Last updated January 1, 2008 3:04 p.m. PT
YAKIMA, Wash. -- Alex Four-Horns leans forward as far as his aching body will allow while his pain nurse massages a mixture of castor oil, ginger and lavender into his shoulder.
Castor oil has a soothing effect, giving Four-Horns some short-term relief from chronic pain, the result of a life-threatening automobile accident three years ago that left him in a coma for a month, broke both his thigh bones and damaged his knees and hips.
Once a strong, athletic man, Four-Horns, 29, now moves slowly, and he finds it difficult to keep up with his sons, ages 2 and 8. "My hip went out when I was putting up the Christmas tree with my boys," he said.
Healing oils, a lot of ibuprofen and occasional electrical nerve stimulation are the only pain management tools available to Four-Horns.
The state Medicaid program pays for occasional visits from nurse Dionetta Hudzinski to his home not far from downtown Yakima. Hudzinski, who has long been active in advocating for people with chronic pain, wonders if he might benefit from a prescription painkiller. But she can't find a doctor to treat him for pain.
Four-Horns' case illustrates what University of California pain physician Dr. Scott Fishman calls a war between two urgent public health problems - the need to address many patients' undertreated and untreated chronic pain and the need to reduce the nation's alarming rate of prescription drug abuse.
Washington state became a battlefront in the pain war earlier this year when a group of state agency medical directors, led by Dr. Gary Franklin of the Department of Labor and Industries and in consultation with practicing pain specialists, issued voluntary guidelines to physicians for prescribing opioids for noncancer pain. Opioids such as OxyContin are powerful painkillers that mimic morphine. Heroin is made from morphine.
The state's chief recommendation is that doctors limit the total opioid dose to the equivalent of 120 milligrams of morphine a day. At that level, the state urges doctors to seek a consultation with a pain management specialist. No other state recommends a dosing limit, although others are exploring the idea.
The dosing guideline is about half the maximum average daily dose of 250 milligrams taken in recent years by injured workers and Medicaid clients with chronic, noncancer pain, according to Franklin. Doses in some cases exceeded 1,000 milligrams, he said. In contrast, some cancer specialists say their patients with chronic pain might require more than 600 milligrams of morphine a day.
Since the guidelines were published in March, they have become a flashpoint in the national debate over finding the balance between treating pain and stopping the illegal diversion of prescription painkillers into street drugs. The American Academy of Pain Medicine, an association of pain physicians, recently came out strongly against the guidelines, warning that they will scare doctors away from legitimately treating chronic pain. They attack the 120 mg dosing limit as unscientific and say there simply aren't enough pain specialists to take referrals from family doctors.
"Doctors don't have anyone to send these patients to," said Fishman. "They'll say, 'I'm just not going to prescribe.' It will drive down the number of prescriptions and the government will look like it's succeeded. But whether this helps the prescription abuse problem, who will know?"
Fishman said the dosing guideline is motivated by cost savings. "This will save the state a lot of money," he said. "These drugs are expensive."
Franklin said the guideline is about saving lives. "Nothing else."
Nevertheless, the state has been under pressure to curb its more than $500 million annual expense for Medicaid prescription drugs. An estimated 70 million Americans suffer chronic pain from a variety of diseases, such as arthritis, headache, fibromyalgia, and diabetes. Experts say people at lower income levels and members of ethnic groups, particularly African Americans, suffer disproportionately from chronic pain, often the result of discriminatory health care.
Franklin said it's too soon for the state to determine if the dosing limit is cutting down on prescription drug abuse. But he said doctors appreciate the standards. He said they have received more than 6,000 hits on the state medical directors' Web site, which offers a calculator to help people figure out if they are exceeding the dosing limit. This first year of the guidelines is "an educational pilot," he added.
Asked what's next, Franklin said it's too soon to know. "The state is trying to do this without waving a big stick, and I think it's exactly the right thing to do."
Abuse of prescription painkillers, particularly by minors who steal them from their parents, has been a growing problem since the mid-1990s. That's when the medical establishment overcame a longstanding phobia about using opioids to treat people with chronic, noncancer or end-of-life pain.
