Do rules hamper remedies for pain?

This article focuses of Washington state, but provides some needed background on opiate prescribing patterns. It appears opiates for pain relief are more readily available than they were 15 years ago.

Until about a decade ago, doctors reserved opioids largely for patients who had cancer. Wider use has come recently as doctors learn more about pain management and researchers have reported that only a small percentage of patients who properly take opioids ever become addicted.

The reigns on these drugs have tightened up over the last several years as there have been concerns about overdoses and prescribing patterns:

...[in] the late 1990s that Washington's workers'-compensation program began covering opioids.
advertising

Almost immediately, accidental deaths became a concern here and elsewhere in the nation. Between 1996 and 2002, 32 injured workers in Washington died after accidentally overdosing on opioids, according to state data.

In 1996, the state's typical workers'-compensation patient took 88 milligrams of morphine-equivalent doses a day. In 2005, the average daily dose was 151 milligrams -- a jump that state officials suspect is caused by an increased tolerance.

In response, some states, including Washington have started developing guidelines for opiate prescribing:

Some states already have opioids guidelines for people covered by state programs, such as starting doses for new patients. But Washington has gone further by setting a suggested daily-dosage ceiling.

Long-term use of opioids can pose hazards for both doctors and patients, said Dr. Jeffery Thompson, medical director of Washington Medicaid. For instance, high doses of it can actually exacerbate pain, which then can prompt doctors to prescribe even more.

Physicians who don't specialize in pain treatment "don't have the knowledge or all the tools," Thompson said. "These are very difficult clients."

The state created the opioids guidelines specifically for those primary-care physicians. The advisory is intended for patients with chronic pain, not for people with cancer or temporary pain or pain associated with terminal illnesses.

The guidelines do not dictate a limit on narcotics dosages, and there are no sanctions for exceeding the guidelines.

The biggest fear is that doctors simply will stop prescribing opioids to legitimate patients.

"Because it comes from a government agency, the guidelines could be perceived by many as imposing new restrictions," said Aaron Gilson, an associate director with the Pain & Policy Studies Group at the University of Wisconsin.

The state strongly recommends that patients rarely take more than 120 milligrams of morphine or its equivalent per day (for example, 800 milligrams of codeine is equivalent to 120 milligrams of morphine). For doses above that level, physicians are advised to send patients to pain specialists.

The state also advises doctors to ask patients to take random urine tests to verify that they're taking the prescribed medications, as well as to rule out illegal drug use.

I don't know enough to opine on the dosage guidelines. It seems to me that this is a case of tension between two real problems and we (the royal "we") are still in the process of trying to find balance. If it weren't for my history of addiction and recovery, I'd probably be pretty offended and resentful about having to submit to drug screens, but claims of Draconian restrictions seem to ignore that the prospects for pain patients are significantly better than 10 or 15 years ago.

It's too bad there's so much hyperbole in discussions about the matter, otherwise we might find some balance a little sooner.