Recent Newspaper & Online Columns by Kate Scannell MD

Managing pain may soon get even more difficult

February 3, 2013

Tags: pain management, hydrocodone, drug addiction

By Dr. Kate Scannell, Syndicated Columnist
First Published in Print: 02/03/2013

An elderly woman hobbled into my clinic, precariously balanced with the assist of two canes. Her face had a worn and ashen look, depleted of all vitality. The seemingly simple act of getting into a chair exhausted her.

Disabling arthritis had largely restricted her to a life lived within apartment walls, one devoid of a pain-free day over many years. I tried to contain my astonishment upon hearing she had never used an analgesic stronger than aspirin or acetaminophen. Before I could ask why, she offered matter-of-factly: "Because my doctor said it would turn me into an addict."

On another day, I was working in an emergency room and staring at my new patient who lay motionless on a gurney -- a young drug abuser who'd become unresponsive after overdosing on prescription painkillers. We kept monitoring his weakening breaths, evaluating whether to intubate him. Meanwhile, his fidgety girlfriend occasionally offered that we needn't worry -- because he "always" came out from under the pills "just fine."

I'm sorely reminded of these two patients by last week's news about yet another governmental initiative to regulate physicians' management of pain. Basically, the initiative aims to tighten controls over doctors' abilities to prescribe painkiller narcotics that contain hydrocodone -- drugs with brand names like Vicodin and Norco. And, unfortunately, I don't see it helping either of my patients with their very different narcotic problems.

Thinking about the initiative actually gives me a headache -- not just because of added pressures from more regulatory burdens, paperwork, and federal scrutiny should the initiative be implemented. Rather, it's because the new initiative is so potentially harmful to vulnerable patients in pain while, at the same time, offering too small a bandage for too big a wound -- a cosmetic fix for our country's deep and enduring social problem of prescription drug abuse.

This matter should -- or, actually, already does -- concern us all. Because at some point, each of us will likely suffer physical pain -- our own, or our loved ones' -- and be at the mercy of doctors (and regulators) for its relief.

Each of us is also likely to bear the toll of prescription drug abuse. Through our own sad personal experiences involving addiction. The overdose deaths of friends, colleagues, role models. Frustrating encounters with overly-cautious doctors who seem to withhold painkillers when we need them.

So, what actually happens if last week's 19-10 vote of an advisory panel to the Food and Drug Administration is accepted, given final HHS approval, and implemented? Essentially, the federal government will change how it categorizes drugs containing hydrocodone -- switching them into the more tightly regulated category of "Schedule II controlled substances" that includes the likes of OxyContin and fentanyl.

And this is what that re-categorization means in the clinic, between patients and health care providers: It limits the amount of hydrocodone-containing pills that can be prescribed at any one time. It disqualifies nurse practitioners and physician assistants from prescribing these drugs. And because it eliminates a physician's ability to fax or phone-in prescriptions, it also requires patients to obtain from a doctor a new prescription for each refill.

For patients in pain with legitimate need for these medications, such changes will probably make it even more difficult to obtain relief. Those difficulties will be amplified for millions of Americans living in rural or underserved areas of the country where health care is often dependent upon nurse practitioners and physician assistants. Likewise, for the 49 percent to 83 percent of frail nursing home patients in persistent pain who would be required to make frequent trips to doctors' offices for prescriptions. And let's not forget people suffering disease flare-ups on weekends, facing thousand-dollar-visits to emergency rooms to secure a doctor's prescription.

By requiring more patient visits to doctors for prescriptions, the proposed changes will also incur higher health care costs, extra administrative burdens, and greater expenses for patients in terms of co-pays, lost wages, and travel time.

Still, it's also true that the initiative will likely lead to fewer hydrocodone products being diverted to the streets. Hopefully, in turn, that might help to curb our country's epidemic of prescription drug deaths. The most recent data available from the Centers for Disease Control and Prevention attest to the seriousness of this problem -- more than 16,500 Americans died in 2010 after overdosing on opioid-based painkillers.

Certainly, we need to figure out how to curtail prescription opioid diversion and abuse. But the proposed initiative involves a lot of collateral damage to patients in pain, all the while inefficiently addressing the fundamental issues of substance abuse and addiction. Those fundamental issues are not going to be solved by piecemeal legislation that merely reduces one of many drug options on the streets. That's not how addiction and substance abuse are cured. Surely, we have learned that lesson from prior experiences with regulatory and legal prohibitions against other prescription or recreational drugs -- morphine, alcohol, cocaine, heroin, OxyContin, marijuana.

Overall, we physicians need better training in pain assessment and opioid prescribing to equally serve our patients in pain and those suffering substance abuse. And regulators ought to come up with more efficient means to pinpoint handfuls of rogue doctors and patients who are making life more painful for the overwhelming majority of Americans.

Finally, everyone -- regulators and politicians included -- should humbly acknowledge that it's impossible to measure another person's pain. Doctors don't have lab or x-ray tests that can gauge the veracity or intensity of a patient's claim of suffering. And while treating pain is always an imperfect enterprise, it should not be made more imperfect by unreasonable and unreasoned demands that are placed upon it.
Kate Scannell is a Bay Area physician and the author, most recently, of "Flood Stage."
©2013, Kate Scannell

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