DEA, Doctors Issue Guidelines On Use of Powerful Painkillers

By Marc Kaufman
 
  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 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 David 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 
William 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 Patricia 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." 
 
 Russell 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."
 
  Frank 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."