In a dramatic step that could end suffering considered untreatable in the past, the North Carolina Medical Board is endorsing the use of powerful narcotics to manage chronic pain.
The policy shift is a response to growing evidence that drugs derived from opium are rarely addictive and can be the only source of effective pain relief for people disabled by maladies ranging from arthritis to agonizing back pain."This is really wonderful," said Eyssel Gurganus of Halifax County, regional director of the National Chronic Pain Outreach Association, a patients' group. "It will make doctors who are educated about pain less afraid. And I hope it will prompt doctors who don't know about it to get curious."
Many doctors avoid prescribing narcotics because they wrongly assume they will turn patients into addicts, say experts on pain management. Doctors also want to avoid scrutiny from government agencies that monitor what they write on their prescription pads.
As a result, they often routinely deny patients drugs that could help them live normal lives.
In a policy statement distributed last week, the board stresses that it does not endorse casual use of narcotics. But it wants to make clear that it will not punish those who prescribe them when it is medically warranted.
"This is a case of the pendulum swinging back toward patient care and allowing people to live more comfortable lives," said David Work, executive director of the state Board of Pharmacy. "For a long time, in the name of fighting drug abuse, physicians and pharmacists were discouraged from being involved in heavier narcotic therapy."
The board action is part of a swelling national movement that says patients have been under-treated for the wrong reasons. Medical boards in Texas, California and elsewhere have taken a similar stand. Legislatures in five states have passed laws emphasizing it is legal to prescribe the drugs for medically valid reasons.
Dr. Gerald Aronoff of Charlotte, the incoming president of the American Academy of Pain Medicine, cautions that narcotics should be reserved for only a small number of people with chronic pain. They are the best choice when there is no other option for patients who have no history of drug abuse and can be closely monitored for side effects.
"I think the pendulum could swing too far," said Aronoff, medical director of the Mid-Atlantic Center for Pain Control.
But Dr. Alan Spanos, a pain expert who practices in Raleigh and Chapel Hill, says thousands of people in North Carolina with chronic pain - whether from arthritis, nerve damage or joint disorders - could benefit from stronger drugs.
Among pain experts, there is wide agreement that many doctors misunderstand narcotics. While patients do become physically dependent on the drugs - just as diabetics need insulin - it is very rare for them to get intoxicated or crave the drugs for pleasure, Spanos said.
But physicians often chastise their patients for even asking for drugs.
"Doctors routinely accuse patients of being drug addicts simply because they plead for the drugs," Spanos said. "It's a visceral response based on a fear of street drugs."
Many doctors also assume that patients will build up a tolerance for the drugs and will need greater and greater doses. But research has proved that to be untrue; eventually, a patient's need for the drugs plateaus. And while many experience side effects initially, such as sleepiness, nausea and cloudy thinking, the effects are usually temporary if the drugs are taken properly.
Fear is another obstacle to improved pain treatment. Doctors know that state medical board investigators and the federal Drug Enforcement Administration monitor pharmacies to see which doctors prescribe a lot of narcotics. Investigators tend to show up at doctors' offices demanding to review medical records if they think something is wrong. Doctors who cannot prove they are prescribing the drugs properly risk a warning from the board or, at worst, losing their license.
Such oversight is necessary because there is a vigorous black market for prescription narcotics. A single tablet of the narcotic analgesic dilaudid, for example, can command $25 on the street, according to Judett Black, a DEA supervisor in Greensboro, N.C.
In the coming months, the medical board plans to monitor arrests for street sales of prescription drugs to see if there is a detectable increase. It will also watch to see if demand for drug treatment services rises.
In Texas, the DEA says doctors have been prescribing more narcotics since 1993, when the medical board there assured them that they could. But agents have observed no substantial increase in the illegal trade of pain pills, said Johnny Phelps, special agent in charge of the DEA in Dallas.
To help doctors make the right decision about prescribing narcotics, the North Carolina medical board will launch a statewide campaign to teach medical workers about the merits of substances that doctors often shun, including morphine, codeine and fentanyl.