BARRY MEIER | The New York Times Modified May 04, 2012
It was the type of conversation Dr. Claire Trescott dreads: telling physicians they are not cutting it.
But Group Health, which 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 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 long have been on high alert about powerful painkillers like OxyContin because of their widespread abuse.
Now the alarm is extending 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 hundreds of thousands of patients nationwide might 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 doctors often keep patients on the drugs for years and 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 in the state of 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, a 50-year-old Shelton resident, said 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.
Link said the six doctors she sees for various medical conditions are not communicating, and are withholding medication that could relieve her pain. As a result, she spends most of her time in bed. Everyday tasks such as walking the dog, grocery shopping or playing with her four grandsons can overwhelm her.
?I?m having to beg and nobody helps me,? she said. ?They think I?m drug-seeking or something, and I?m not. This is documented pain throughout my body.?
NEW USE FOR OPIOIDS
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.
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 the medications were extremely valuable and their benefits needed to be factored into policies like the one in Washington.
?I don?t think opioids need to be thought of any differently than any other therapies,? said 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 in Seattle, Dr. Jane C. Ballantyne, said she once agreed with Portenoy but 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.?
ALARMS SOUNDED
The clues were buried in the dullest of places: thousands of workers? compensation claims.
In 2006, Dr. Gary Franklin, medical director for the state Department of Labor & Industries, called together 15 medical experts to discuss some troubling data found in the records.
Thirty-two injured workers prescribed opioids for pain had died of overdoses involving the drugs. In addition, in just a few years, the strength of the average daily dose of the most powerful opioids prescribed to patients treated through the workers? compensation program had shot up by more than 50 percent. The number of patients taking the drugs in large quantities had grown to 10,000.
Doctors often increase opioid dosages because patients can adjust, or develop tolerance, to the drugs and need greater amounts to get the same effect. Pain specialists argued it was safe to increase dosages so long as doctors made sure patients were improving.
But the Washington data suggested doctors were not monitoring patients; they were simply prescribing more and more.
?Doctors end up chasing pain? instead of focusing on treating the underlying condition, she said.
In 2007, the Washington panel approved a guideline that urged doctors to refer patients on large dosages for evaluation if they were not improving. Two professional groups representing pain specialists had already taken a similar step.
But Washington?s action had an important difference that soon proved contentious: it set a dosage level meant to prompt the referral.
As with most medical guidelines, Washington doctors largely ignored the panel?s suggestions, a later survey found ? until last year, when the guidelines became law.
That bill moved so quickly through the Legislature that its opponents were caught off guard.
Even some supporters of the new law agreed there was little evidence to support the dosage threshold, which was the amount of any opioid equivalent in strength to a daily dose of 120 milligrams of morphine.
?I thought the new law was a necessary evil,? said one Seattle-area physician, Dr. Charles Chabal.
Before the widespread use of opioids, the clinic at UW?s medical school was known for an approach to chronic pain that emphasized nondrug treatments such as physical therapy and counseling. Some specialists, such as Ballantyne, are determined to revive that tradition.
?If doctors understood how hard it is to get patients off of these drugs, they would not prescribe them to begin with,? she said.
Since then, other researchers have published papers about the drugs? medical dangers. Studies have shown, for example, that the drugs greatly suppress the production of sexual hormones.
A LOST GENERATION
Big health care systems such as Group Health, which treats 420,000 patients at 25 clinics throughout Washington, can oversee how doctors prescribe drugs and provide patients with alternative treatments. Over the last four years, Group Health has cut the percentage of patients on high opioid dosages in half, the system says, and reduced the average daily dose among patients who regularly take opioids by one-third.
The system is examining how those changes have affected patients.
Studies elsewhere suggest the benefits of lower opioid use might be significant for many patients. For example, Danish researchers have published a study indicating that chronic pain patients getting nondrug treatments recover at a rate four times as high as those on opioids.
However, few programs are in place to deal with patients now on high opioid dosages who are not benefiting from them.
If the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction suggest it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle.
?I think we are dealing with a lost generation of patients,? Ballantyne said.
Olympian staff writer Stacia Glenn contributed to this report.rachel crow rachel crow steelers browns va tech dan gilbert david stern david stern
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