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Educate docs to keep pain control and quality of life on track
Take one of the most powerful narcotics on the market, crush it into a fine powder, and you’re left with one of the most sought-after illegal drugs on the street. Legally sold in a time-release pill to treat chronic pain, OxyContin is one of the most effective narcotics used by physicians to treat pain caused by cancer and other diseases. Those who use OxyContin illegally grind the pill to disable its patented time-release mechanism and then snort or inject the drug to achieve a potent and immediate opiate high.
The drug is so effective and addictive as an illegal street drug that its going rate is a dollar a milligram, or $40 for a 40 mg pill. OxyContin prescriptions have more or less doubled in number each year since
its release in 1995. The manufacturer of the pill, Purdue Pharma of Norwalk, CT, raked in $1.14 billion in OxyContin revenues in 2000, up from $55 million in 1996. Last year, doctors wrote more than six and
a half million OxyContin prescriptions, and OxyContin ranked as the 18th best-selling prescription drug in the country (as measured by retail sales) and the No. 1 opioid painkiller.
But recent tales of OxyContin abuse and arrests of physicians are making some doctors reluctant to prescribe the drug. The National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA, is concerned that reports of the illegal trade and subsequent crackdowns by authorities will lead physicians to cut back on prescribing OxyContin and other drugs containing oxycodone, the active ingredient in OxyContin.
Among many hospices, OxyContin is not widely used because of
its cost. More often, other drugs with oxycodone are used, such as Endocet, Oxycet, Percocet, Roxicet, Roxilox, and Tylox. Chemically, oxycodone is a close relative of the other opium derivatives and synthetics, including heroin, morphine, codeine, fentanyl, and methadone.
"We’re hearing concerns about this in the field, that physicians are reluctant to prescribe it," says John Millett, a spokesman for the NHPCO. "Treating pain is the linchpin in improving quality of life among dying patients. Once pain is addressed, we can get to issues such as spirituality that can effect quality of life."
In a written statement, the NHPCO said: "To ensure that patients and families who are coping with terminal illness have access to adequate pain relief, overreactions, misperceptions, and fears fueled by recent media coverage of OxyContin must be dispelled." (See full NHPCO statement on p. 112.)
Concerned about the growing abuse of its drug, Purdue Pharma announced in early August that it is working on a patent application for a new formula of the opiate-based drug that would make it less susceptible to abuse and addiction.
The new formulation would make it "a lot more difficult to get a high" from OxyContin by ingesting the crushed pill, says Robin Hogen, executive director of public affairs for Purdue Pharma. Hogen says the new drug would have to pass through clinical trials required by the Food and Drug Administration, which means it might be two to three years before it could be prescribed by doctors. Among the hurdles, Hogen says, are efficacy trials that would show how well the new formula handles pain relief.
Will the new formulation become available in time to alleviate the fears of physicians, who are key agents in the battle against pain? Experts believe that physician concerns must be addressed or the pain management movement could suffer serious setbacks, including an across-the-board cutback in narcotic use for pain management.
"Pain is already being undertreated in this country," Millett laments. "There is a real question over whether this is going to affect quality of life among the dying."
Ruth Patzer, RN, MBA, administrator for Home Health & Hospice of St. Joseph in Bangor, ME, knows this problem all too well. It was almost two years ago when OxyContin abuse became front-page news in eastern Maine. Back then, OxyContin abuse was considered a regional problem, labeled "hillbilly heroin" and confined to areas far from big cities.
At first, the abuse of OxyContin nationwide seemed sporadic, limited to areas that were home to large populations of disabled and chronically ill people in need of pain relief. These typically were places blighted by high unemployment and a lack of economic opportunity, or areas that were far from the interstates and big cities where heroin and cocaine dominate the illicit drug trade.
As soon as OxyContin became associated with illegal use, the specter of being characterized as a drug dealer loomed large in the minds of physicians, including those who referred patients to Patzer’s hospice.
"Physicians were certainly intimidated," says Patzer. "We had one physician call us up and tell us that he would no longer prescribe OxyContin and that he was taking his patient off it."
Primary care physicians were most at risk of succumbing to the hysteria brought about by reports of OxyContin abuse, says Terence Gutgsell, MD, medical director of the Hospice
of the Bluegrass in Lexington, KY. Like Maine, Kentucky was one of the original hotbeds for OxyContin abuse.
There are growing signs that experiences like Patzer’s and Gutgsell’s are occurring in larger communities and are no longer an isolated problem. This year, authorities have seen OxyContin abuse move into the East Coast, the Deep South, parts of the Southwest, and into suburban communities throughout the Eastern United States.
In Miami-Dade County, there have been 11 overdose deaths so far this year in which oxycodone was the probable cause, and 11 more in Philadelphia.
Police in Bridgeport, CT, arrested a local doctor in July for prescribing tens of thousands of OxyContin tablets to patients, often without any medical examination at all, according to police. And in the suburbs of Boston, police say more than a dozen pharmacies have been held up by
a gang of young men wearing baseball caps and bandannas, looking for OxyContin.
Talking to doctors
Both Patzer and Gutgsell agree that hospices must engage their referring physicians in a continuous dialogue, not only about OxyContin, but about the effectiveness of narcotics altogether.
St. Joseph’s hospice program embarked on an immediate intervention once news stories came out. "We talked directly to physicians," says Patzer. "We had the good fortune of intervening immediately. We reasoned with physicians that OxyContin is very effective and that the quality of life of their patients would be effected if they are given less effective pain management drugs."
Since then, Patzer says her hospice has not let up in its educational efforts. Hospice staff discuss pain relief drugs with every physician on a daily, weekly, or case-by-case basis.
"We stress individual treatment," says Patzer. "We tell them that every patient is different and that use of OxyContin should be approached individually as opposed to globally. When you globalize the use of a drug, it’s easier to dismiss using it."
As hospices stress the importance of meeting patients’ pain management needs, physicians should be reminded of various pain management guidelines that include directions for narcotic use.
Most state medical boards, for example, have adopted guidelines. The Federation of State Medical Boards has adopted model guidelines for the use of controlled substances in treating pain. The guidelines have been adopted by 48 of 69 medical boards.
The guidelines recommend that doctors complete a thorough medical history and physical examination before drawing up a written treatment plan. In addition, doctors should periodically review the treatment course, paying special attention to patients who are at risk for misusing their medications, such as those with a history of substance abuse or a psychiatric disorder along with pain.
In its guidelines for managing cancer pain, the Agency for Health Care Policy and Research in Silver Spring, MD, stresses individualized regimens. (See AHCPR guidelines for drug use in pain management, p. 111.) AHCPR guidelines call for choosing drugs to manage pain or other symptoms, identifying the specific cause(s) of the pain, evaluating the pain’s intensity and quality, and then matching the drug to the pain intensity and other characteristics.
According to AHCPR guidelines, the simplest dosage schedules and least invasive pain management modalities should be used first. After drug therapy has been started, pain should be assessed to determine the ongoing effectiveness of the analgesic therapy.
For opioid analgesics, if pain relief is inadequate, the dose should be increased until pain relief is achieved or unacceptable side effects occur. In the case of NSAIDs and adjuvant analgesic drugs, which have ceiling effects to their analgesic efficacy, if the upper limit of the recommended dose is reached and pain relief is not achieved, then that particular drug should be discontinued and a second drug in that class should be used.