Tightening the Lid on Pain Prescriptions
 
Doctors Shift Amid Alarm on Overdose
 
 
   
By BARRY MEIER
Published: April 8, 2012
   
   
....SEATTLE — It was the type of conversation that Dr. Claire Trescott dreads: telling physicians that they are not cutting it.
   
....But the large health care system here that Dr. Trescott helps manage has placed controls on how painkillers are prescribed, like making sure doctors do not prescribe too much. Doctors on staff have been told to abide by the guidelines or face the consequences.
   
....So far, two doctors have decided to leave, and two more have remained but are being closely monitored.
   
....“It is excruciating,” said Dr. Trescott, who oversees primary care at Group Health. “These are often very good clinicians who just have this fatal flaw.”
   
....High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States. And over the last decade, the number of prescriptions for the strongest opioids has increased nearly fourfold, with only limited evidence of their long-term effectiveness or risks, federal data shows.
   
....“Doctors are prescribing like crazy,” said Dr. C. Richard Chapman, the director of the Pain Research Center at the University of Utah.
   
....Medical professionals have long been on high alert about powerful painkillers like OxyContin because of their widespread abuse by teenagers and others for recreational purposes.
   
....Now the alarm is extending from the street to an arena where the drugs had been considered legitimate and safe: doctors’ offices where they are prescribed — and some say grossly overprescribed — for the treatment of long-term pain from back injuries, arthritis and other conditions.
 
....Studies link narcotic painkillers to a variety of dangers, like sleep apnea, sharply reduced hormone production and, in the elderly, increased falls and hip fractures. The most extreme cases include fatal overdoses.
 
....Data suggest that hundreds of thousands of patients nationwide may be on potentially dangerous dosages. And while no one questions that the medicines help countless patients and that most doctors prescribe them responsibly, there is a growing resistance to their creeping overuse. Experts say that doctors often simply keep patients on the drugs for years and that patients can develop a powerful psychological dependence on them that mirrors addiction.
 
....But changing old habits can be difficult — for doctors and patients alike.
 
....The most aggressive effort is under way here in Washington, where lawmakers last year imposed new requirements on doctors to refer patients taking high dosages of opioids — which include hydrocodone, fentanyl, methadone and oxycodone, the active ingredient in OxyContin — for evaluation by a pain specialist if their underlying condition is not improving.
 
....Even before the new provisions took effect, some doctors stopped treating pain patients, and more have followed suit. Christine Link, 50, said that several doctors had refused to refill the prescription for painkillers she had taken for years for a degenerative joint disease.
 
....“I am suffering, and I know I am not the only one,” she said.
 
....Washington State officials acknowledge some of the law’s early deficiencies, including its sometimes indiscriminate application, and they are seeking to address them. But there is no retreat on the goal of moderating opioid use, and the movement extends well beyond Washington.
 
....The federal Centers for Disease Control and Prevention has urged doctors to use opioids more judiciously, pointing to the easy availability of the drugs on the street and a mounting toll of overdose deaths; in 2008, the most recent year with available data, 14,800 people died in episodes involving prescription painkillers.
 
....The Departments of Defense and Veterans Affairs are trying new programs to reduce use among active-duty troops and veterans. Various states are experimenting with restrictions, including Ohio, which is considering following the Washington model.
 
....“We are trying to prepare our state for what we hope is the inevitable curbing of the use of opiates in chronic pain,” said Orman Hall, the director of Ohio’s Department of Alcohol and Drug Addiction Services.
 
....The long-term use of opioids to treat chronic pain is relatively new. Until about 15 years ago, the drugs were largely reserved for postoperative, cancer or end-of-life care. But based on their success in those areas, pain experts argued the medications could be used to treat common kinds of long-term pain with little risk of addiction.
 
....At the same time, pharmaceutical companies began to promote newer opioid formulations like OxyContin for chronic pain that could be used at greater strengths than traditional painkillers. Sales of painkillers reached about $8.5 billion last year, compared with $4.4 billion in 2001, according to the consulting firm IMS Health.
 
....Along with Purdue Pharma, the maker of OxyContin, other producers include Johnson & Johnson and Endo Pharmaceuticals.
 
....Dr. Russell K. Portenoy, who championed the drugs’ broader use, said the new data about the potential high-dose risks was concerning. But he added that the medications were extremely valuable and that their benefits needed to be factored into policies like the one in Washington State.
....“I don’t think opioids need to be thought of any differently than any other therapies,” said Dr. Portenoy, chairman of the pain medicine and palliative care department at Beth Israel Medical Center in New York. “It is just that right now, they have got our attention.”
 
....A pain expert here in Seattle, Dr. Jane C. Ballantyne, said she once agreed with Dr. Portenoy, but she now finds herself in the role of former believer turned crusading reformer.
 
....“We started on this whole thing because we were on a mission to help people in pain,” she said of the medical profession’s embrace of opioids. “But the long-term outcomes for many of these patients are appalling, and it is ending up destroying their lives.”
   
   
   
   
   
The rest of this article is available at:
   
http://www.nytimes.com/2012/04/09/health/opioid-painkiller-prescriptions-
pose-danger-without-oversight.html?_r=1&hp