DEA, Doctors Issue Guidelines On Use of Powerful Painkillers

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DEA, Doctors Issue Guidelines On Use of Powerful Painkillers

By Marc Kaufman

Washington Post Staff Writer

Thursday, August 12, 2004; Page A04

The Drug Enforcement Administration and top pain specialists yesterday

jointly issued detailed new guidelines designed to reassure worried doctors

that they will not be prosecuted for prescribing high doses of powerful

morphine-based painkillers for patients who need them for intractable pain.

The guidelines also make clear that doctors have responsibilities to ensure

that their patients are not abusing prescription opioids such as OxyContin

and are not doctor-shopping to collect narcotics for illicit sales.

The pain control guidelines make clear that even heavy use of prescription

opioids, such as OxyContin, can be appropriate. (Toby Talbot -- AP)

The new document, which will be distributed to law enforcement agencies and

all doctors who apply for DEA approval to prescribe controlled drugs, is an

effort to resolve a controversy that has bedeviled pain specialists.

An earlier consensus paper failed to clarify the issues, leading to a

situation in which many patients with severe pain have been turned away by

doctors and pharmacists concerned that prescribing and dispensing opioid

painkillers would get them in trouble with the law.

" We hope this is a step in the right direction, to reverse an increasingly

unfriendly environment for pain management, " said one of authors of the new

guidelines, University of Wisconsin pain studies director E. Joranson.

Getting the agency to publicly declare its position on prescribing opioids

" will make more clear that the DEA understands good medicine and would be

avoiding it in their investigations, " he said. " A lot of people don't feel

now that's the case. "

The new guidelines spell out the steps that ensure proper prescribing, such

how to diagnose severe pain and keep proper records to justify the

prescribing of a narcotic painkiller. Written largely in a

question-and-answer form, the document makes clear to law enforcement

authorities that even heavy use of prescription opioids can be appropriate

and that the physical dependence it brings is not the same as physical

addiction.

The DEA and other law enforcement agencies stepped up their prosecutions of

doctors, pharmacists and some of their employees after the prescription

narcotic OxyContin became widely used and abused in the late 1990s,

resulting in numerous overdoses. With hundreds of doctors charged in recent

years, pain patients and doctors who treat them have complained of a growing

climate of fear -- adding to what is widely seen as a serious nationwide

problem of inadequate pain treatment.

Among the high-profile prosecutions of pain specialists is that of

E. Hurwitz, a nationally known doctor from McLean accused of drug

trafficking. Hurwitz is scheduled to go on trial this fall.

" In numerous meetings over the past several years, it has become obvious

that there are many misconceptions about the DEA's role and even the DEA's

fundamental beliefs about the use of prescription opioids, " said another

author of the guidelines, DEA diversion control official M. Good.

" Many of these misconceptions lead to unwarranted fear that doctors who

treat pain aggressively are singled out for enforcement actions, and that

the goals of protecting the public health from drug abuse have come into

direct conflict with the goals of promoting the public health through

effective pain control, " she said. " Undertreatment of chronic, serious pain

is considered a major medical problem. "

K. Portenoy, another author of the guidelines and a pain specialist

with New York's Beth Israel Medical Center, said opioid painkillers are

appropriate treatment for serious pain from cancer and AIDS, as well as

among the terminally ill. But about 40 percent of those patients are

undertreated, he said.

" What this document does is make clear [that] we in pain management and DEA

are on the same page, and that we're willing to endorse the same

principles, " Portenoy said. " We need to create a culture of respect for the

policies. "

Joranson, director of the Pain and Policy Studies Group at the University of

Wisconsin Medical School, said the DEA's written acceptance of basic pain

management principles could be useful in persuading some states to change

their laws on prescription opioids. He said his group has found that 20

states have laws that could be detrimental to pain patients. He added that

the new guidelines will be sent to officials in those states.

The new document was met with skepticism by some advocates for pain

patients, who said it will do little to calm jittery doctors or decrease the

illicit use of prescription narcotics.

" The Department of Justice and other prosecutors are misidentifying quality

pain management for drug dealing and have apparently convinced academic pain

medicine that these doctors were 'diverting drugs,' " said Siobhan Reynolds,

founder of the Pain Relief Network. " The DEA blames doctors as the number

one reason why pharmaceutical drugs are on the street, when the truth is

they are smuggled in, stolen from trucks and freely bought and sold all over

the Internet. "

Fisher, a California doctor who was tried and acquitted on charges

related to prescribing opioid painkillers, said the new document " is an

articulation of the status quo in the management of chronic pain. . . . The

underlying problem is that our national pain policy is an expression of

social concerns, rather than scientific knowledge. "

http://www.washingtonpost.com/wp-dyn/articles/A57933-2004Aug11.html