Oct 25, 2006
By: Leah Beth Ward
Yakima Herald Republic (WA)
Concerned about a “troubling pattern” of increased deaths associated with prescription narcotics, a group of state and private medical officials is drafting guidelines that would recommend a maximum daily dosage of powerful narcotic painkillers such as OxyContin.
“You’ve heard of the Opium Wars between England and China,” said Dr. John Loeser, a Seattle neurosurgeon and pain-management expert, referring to the mid-1800s battles over the opium trade. “Well, we have opium wars in the U.S. right now.”
Loeser is a physician adviser on a multistate agency committee developing the guidelines.
If adopted in early 2007 as planned, the guidelines would be educational-only during the first year. Language that would allow agencies to mandate the guidelines has been dropped, according to Dr. Gary Franklin, medical director at the Department Labor and Industries.
Besides OxyContin — a brand name for oxycodone — common opioids include endorphin, fentanyl and methadone. The long-acting drugs are used for severe pain.
The current draft sets a maximum daily dosage of 120 milligrams of morphine or its equivalent per day for chronic pain sufferers. Cancer patients and others in end-of-life care would not be subject to the maximum. Rarely, and only in consultation with a pain-management expert, should the daily dose exceed the 120-milligram threshold, the draft states.
According to Franklin, dosages are running as high as 150 to 250 milligrams. “There are quite a few people taking very high doses, and that’s what we’re worried about,” he said.
According to verified death records kept in workers’ compensation cases by L&I — the lead agency in the multiagency effort — 32 deaths in the state between 1996 and 2002 were “definitely or probably” related to accidental overdose of opioids. During the same time period, the average daily dose of equivalent drugs rose by 50 percent, to 132 milligrams a day.
Officials are concerned about a relationship between the deaths and higher doses, and say it might be related to a lack of scientific evidence about the long-term safety of the drugs as well as the development of a tolerance to them among patients over a number of years.
While the draft guidelines won’t recommend that doctors automatically decrease the dose of a patient taking more than 120 milligrams, they will advise an assessment from a specialist, especially if the patient is showing signs of dependence or addiction.
Recreational use of opioids has grown since the mid-1990s, according to the National Institute on Drug Abuse, a unit of the National Institutes of Health. Abusers may snort or inject opioids to get high. But a side effect can be a decrease in the rate or depth of breathing, which can cause a fatal condition known as respiratory depression.
Loesner said the health-care industry is divided over opioids, with one contingent advocating liberal use for those enduring chronic pain and the other advocating a pull-back.
“There’s very little data on the subject, so there is a contentiousness in the health-care world,” he said.
OxyContin was approved by the Food and Drug Administration in 1995, reversing a previous professional bias against medical use of narcotic painkillers.
In addition to L&I, the departments of Corrections, Health and Social and Health Services, as well as the Health Care Authority, are developing the proposal. But Franklin said it was initiated by private health-care providers, especially family physicians, who want guidance.
Several professional organizations and boards are reviewing the proposal, including the state Board of Pharmacy and the Medical Quality Assurance Commission, which regulates health professionals.
According to L&I, North Carolina and Utah are working on new guidelines and Texas is considering administrative laws that would require treatment plans showing guidelines are being followed.
http://www.yakima-herald.com/page/dis/287343000169346
