My husband is in a lot of pain from his prostate cancer. Can his doctor get in trouble with the DEA for increasing medication doses?

My husband is often in pain from his prostate cancer that went to the bone but my doctor is reluctant to increase his medications. He says that he can get into trouble with the DEA if he raises the doses too much. Is there something to his concern or not?

I am sorry that you and your husband are facing dealing with pain. These days there are so many effective approaches that no one should be in pain.

Safe and effective chronic opioid therapy for chronic cancer related pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Diversion means using lawfully obtained medications for the purposes of drug abuse. Although evidence is limited in many areas related to use of opioids for chronic cancer pain, several guidelines provide recommendations developed by multidisciplinary expert panel after a systematic review of the evidence. There are other approaches than merely increasing doses of narcotics, although that also is often justified.

Generally, narcotics are not the only modality that can be used to treat pain. Adjuvant therapies together with narcotics can be very helpful. For example, steroids and non-steroidal anti-inflammatory drugs, such as ibuprofen(Advil) can reduce the inflammation associated with tumors pressing on tissues, and certain anti-depressants and anti-seizure drugs can modify how the brain perceives and processes pain and lessen the subjective experience of pain. There are also procedures, such as nerve blocks, that can be helpful when pain is localized.

Cancer pain can require very high doses of narcotics. Guidelines provide guidance and in some case, recommend a specialty pain management consultation. A diagnostic re-evaluation is often indicated to exclude cancer progression. If there is progression, the best pain management is successful treatment of the underlying disease. It may sometimes be possible to switch to a different narcotic, which reduces tolerance and allows a lower dose, or decrease total narcotic dose by using adjuvant analgesics, steroids or neuro-modifiyng drugs discussed above, but there remain situations in which very high doses are required despite all efforts. Intravenous patient controlled analgesia(PCA) with outpatient medication via a pump, or intrathecal catheters present other options. Both of these methods of administration reduce the side effects and allow the lesser dose to be as effective.

Risk of addiction in cancer patients is very low, around 2%, but using several instruments can reduce it even farther: CAGE questionnaire, Cyr-Wartman Screen, Skinner Trauma Screen, Screener and Opioid Assessment for Patients. These instruments can identify addiction prone personalities.It is important to understand the distinction between addiction, a psychological syndrome, and habituation, which is the body getting used to narcotics and requiring higher doses. Habituation can be easily treated; addiction is much more difficult to treat. Unfortunately, overrated fear of addiction or unwarranted anxiety about attracting the attention of the DEA, sometimes leaves patients with inadequate pain control.

Failure to provide adequate pain control to cancer patients is a deviation from the standard of care and can be grounds for a malpractice suite, or it can play a role in increasing recovery. The use of national guidelines or local state policies can be helpful to both plaintiff and defense. State pain policies can shield practitioners who have complied with the state policy, or a damn physician who have not. Some state policies are so restrictive that they automatically put the defendant at a disadvantage. An expert who is familiar with the use of guidelines and local policies can prove invaluable in the litigation of cases the involve standards of pain management.

Davis MP, Weissman DE, Arnold RM, Opioid dose titration for severe cancer pain: a systematic evidence-based review.J Palliat Med. 2004 Jun;7(3):462-8.
Washington State Agency Medical Directors’ Group. Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid treatment. Olympia (WA): Washington State Department of Labor and Industries; 2010. 55 p. [123 references].
Friedman DP. Perspectives on the medical use of drugs of abuse. J Pain Symptom Manage 1990; 5: S2-S5.
Joranson DE, Gilson AM, Dahl JL, Haddox JD. Pain management, controlled substances, and state medical board policy: A decade of change. J Pain Symptom Manage. 2002;23:138-147.
Furrow BR. Pain management and provider liability: No more excuses. J Law Med Ethics. 2001;29:28-51.
Ziegler SJ, Lovrich NP Jr. Pain relief, prescription drugs, and prosecution: A four-state survey of chief prosecutors. J Law Med Ethics. 2003;31:75-100.

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