Issue of Drugs and Pain Strikes a Nerve

Amid Painkiller Abuse Fears, Those With Legitimate Need Sometimes Go Without

By LEAH BETH WARDYakima Herald-Republic
Jan. 3, 2008—
YAKIMA, Wash. (AP) - Alex Four-Horns leans forward as far as his aching body will allow while his pain nurse massages a mixture of castor oil, ginger and lavender into his shoulder.
Castor oil has a soothing effect, giving Four-Horns some short-term relief from chronic pain, the result of a life-threatening automobile accident three years ago that left him in a coma for a month, broke both his thigh bones and damaged his knees and hips.
Once a strong, athletic man, Four-Horns, 29, now moves slowly, and he finds it difficult to keep up with his sons, ages 2 and 8. "My hip went out when I was putting up the Christmas tree with my boys," he said.
Healing oils, a lot of ibuprofen and occasional electrical nerve stimulation are the only pain management tools available to Four-Horns.
The state Medicaid program pays for occasional visits from nurse Dionetta Hudzinski to his home not far from downtown Yakima. Hudzinski, who has long been active in advocating for people with chronic pain, wonders if he might benefit from a prescription painkiller. But she can't find a doctor to treat him for pain.
Four-Horns' case illustrates what University of California pain physician Dr. Scott Fishman calls a war between two urgent public health problems -- the need to address many patients' undertreated and untreated chronic pain and the need to reduce the nation's alarming rate of prescription drug abuse.
Washington state became a battlefront in the pain war earlier this year when a group of state agency medical directors, led by Dr. Gary Franklin of the Department of Labor and Industries and in consultation with practicing pain specialists, issued voluntary guidelines to physicians for prescribing opioids for noncancer pain. Opioids such as OxyContin are powerful painkillers that mimic morphine. Heroin is made from morphine.
The state's chief recommendation is that doctors limit the total opioid dose to the equivalent of 120 milligrams of morphine a day. At that level, the state urges doctors to seek a consultation with a pain management specialist. No other state recommends a dosing limit, although others are exploring the idea.
The dosing guideline is about half the maximum average daily dose of 250 milligrams taken in recent years by injured workers and Medicaid clients with chronic, noncancer pain, according to Franklin. Doses in some cases exceeded 1,000 milligrams, he said. In contrast, some cancer specialists say their patients with chronic pain might require more than 600 milligrams of morphine a day.
Since the guidelines were published in March, they have become a flashpoint in the national debate over finding the balance between treating pain and stopping the illegal diversion of prescription painkillers into street drugs. The American Academy of Pain Medicine, an association of pain physicians, recently came out strongly against the guidelines, warning that they will scare doctors away from legitimately treating chronic pain. They attack the 120 mg dosing limit as unscientific and say there simply aren't enough pain specialists to take referrals from family doctors.

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