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Painkiller use soars with shift in practice

SEATTLE – Ten years ago, the state of Washington began a major push to make sure doctors weren’t undertreating pain. The change was revolutionary for people dealing with chronic pain, but it was also a boon for drug dealers and those with addiction problems.

Between 1997 and 2005, the number of people using five major painkillers rose 96 percent in Washington state, according to an analysis of statistics from the U.S. Drug Enforcement Administration.

Oxycodone, commonly known as Oxycontin, is responsible for most of the increase in this state. Use of oxycodone increased by 500 percent between 1997 and 2005. Use of morphine and hydrocodon, commonly known as Vicodin, have also increased dramatically: morphine by 223 percent and hydrocodon by 166 percent.

Oxycontin, morphine and Vicodin are three of the most common prescription pain medications – popular among doctors for their effectiveness and among drug abusers because they are fast-acting and hit the body’s pleasure centers.

“We’re now in the decade of pain,” says Dr. Gordon Irving, a pain medicine expert at Swedish Medical Center in Seattle.

Awareness of pain management among doctors and the general public has never been higher, Irving said, but that has both pluses and minuses.

Abuse of prescription pain medicine has increased. The number of deaths involving opiates has also been on the rise, although Washington medical examiners report opiate deaths usually involve more than one drug, both legal and illegal.

“You have a disconnect between people requesting or demanding adequate pain treatment and doctors not knowing how to respond,” Irving said.

When the state government made a big push to make sure doctors weren’t undertreating pain – including the Medical Quality Assurance Commission’s guidelines for management of pain issued in April 1996 – medical providers got the message, said Dr. Jeff Thompson, chief medical officer at the Department of Social and Health Services.

New products came on the market about the same time, some offering large doses in time-release pills. These new ways of delivering the drugs were popular with doctors, their patients and the people who sell drugs illegally, Thompson said.

He wouldn’t blame the drug makers or the change in policy.

“We’re not really interested in that debate. We’re interested in making sure that people get the right medicines to treat their pain,” Thompson said.

When pain management got better, opiates became the treatment of choice, and that is a good thing, said Dr. Richard Ries, professor of psychiatry and director of the Addictions Division in the Department of Psychiatry at the University of Washington Medical School. The problem is that doctors at first were underdosing patients and then went in the opposite direction.

They apparently didn’t read the fine print, Ries said. Most primary care doctors have not had enough pain relief training to know which kinds of pain call for opiates. Second, doctors need to make sure they know patients’ addiction history and family story before prescribing opiates.

Many people with severe pain are still being undertreated, and those who shouldn’t be given opiates are still getting them, Ries said. But he adds that doctors and government officials are starting to talk about stopping the pendulum swing between over- and under-medication.

State health officials issued new guidelines earlier this year. Those guidelines will likely turn into rules, giving doctors and their patients dosage thresholds where they should stop and assess if the drug is helping or hurting.

Some of the new guidelines are controversial – including a dosage threshold at which doctors are advised to refer their patients to pain specialists, Thompson said.

Thompson said the effort has helped doctors in Washington get 10 percent of these excessive narcotic users enrolled in substance abuse programs, and has led to a slight reduction in emergency room narcotic prescriptions.

Irving said the state should also think about mandating pain education for doctors renewing their medical licenses. California doctors are required to do 12 hours of pain education each time they renew, but Washington only has general education requirements.