Research at the time showed that carefully managed treatment with opioids brought patients sustained relief from pain and improved function. Addiction rates appeared low.
Dr. Gary Bos, an orthopedic oncologist in Yakima, remembers the push to use the narcotics by medical associations and pharmaceutical manufacturers. At the time, he was practicing in North Carolina. "Doctors were walking around with little buttons that said 'pain' with a big red slash through the word," he said.
Bos said he and a lot of his colleagues were skeptical. "Many of us stood back and thought it was wrong. And sure enough, we got a whole bunch of addicts."
In the United States, office visits for potent prescription opioids increased nearly fivefold between 1980 and 2000. In the state of Washington, the rate increased 2.5 times. According to national figures, 9.5 percent of high school seniors in 2005 used hydrocodone, often marketed as Vicodin.
Franklin and his colleagues began studying the issue through the lens of the state workers' compensation system. In 2005, they published a paper showing that prescriptions for the most potent opioids as a percentage of all opioids jumped from 19 percent in 1996 - when the medical standards were relaxed - to 37 percent, or 57,000 prescriptions, in 2002. Daily dosages of the long-acting narcotics increased 50 percent, from 88 mg a day to 132 mg.
The most controversial finding in the Franklin study was that 32 people died in the six-year study period either "definitely or probably" from an accidental overdose of prescribed opioids. Another 12 deaths were "possibly" related to an overdose.
The Franklin study didn't draw any definite conclusions about why prescription narcotic rates rose in that time. But it suggested that people taking the drugs for chronic pain developed either a tolerance to them or an abnormal sensitivity to pain because of them. Deaths could be prevented, the study said, with "prudent" guidelines on the use of the narcotics for chronic pain.
Judith Paice, who directs the cancer pain program at Northwestern University medical school in Chicago, said the data used in the Franklin study were flawed because they didn't document the actual dosage taken by the 44 patients who definitely or probably died of an overdose.
Paice, a registered nurse with a Ph.D, objected to Washington state's guidelines on behalf of the American Pain Society, an association of scientists, clinicians and other medical professionals that tries to change public policy and clinical practice to reduce pain-related suffering.
More than half of her patients in Chicago take more than the equivalent of 120 mg of morphine a day. She said some are cancer survivors dealing with chronic pain from nerve damage. "I have survivors who can't bend over and tie their shoe laces," Paice said.
It's not practical, she contends, for doctors to refer patients at the maximum dosage to the kind of pain specialist the state is recommending. Such physicians are in short supply, mainly because they have to spend a lot of time with patients and aren't reimbursed very well. "That's the dirty truth," Paice said.
On its Web site for doctors, the state medical directors group lists only seven physicians certified in pain medicine or recognized as experienced in management of chronic pain. The closest to Yakima is a Richland doctor, who only takes patients by referral from other doctors.
Franklin stands by the state's guidelines. Still, he said he's "taking some heat" on the specialty consultation. "There really is an access issue," he acknowledged. One possible solution, he said, is having specialists conduct consultations by phone or even via the Internet.
While the medical experts debate, Alex Four-Horns keeps the heat on high in his small house. The cold weather, he said, accentuates the pain in his thighs, where metal rods hold his bones together. "I literally don't move when it gets this cold," he said.
Four-Horns has never raised the subject of narcotic painkillers when he has had occasion to see a doctor. He's wary of being labeled a drug-seeker or drug abuser because he's American Indian. "I don't know if it was stereotyping but it was not a topic I felt comfortable bringing up," he explained.
For his pain, he takes 800 mg of ibuprofen two or three times a day, putting him two times above the recommended dosage for moderate pain. It's been three years since the accident landed him in Seattle's Harborview Medical Center, the region's trauma center. So he worries about the cumulative effect of the ibuprofen on his heart and liver. So does Hudzinski, his nurse.
Hudzinski said when she sees patients like Four-Horns, her goal is to assure them their pain and their need for pain relief is real. She believes that has helped Four-Horns over the two years she's been seeing him. "We haven't cured his pain, but his perception of his pain has changed," Hudzinski said.