse prevention. The concept of balance is attracting new support on both law enforcement and treatment sides.

"I think we have a special obligation to reassure the medical community that we are not talking about [investigating] appropriate pain management," said Oklahoma's attorney general, W. A. Drew Edmondson.

As recent president of the National Association of Attorneys General, Edmondson launched an initiative encouraging attorneys general nationwide to be more active in end-of-life care issues - including making sure that dying patients are able to get the pain relief they need.

The national Federation of State Medical Boards, representing the boards that license and sanction the nation's doctors, has taken its own progressive stand, recently approving updated painkiller-use guidelines.

They inform doctors that treatment of pain is a public health priority; doctors won't lose their licenses if they dispense painkillers in legitimate ways. In fact, says the federation, medical boards in two states, Oregon and California, have disciplined physicians for not giving patients enough pain medication.

Could undertreatment of pain become a hot new medical malpractice issue? Three years ago, an Alameda County, Calif., jury found that a physician had been reckless and committed "elder abuse" by denying adequate pain treatment to an 85-year-old lung-cancer patient dying in agony as his family watched helplessly.

But for all the progressive national moves toward a balanced approach on painkillers, many doctors and law enforcers remain in a tug of war, with patients "see-sawed between the two," said Willard Andrews, an oncologist at Abington Memorial Hospital.

Figures from the two camps can conflict.

Pain doctors and experts, including those at the respected Pain & Policy Studies Group at the University of Wisconsin, point to surveys showing that specific patient groups suffer needlessly from under-prescription of narcotic medications.

Widely accepted figures indicate that 40 percent of cancer patients are not getting the pain relief they need, and that 50 percent of hospice patients die in moderate to severe pain.

But there are no good figures on the total number of Americans in unrelieved pain. "What I've heard is anywhere between 10 million and 100 million," said Will Rowe, executive director of the American Pain Foundation, which is seeking funding for a nationwide pain survey.

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On the law-enforcement side, investigators point to figures showing that prescription painkiller abuse is rising. Newly released federal statistics say admissions for narcotic painkiller abuse more than doubled between 1992 and 2002 - the latter year recording 84,000 admissions involving painkillers.

And investigators also pose this tough question: If so many people are not getting the pain meds they need, then why is the painkiller drug market booming? OxyContin sales alone totaled $1.9 billion for the 12 months ending in June this year, up 11 percent from 2003, according to new data from IMS Health, a leading pharmaceutical information and consulting company.

Painkillers "have been marketed by companies and used by doctors for reasons they weren't meant to address," said Pennsylvania's attorney general, Jerry Pappert. "Sprained ankle? I don't think so."

Meanwhile, new painkiller restrictions may assist the law-enforcement side but at the expense of pain patients.

The same DEA that issued progressive guidelines on painkiller use is also considering moving hydrocodones - a narcotics class that includes the popular painkiller Vicodin - into a more restricted prescription category. That could mean more problems for pain patients, including those who now depend on Vicodin because their doctors are reluctant to prescribe already highly restricted drugs such as Percocet.

Locally, in a move meant to discourage pain medication abuse, Independence Blue Cross recently began requiring that doctors file a preauthorization form before a patient is allowed to fill a prescription for more than 60 tablets of any controlled painkiller.

Doctors say the new requirement will give them more paperwork and could discourage legitimate painkiller use. "For legitimate patients, it's absolutely a headache to do this," complained King of Prussia internist Frederic Becker.

Although she applauds the new DEA guidelines, Pam Kedziera, nurse manager of the pain management team at the Fox Chase Cancer Center in Philadelphia, thinks there are many hurdles ahead before America truly achieves a balanced approach on the use-abuse of pain medications.

Patients themselves, she says, have been so stigmatized by the bad publicity over painkillers that they are hesitant to ask for the relief they know they need. "People are so afraid of being labeled" as addicts, Kedziera said. "Patients have to learn to say to doctors, 'The pain is no better than when I started this, so what do we do next?' "

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