Skip to comments.New Pain Guidelines Help MDs and Patients
Posted on 08/12/2004 8:01:37 PM PDT by neverdem
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 healthcare 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.
ON THE NET
New pain guidelines: http://www.medsch.wisc.edu/painpolicy
Take it from someone who knows skeletal and deep tissue pain on a frequent basis, sometimes you just can't medicate pain away unless you go for a chemical coma.
Have you been to a pain specialist?
Has anyone had this experience? Ten years ago, I blew disks out in my neck, then later in my lower back. My doctor told me that he wanted me to take Ultram for pain management. Pacific Care rejected my perscription, and suggested Vicodin, Percodan, Percocet, Tylenol 3's, etc. Why did they reject a drug that is non narcotic yet yields the same relief as the dope? Ultram was 1.25 per pill, yet the insurance company would rather I take something that could be addictive to save a buck. Unreal.
My doctor saved all the physician samples, and every once in a while I would call the office and they'd pack me a plastic bag. When you really need pain relief, you don't abuse it. You hoard it. My son hurt his back around Christmas vacation slipping on the ice. He gave me his muscle relaxers. They come in handy when the lower back feels a little crunchy. Better than nothing.
This the end result of the government controlling health-care.
As far as physician's "unwarrented" fear of being persecuted by the DEA (not to mention lawyers)...yeah right.
I do pain management, and physician's fear of DEA persecution and lawsuits is most certainly "warranted".
Does it lead to the undertreatment of pain? Most certainly. Does it lead to unnecessary delays in the prescribing of adequate pain medicine until we exhaust ALL potential and more conservative options although through experience we both know they are not going to alleviate your pain? Most certainly, yes.
I hope you receive the miracle you need. Until then, I hope the doctors provide the relief you need. Good luck and God be with you.
Broken femur, ruptured quads, broken clavicals, reconstructed shoulders, clavicular resections every few years, impaled with a 30 pound metal bar, and a bunch of long term hospitalizations. The pain from the injuries is not that bad initially. You get sort of shocky and giddy with the really nasty ones. My pain usually begins with gusto post operative. I don't mind the pain from PT or once I get home, it keeps you sharp.
I've got a broken ankle at the moment and am in a cast to the knee.
My wife complained to my mother after a few years of our marriage because I should have come with a warranty.
I've begun to develop arthritis in a lot of the joints I've banged up and I think I might take the pain management angle after a few more years.
I still ride dressage. It's hard on my back, but at least you don't find yourself under a 1500 lb horse struggling to right itself when things go bad.
Tell me about it. I would far rather use Vioxx than Vicodin for occasional acute back pain. And I can -- if I pay $5 a pill out of my pocket as my prescription plan is useless when it comes to Vioxx unless I have "active stomach ulcer." Ulcer schmulcer, it just works better than anything over the counter and many things that aren't.
Ultram is derived from opiates, but it's still under patent protection. It has a smaller potential for addiction, but some folks still succeeded in becoming addicted. Those other generic opiates that the plan suggested are rated for moderate to moderately severe pain like Ultram, just cheaper.
Well, what do you expect?
If Vicodin costs less to the corporation providing your medication (regardless of the differing side effect profiles), what do you think they're going to "approve" for you?
Remove your financial consideration, and they're going to give you the low cost option.
Reminds me of when I was in the Navy...
Every day I had the option of Eggs, Bacon and assorted other high cholesterol breakfast items FOR FREE.
In the back of my mind though I couldn't help but remember that if I stayed in the USN for 20 years and retired, wouldn't my early demise be cost-beneficial to the government?
Follow the dollars, and you will see the light on even the most hazy of roads.
Vioxx helps back pain? Well at 5 bucks per pill, it won't do me any good. You know after I lost my medical benefits, I went to Mexico and got Tramadol, which is generic Ultram. It almost cost the same as the perscription price. I don't want to go into TJ anymore.
If it meant the difference between being able to work and not, the $5 a day could be stomached. But it's true, the insco's couldn't seem to give a hoot about habituation to cheap pills.
I didn't know that. Can you imagine having to take a pre employment drug test....and failing????
Not if you have a legitimate prescription.
Have you ever checked out a book called Somatics? The basic theory is that most pain comes from tight muscles, rather than from the joints or bones, especially after severe injuries. I used to have chronic back pain, but now I can practice my golf game for hours, and do quite a bit of walking.
A legitimate prescription helps. What doesn't help is that your employer is going to want to know what you're taking them for, then find a way to either fire you or not hire you. *snicker at Americans with disabilities act*.
I am glad you still get on a horse. It may be tough on the back, but it's good for the mind. After my car accident(s), I rode out the pain of broken ribs, sternum, jaw, etc., on horseback, over the months from slow walk to trot, canter and gallop. It took a while, but it helped better than phy. thpy. Now, when I am sore from work, I will brush my horse in the warm sun and it helps. Horse likes it too.
Well, Take it easy, pardner,