Narcs Crack Down on Pain Relievers

Medical science is wonderful, as long as you're dealing with something really esoteric and unpronounceable. There are great things happening in the field of surgery, using computers and miniaturized television cameras. Heart transplants are an everyday affair, and there are new drugs for cancer, and even AIDS while not curable, can be controlled for periods of years.

But the common cold is still with us, the flu doubly so this year, and the best that can be done for male pattern baldness is to slow down hair loss until you've reached an age where sex appeal isn't a concern.

And there is no good treatment for pain, which is about as basic as you can get. There are lots of treatments, and most of them work for a little while, but there's nothing that works well for a long time.

There are three basic types of analgesics: acetaminophen, NSAIDs, and narcotics. Acetaminophen (Tylenol is the best known brand) works for mild pain, and as long as you keep the dose low enough, it's safe. It's not useful for more severe pain.

NSAIDs, non-steroidal anti-inflammatory drugs, are a large group of compounds including aspirin, ibuprofen (Advil, Motrin), naproxene (Aleve, Naprosyn) and lots of others. They can relieve pain fairly well, but they also cause ulcers and bleeding. One British study indicated that one-third of hospital admissions of patients over the age of 65 was due to the side effects of NSAIDs. The newer drugs in this class, Celebrex and Vioxx, were supposed to correct this problem, but the recent withdrawal of Vioxx because of an increased death rate throws things back to the drawing board.

Narcotics such as morphine, codeine, meperidine (Demerol) and close relatives such as propoxyphene (Darvon) are generally effective even against severe pain, but they have their own list of adverse effects and, perhaps even more significantly, a host of legal restrictions.

Narcotics are addictive, and a societal problem, and some portion of the narcotics drugs which enter the system for legitimate medical use do get diverted to drug abuse. Because of this, the Drug Enforcement Administration keeps a wary eye on any physician, any pharmacist, who prescribes or dispenses large quantities of narcotics.

On Oct. 19 the New York Times reported on the case of a physician who was jailed for narcotics diversion which, it was originally stated, led to the deaths of some of his patients. "He lost his home and his medical practice and served five months in jail before it was discovered that the patients had died from accidents or from medical illnesses, not from the narcotics he prescribed."

Fear of regulatory agencies has been a problem for physicians who try to practice responsible pain management. While some patients legitimately need high-dose narcotics, some inspectors seem to see any M.D. with a pain practice as a legitimate target. Physicians and pharmacists become afraid to prescribe and dispense the narcotics needed for adequate pain control. Patients with severe pain syndromes live in fear that they may not be able to get their medication.

The National Institutes of Health has issued guidelines calling for more aggressive treatment of pain, but good clinical medicine doesn't mean much compared with the risk of jail time and loss of a medical license. Dr. Russell Portenoy, a leading pain management specialist, has estimated that 40% of patients with severe pain are being undertreated.

On Aug. 11, the Associated Press reported that the DEA, in cooperation with leading pain experts, published guidelines for treatment of pain. David Joranson, director of pain policy at the University of Wisconsin-Madison Medical School, who helped write the guidelines was quoted as saying "Pain medicine is not to contribute to abuse, and law enforcement is not to interfere in patient care." As long as physicians followed the proper steps in examination and record keeping, they were assured that they could prescribe narcotics without concern for regulatory interference.

On Oct. 21st, the Washington Post reported that the DEA had withdrawn its support for the guidelines, and had taken the document off its web site earlier in the month. The agency gave no explanation except to say that it contained "misstatements." The physicians who had worked with the DEA said they had been given no indication that the agency was dissatisfied with the guidelines or intended to remove them. The Post reported that the DEA's decision might have been related to a request by defense attorneys to introduce the guidelines in a pending case against a Virginia physician. After the defense had asked to introduce the guidelines, the prosecuting attorney filed a motion in the case asking that the guidelines be excluded as evidence, saying that they do "not have the force and effect of law."

There's no question that some narcotics get diverted from legitimate use to drugs of abuse. The amount, though, is probably a lot less than the amount of opium being shipped in from Afghanistan now that the US is busy in Iraq. Meanwhile, Blackstone's injunction that it is better for 10 guilty people to go free than for one innocent person to suffer has gone out the window in the relentless pursuit of high conviction rates -- and so has a carefully crafted compromise that, for a short time, promised to make it safe to practice responsible medicine.

Addendum: last summer the American Medical Association rejected a proposal that physicians refuse to treat trial lawyers. Given the attitude of the DEA, it seems that trial lawyers are worth saving after all.

Sam Uretsky is a pharmacist living on Long Island, N.Y.

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