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Treating pain without fear


Federal regulators are less suspicious of doctors who prescribe opioids for patients, but barriers to adequate treatment remain.

"The idea that prescribing opioids to treat pain will trigger special scrutiny by the Drug Enforcement Administration is false."

"The amount of dosage units per prescription will never be a basis for investigation for the overwhelming majority of physicians."

"DEA . . . wishes to dispel the mistaken notion . . . that the agency has embarked on a campaign to 'target' physicians."

"In any given year, less than one in every 10,000 physicians loses his controlled substance registration based on a DEA investigation for improper prescribing," a top DEA official told Congress last year.

The agency's recent remarks are a far cry from its menacing stance in 2004, when it proclaimed that the government "can investigate (physicians) merely on suspicion that the law is being violated, or even just because it wants assurances that it is not." That sent a clear and chilling message: Doctors who prescribe narcotics to alleviate suffering will be watched. Some physicians believe that's still the case.

Climate warming at the federal level

Medical leaders and top pain specialists say substantial progress has been made with DEA and state regulators, who are now more understanding of the amount of narcotics some patients need to alleviate their pain.

"Eighty percent of chronic pain patients take less than 200 milligrams of oxycodone a day," says Russell Portenoy, chairman of the Department of Pain Medicine and Palliative Care at New York's Beth Israel Medical Center. "In my practice, we have some patients who need 2.5 grams a day. There is a subpopulation of patients where benefits can occur only at these high dosages. Regulators are finally starting to understand this."

A major sea change occurred in September 2006, when the DEA reversed its position barring physicians from writing multiple prescriptions with instructions that they be filled on future dates. Now, patients who use powerful painkillers are able to get up to a 90-day supply.

How did this occur? Following scathing criticism from medical leaders, DEA officials sought input from professional organizations and listened to the 600 physicians who contacted the agency. DEA Administrator Karen Tandy, who's well aware of the reputation the agency has among some physicians, acknowledged that the agency had been wrong about the 90-day rule. "DEA agents are parents and adult children of patients in pain, and we appreciate the need for effective, accessible pain relief to prevent needless suffering," Tandy says.

"We now have a good relationship with the DEA," says Rebecca J. Patchin, an anesthesiologist and pain management specialist in Loma Linda, CA, and an AMA trustee. "Karen Tandy has invited the AMA and other professional groups to talk with her senior staff on several occasions.

"Still, pain is undertreated. Lack of education about pain management is part of it, but many doctors are still concerned that if they prescribe controlled substances, they could lose their licenses," Patchin says.

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Jennifer N. Lee, MD, FAAFP