Utah patients who need pain pills will be scrutinized far more closely as the state attempts to halt a rash of overdose deaths.
If you get a prescription, expect to be randomly tested for illegal drugs and overuse of pain pills and to sign a contract agreeing not to drink alcohol or seek pills from other doctors. And there may be limits on the amount of drugs you can take without seeing a specialist.
The state health department outlined those recommendations and others in a draft set of guidelines, written for doctors prescribing opioids like oxycodone for long-term treatment of chronic, non-cancer-related pain. They have yet to be officially adopted --- the public comment period ends Dec. 15 -- but once they are, some or all of the suggestions could become required by insurance companies.
The goal is to balance helping patients in pain with keeping them and the community safe. But some of the doctors who helped develop the guidelines wonder if the right balance has been struck: Those who believe pain pills are over-prescribed say there aren't enough restrictions, and pain specialists say there are too many.
Alan Colledge, an Orem and Provo orthopedic doctor and member of the guideline panel, is in the first camp. He said there is little if any evidence that chronic use of narcotics for chronic pain works, a point bolded in the guidelines. But he said it does cause patients to become dependent, to have more pain and lose their motivation.
While the guidelines recommend doctors start patients on a trial dose first, Colledge said doctors should consult with a peer even before the trial. "These are not like hypertensive medications. You don't just stop them. Once you've given that trial you've forever changed that individual. ... We really need to step back look at what we're doing and make certain we're not creating more problems."
Lynn Webster, a Salt Lake County pain management and addiction doctor, supports the guidelines' emphasis on assessing whether patients are at risk for abuse before and during treatment. The medical director of Lifetree Clinical Research and Pain Clinic and a member of the guidelines panel, he said primary care doctors don't do that enough.
But the recommendation that opioids be used as a last resort is inappropriate for some patients in severe pain, he added. And he strongly disagrees with the call for doctors to consult a pain specialist for patients who need high doses, defined by the state as equivalent to 120 to 200 milligrams of morphine a day.
Twenty percent of patients in moderate to severe pain "need more than that to survive," Webster said, adding that such patients may seek more elsewhere by doctor shopping or buying it on the street.
He noted there aren't enough pain specialists in the state for referrals and that the state's limit may provide doctors a false sense of security. "It's an arbitrary number," he said.
National guidelines being issued next year by the American Pain Society do not use such a limit, according to Perry Fine, a specialist at the University of Utah's Pain Research Center who was co-chairman of the national guidelines committee.
Instead, the national guidelines recommend such patients be carefully assessed and have more follow-up visits, said Fine, who nevertheless called Utah's guidelines a "heroic effort."
Utah's guidelines advise doctors to try other pain relieving methods, including physical therapy, before turning to the prescription pad. And patients are to be warned not to expect complete relief and that they could become addicted.
"It's aimed at trying to make sure people don't end up on opioids who don't need them or won't benefit from them," said state epidemiologist Robert Rolfs.
The state already is training doctors " how to not kill people with opioids," said Kim Bateman, medical director of the health care improvement group HealthInsight.
He educates doctors, who receive little training on how to deal with chronic pain, about methadone. The pain reliever, also used to help heroin addicts, is most often associated with overdose deaths. Bateman said the doses recommended in package inserts are too high, but doctors don't know it because it's a generic so drug companies don't train doctors how to use it.
While many doctors are grateful for the training, some swear off treating chronic pain as too dangerous. But pain specialists say too many Utahns in pain already go untreated due to fear and stigma about pain pills.
"Chronic pain is not just a benign condition," Fine said. "It's not just a symptom that people can just buck up."
By Heather May
The Salt Lake Tribune
Updated: 12/06/2008 07:20:33 AM MST