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Bad consequences from good ideas Medical profession not prepared for consequences of expanding opioid treatment

The rising use of prescription painkillers represents the best and worst of medicine.

A movement in recent decades to treat pain more aggressively has brought relief to many patients, allowing them to work and live better-quality lives.

But it has exacted a steep price -- an epidemic of drug overdoses, deaths and narcotic drugs diverted to illegal street sales.

"We've got two big public health problems -- millions of people in pain who can benefit from opioids and the exponential rise in prescription drug abuse. The drugs aren't dangerous. But they have to be used thoughtfully," said Steven Passik, a clinical psychologist at Memorial Sloan-Kettering Cancer Center in Manhattan.

Passik and other pain care experts recall that it wasn't so long ago when doctors were reluctant to treat pain with prescription narcotics. No more.

Physicians prescribed 257 million opioids in 2009, an amount that translates into billions of doses. Opioid sales in the United States increased 627 percent from 1997 to 2007, according to data presented recently by the Centers for Disease Control and Prevention.

What happened illustrates how something created to do good can also have unintended bad consequences.

The spread of hospice in the 1970s brought attention to the undertreatment of pain in cancer patients. In response, the prescribing of opioids to cancer patients and those near death became accepted practice.

Physicians and advocacy groups then pushed for greater use of narcotics to treat longer-term pain in patients with noncancer ailments as well. They were aided by the conventional wisdom at the time, based on what little research was available, that said opioids rarely caused addiction or other problems.

Attitudes about pain and its treatment began to change.

In the 1990s, health care organizations issued broad principles for the management of chronic pain. Others promoted pain relief as a patient right.

States passed laws and rules to lessen fear among doctors of criminal charges or professional sanctions.

By 2001, the Department of Veterans Affairs adopted the American Pain Society's concept of pain as the "fifth vital sign," encouraging physicians to assess for pain just as they would check a pulse. The Joint Commission, which accredits hospitals and nursing homes, also started using guidelines requiring the measurement of pain.

Meanwhile, pharmaceutical companies aggressively promoted painkillers to doctors, many of whom receive little or no training in pain management or drug addiction.

Critics cite Purdue Frederick, parent company of Purdue Pharma, to show how marketing amplified the availability of prescription narcotics. In 2001 alone, the company spent $200 million to promote OxyContin, a drug that abusers crushed to defeat its extended-release action.

Purdue denied such a connection in 2007 when three executives pleaded guilty to a misdemeanor charge that the company misled doctors by claiming OxyContin was less addictive than other painkillers because it was long-acting.

"It's hard to overstate the devastation OxyContin brought to the coal states. There was a tsunami of addiction," said Dr. Art Van Zee, a Virginia physician who has written about Purdue.

But perspectives vary on the issue, and doctors bear the ultimate responsibility for making medical decisions.

Ellen Battista, a Buffalo pain specialist, cautioned against overemphasizing the role of drug companies.

"The pharmaceutical industry doesn't take our pens and write prescriptions," she said.

All the influences led more doctors, often encouraged by patients, to prescribe opioids more often and in larger doses to more people in pursuit of an elusive goal -- the end of pain.

Unfortunately, it turned out that treating cancer patients with prescription painkillers was not the same as treating pain in the general population. The risks and benefits of long-term narcotic use for chronic pain proved to be much trickier than originally thought, requiring a cautious approach and closer supervision of patients.

"The medical community underestimated its power to make things worse. We created a culture that says existential suffering can be treated by a pill, procedure or device," said Dr. Alex Cahana, a pain specialist involved in developing new regulations in Washington State.

Increasingly, physicians were being duped by patients, while others were either out of date with appropriate opioid prescribing, dishonest or disabled by the drugs themselves.

"When you look back, there was a rallying cry to treat chronic pain more effectively," said Aaron M. Gilson, senior researcher at the University of Wisconsin's Pain & Policy Studies Group. "But there wasn't a firm foundation of education, skills or research to do it."

-- By Henry L. Davis

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>The drug: Oxycodone

For moderate to severe pain; stronger than hydrocodone.

Trade name: OxyContin, Percocet

Street name: Big blue

Retail Price: $15

Street price: $80 for 80 mg

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