Conflicting federal guidelines are a pain.

Ready for a short quiz on government policy on pain-relieving medication? Identify current federal guidelines from these choices: (a) clinicians should reduce use of pain-relieving drugs, especially narcotics, because current practices rely too much on expensive medication and may create drug dependence among the elderly; or (b) clinicians should increase use of pain-relieving drugs, including narcotics, because current practices are overly cautious and lead to unnecessary suffering; or (c) both of the above.

Unfortunately for nursing homes seeking guidance, the most accurate answer appears to be (c). Some agencies within the Department of Health and Human Services are pursuing policies that are exactly the opposite of pain relief guidelines promoted by another agency within the same department. As a result, clinicians can be criticized for either increasing or decreasing use of medication such as diazepam, hydromorphone, and oxycodone.

Conflicting Federal guidelines on clinical use of pain-relievers were the principal topic of a panel on prescription drugs at the 2nd National Conference on Drug Abuse Research and Practice of the National Institute on Drug Abuse, held in Washington, DC, last July. Clinician and educator Sidney Schnoll, MD, of the Medical College of Virginia, and Bonnie Baird Wilford of George Washington University's Intergovernmental Health Policy Project, agreed that popular concern about drug abuse and dependence is driving policy that ultimately harms most patients and confuses care-givers.

Dr. Schnoll described situations in which post-operative patients demanding a pain-reliever ahead of schedule are given a placebo to determine whether the patient displayed symptoms of addiction to the requested drug. Under current regulations, the clinician may chart that the patient shows early signs of dependence on grounds that the placebo seems to work; clinicians may also chart early signs of dependence because the placebo does not provide relief!

Consensus guidelines issued last year by the federal agency for Health Care Policy Research on the use of analgesics for terminal patients were designed to resolve the resulting confusion. Although the guidelines oppose vague "take as needed" instructions for patient use of analgesics, they also urge physicians to avoid undermedication. There is strong evidence that gradually increased dosage of pain-relievers for terminally-ill patients reduces unnecessary hospitalization and complications, improves patient quality-of-life, and may even prevent suicide. Meanwhile, the risk of dependence on such potentially-addictive drugs as diazepam (Valium) and morphine appears to be very slight when dosages remain within clinical guidelines and the patient avoids alcoholic beverages. Consensus guidelines to be issued this year are expected to come to similar conclusions regarding the use of drugs for chronic pain relief.

Statistics compiled by the Drug Abuse Warning Network (DAWN), a project of the National Institute on Drug Abuse, support the view that abuse of prescribed narcotics is not a major risk for older patients. In 1990, the DAWN system counted 1,000 geriatric emergency room incidents involving narcotics other than heroin and morphine, 933 geriatric incidents involving aspirin or acetaminophen, and 970 incidents involving diazepam (Valium). As for resulting mortality among patients 50 years or older, the frequently-prescribed narcotic meperidine hydrochloride (Demerol) was mentioned in only eight medical examiner reports -- indeed, less than one-fourth the number of aspirin-related reports. Nevertheless, some federal agencies are continuing to push for reduced use of the medications. According to Ms. Wilford, "Some agencies are taking pride in adoption of regulatory programs that cut use of analgesics in half." The George Washington University Intergovernmental Health Policy Project counted 102 pieces of state legislation introduced this year with the goal of imposing further controls restricting prescriptions of pain-relievers.

Wilford believes that the war on drugs ethos, popular misunderstanding of the nature of addiction, and misplaced concerns over the cost of medications contribute to an atmosphere in which physicians are fearful of prescribing sufficient medication to relieve many patients' symptoms. "Physicians pick up very well on the local regulatory environment...there are some medical boards that have deliberately created an environment in which physicians believe they may be brought before the board to justify any use of analgesics."

Wilford suggests that overly-restrictive use of pain-relievers may cause more geriatric addiction than it prevents. Patients who do not receive adequate amounts of narcotic analgesics are likely to engage in drug-seeking behavior to relieve their symptoms. They may "shop" for sources of the drug or horde supplies, and become more vulnerable to symptoms of drug dependence and other drug-related problems.

The problem of drug-seeking behavior was explained in graphic terms by a member of the audience at the NIDA conference panel on prescription drugs. A victim of chronic pain, she described how she spent weeks finding both a doctor and a pharmacist who were willing to provide a large enough dosage of prescription analgesics to enable her to continue working. Ironically, she identified herself as a staff member of the Center for Substance Abuse Prevention, one of the federal agencies charged with preventing drug problems.

Dr. Schnoll argues that the conflict between perceptions of underuse and overuse of pain relievers will continue as long as clinicians receive inadequate training in prescribing medication. According to Dr. Schnoll, most physicians' formal education on prescriptions begins and ends with instructions on how to fill out the necessary documents. Their actual training on the use of narcotic analgesics and other pain relievers consists of observations while they are interns in a hospital ward. This means that their understanding of prescription use often is based on the special case of administration of medication in an inpatient setting. Most physicians have no direct observation of prescription use in the less structured setting of a nursing home or in the geriatric patient's own residence. In the case of narcotic drugs, physicians may be influenced less by research findings than by such informal sources as popular myths or pharmaceutical company promotional material.

While it may be true that the restrictive regulations on administration of pain-relievers are helping to prevent potential abuse, Bonnie Wilford, however, said she questions the "social algebra" that results in denying medication to ease patient suffering: "If we want to pay that price, we can pay it, but I think it's a price not worth paying." Physicians and nursing homes may agree, and can only hope that the regulators will eventually agree, as well.