New pain rules leave patients hurting

Law aims to cut overdose deaths; many doctors balk at its demands, responsibilities




An effort in Washington to curb a steep rise in prescription-drug overdose deaths — the most ambitious crackdown in the nation — has prompted a number of doctors and clinics to stop taking new chronic-pain patients on opiates, and in some cases to cut off current pain patients.

The hard new line marks the end of a period of relatively liberal prescribing that began in the late 1980s.

Before then, studies showed that pain was being seriously undertreated, even in dying patients. The statistics and stories fueled assisted-death campaigns in Washington and Oregon and prompted medical boards to reassure doctors not to fear discipline for relieving pain.

Local angle

Engrossed Substitute House Bill 2876, which requires licensing boards to establish tougher rules for treating pain patients, was introduced by state Rep. Jim Moeller, D-Vancouver.

Moeller was prompted to introduce the bill in part by the story of Vancouver’s Payette Clinic.

The clinic has been linked to the overdose death of an Oregon high school senior who died after smoking an oxycodone pill originally prescribed to a Payette patient.

In December 2009, the clinic’s director lost the ability to prescribe narcotics for two years after the Department of Health investigated numerous complaints that she was prescribing extremely high doses of opioids without appropriate assessment or ongoing monitoring.

But as opiate prescribing increased, so did the deaths — to alarming levels.

Last year, Washington lawmakers attempted to reverse the trend, requiring licensing boards to craft tougher rules for treating pain patients, except for those with injuries, surgery, cancer or who are dying.

The rules don’t take effect until Jan. 1, but many doctors say they already mean a lot of work, requiring them to gather records, check emergency-room reports, sign pain contracts with patients and arrange consultations as they try to assess an invisible affliction.

For now, the effort has engendered more questions than answers.

Are doctors simply using the new law as an excuse to dump pain patients, who can be needy and demanding — and, in some cases, addicted? Will the new rules cut down on overdose deaths — or just make life unbearable for the many patients who are legitimately hurting? One University of Washington Medicine neighborhood clinic stopped taking new chronic-pain patients on opiates after patients flooded in, saying their doctors had cut them off.

Two large statewide physician groups have asked the state’s medical-licensing board to amend the rules, saying they are so detailed that doctors could too easily face discipline or legal liability.

The result, warned the Washington State Medical Association and the Washington Academy of Family Physicians, likely will be that many doctors refuse to see pain patients. The board has declined to act.

Dr. Carl Olden, head of the family practitioners’ group, said pain-management specialists in Yakima are overwhelmed with pain patients, particularly those on Medicaid, who say their primary-care doctors no longer prescribe the meds they seek.

Dr. Alex Cahana, head of the UW’s Division of Pain Medicine and chief proponent of the new regulations, thinks many doctors have been too quick with the pills, in part because they have little training in other modes of relief, a situation he is working to change at the UW.

In a report this year, the federal Institute of Medicine estimated that chronic pain affects 116 million American adults and that relieving it should be a national priority.

For some pain patients, the changes are unnerving.

“I’m living in fear of cutoff,” said Denis Murphy, 72, who contracted a painful nerve disorder after a case of shingles.

Others say they know they need to reduce their medication but haven’t been given help to do so.

Across the state, more than half of those who died were patients on Medicaid, according to state figures. The most common pain drug was methadone, increasingly prescribed for Medicaid patients after the state restricted other medications.

Many providers said they expect the new rules will ultimately prove helpful but worry that some patients may try risky alternatives in the meantime, taking dangerous levels of acetaminophen or ibuprofen, or even buying opiates on the street.