Tightening the Lid on Pain Prescriptions

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, arthritisand 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.”

Alarms Sounded

The clues were buried in the dullest of places: thousands of workers’ compensation claims.

In 2006, a state official here, Dr. Gary Franklin, called together 15 medical experts to discuss some troubling data found in the records.

Thirty-two injured workers who were 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, including Dr. Portenoy of Beth Israel, had argued that it was safe to increase dosages so long as doctors made sure that patients were improving.

But the Washington data suggested that doctors were not monitoring patients; they were simply prescribing more and more. Such practices are common, said Dr. Trescott, the official at Group Health in Seattle, because treating pain patients, who are often also depressed or anxious, is time-consuming and difficult.

“Doctors end up chasing pain” instead of focusing on treating the underlying condition, she said.

That is what happened several years ago to a former nurse, Mary Crossman, after she was found to have lupus, an autoimmune disease that can cause severe joint and muscle pain. Her doctor put her on OxyContin and methadone and then raised the dosage every six months or so after she developed tolerance to the lower dosage.

Five years later, she was taking dosages so high that another doctor who examined her was shocked. “She said, ‘I don’t want you to die,’ ” Mrs. Crossman recalled.

In 2007, the Washington State 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 the Washington action had an important difference that soon proved contentious: it set a dosage level meant to prompt the referral.

As with most medical guidelines, doctors in Washington 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 State Legislature that its opponents were caught off guard. The maker of OxyContin, Purdue Pharma, tried and failed to stop it. Several national pain experts, including some with ties to the drug industry, also sought to block it, saying the new provisions would cause chaos by restricting patient access to care.

Even some supporters of the new law agreed that 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. Nonetheless, they believed that drastic change was needed.

“I thought the new law was a necessary evil,” said one Seattle-area physician, Dr. Charles Chabal.

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