Thursday, April 26, 2012
Access to pain relief is a fundamental human right, yet waiting times for pain care in Canada grow longer by the day, pain doctors and leaders of patient groups say.
Many patients who need opioids to help control pain can't find a family doctor willing to treat them, the one-day gathering in Ottawa heard. Even children are suffering under-treated and poorly managed pain.
Chronic pain "assaults us physically, emotionally and spiritually," said Lynn Cooper, president of the Canadian Pain Coalition. "Pain can be devastating, debilitating, demoralizing and dehumanizing. And all too frequently, it turns deadly."
Those living with chronic pain experience stigma, discrimination and the "shame of pain, when we are labelled as complainers, malingerers and drug seekers," Cooper said.
"Access to pain management is a right not being met in Canada," she said. "Canada as a developed country has a moral imperative to do better than this. We can do better than this."
It is estimated that one in five Canadians - about six million people - is living with chronic pain of some kind. In the next two decades, as the population ages and modern medicine allows people to survive serious illness, that ratio is expected to swell to one in three.
Pain researchers, doctors and patient groups want a national pain strategy that would see more specialized pain clinics, more training of doctors in the diagnosis, treatment and prevention of pain and improved community-level care.
The summit heard that six to eight per cent of children in Canada live with intense and frequent pain - persistent pain from surgery or trauma, juvenile fibromyalgia, arthritis, chronic headaches and chronic abdominal pain - but that children have even poorer access to pain treatment than adults.
"Imagine being the parent of a child with cancer who won't even let you hug her because it hurts too much," said Dr. Allen Finley, professor of anesthesia and psychology at Dalhousie University in Halifax, and a world leader in pediatric pain management.
"Imagine being a teenager with chronic pain who nobody believes. Imagine being too young to find the words to say, it hurts," said Finley, medical director of pediatric pain management at IWK Health Centre in Halifax.
He said one of his patients described the pain as feeling like "meat knives carved into my joints, running through my bones and jabbing into my soft tissues. And it's not the kind of thing you get used to, either."
Finley said there are "hugely more children" affected by pain than the half-dozen pediatric pain clinics across the country can begin to handle.
"We need another strategy," he said. "We need more staff and support to not only treat those kids directly but also to build capacity in primary care to prevent problems from becoming difficult," he said.
People with chronic pain are stigmatized and frequently treated as addicts, or would-be addicts, the summit heard.
"What a cruel thing to do someone who is already suffering from pain," said Dr. Michael Cousins, director of the Pain Management Research Institute at the University of Sydney in Australia.
- 1 in 5 Canadians suffer from chronic pain daily
- Children are not spared with 2% of boys and almost 6% of girls between 12 and 17 years of age report chronic pain 
- Pain is a major concern for older adults because of its high prevalence – estimated to be as high as 65% for those living in the community and up to 80% of older adults living in long-term care facilities
- Chronic pain costs more than cancer , heart disease and HIV combined with direct health care costs of $6 billion
- Productivity costs related to job loss and sick days are estimated to be $55 TO $60 billion per year
- Veterinarians get five times more training in pain than people doctors and three times more training than nurses
- Chronic pain is associated with the worst quality of life as compared with other chronic diseases such as chronic lung or heart disease
- There is double the risk of suicide as compared with people without chronic pain
- Schopflocher, D., R. Jovey, et al. (2010). "The Burden of Pain in Canada, results of a Nanos Survey." Pain Res Manage: In Press.
- Joe McAllister, The Medical Post - January 26, 2011. "Statistics Canada, 2007/08 Community Health Survey, 24 month file."
- Hadjistavropoulos, T., S. Gibson, et al. (2010). Pain in older persons : a brief clinical guide. Chronic Pain Management: A Clinical Guide. M. E. Lynch, K. D. Craig and P. W. H. Peng. Oxford, UK, Wiley-Blackwell: 311-318.
- Watt-Watson, J., M. McGillion, et al. (2008). "A survey of prelicensure pain curricula in health science faculties in Canadian universities." Pain Res Manage.
- Tang, N. and C. Crane (2006). "Suicidality in chronic pain: review of the prevalence, risk factors and psychological links." Psychol Med 36: 575-586.
Barriers to Better Pain Management
Tuesday, April 24, 2012
Friday, April 20, 2012
Except, there is no foot. Campbell's legs were blown off on a midday in June 2008, when a buried improvised explosive device was detonated beneath him during a Taliban ambush in Afghanistan.
His left leg was all but vaporized in the explosion; his right leg barely hung on by a few strands of shredded bone and tissue.
Today, he suffers phantom limb pain where his left leg below the knee used to be — an excruciating kind of torment so severe he needs methadone to manage it. He's on maximum allowable doses of other pain medications, their list of side-effects long. "But I have no choice," the 47-year-old father of two says. "It's that, or I don't want to live."
As the nation's largest military deployment since the Second World War ends, a new and constant companion will follow many wounded soldiers from the battlefield: Chronic, life-altering pain.
Leaders in Canada's pain community say the unprecedented numbers of soldiers who survived injuries that in past wars would have killed them will need a high level of care in a country where pain is under-treated, and under-funded. U.S. doctors are reporting that half of Iraq and Afghanistan vets treated at military hospitals are experiencing some form of persistent and significant pain.
"We owe Canadian warriors the best pain care possible," says Dr. Mary Lynch, director of research at the Pain Management Unit at the Queen Elizabeth II Health Sciences Centre in Halifax.
"But if the military has to rely on the civilian system of complex pain care, it will be grossly inadequate," she said. Canadian civilians are facing waits of more than a year at specialized pain clinics. Vast areas of the country have no access at all.
A first-ever Canadian pain summit to be held next week in Ottawa will hear how a U.S. army-led task force on pain has led to an overhaul of how wounded soldiers are being treated, from the battlefield through rehabilitation once home. Specialized pain clinics are being set up at civilian and army medical centres across the U.S. that take a holistic approach. A military criticized for over-relying on opioids to manage pain — leading to high rates of addiction among injured soldiers — is now embracing acupuncture, meditation, yoga and other alternative therapies.
"We know that this is something that we need to be aggressively managing," states Col. Chester (Trip) Buckenmaier III, program director for the U.S. Defense and Veterans Center for Integrative Pain Management.
"We've been talking about the 'rock stars,' if you will, of the conflict — those soldiers that have obvious injuries from an IED, for example, where there's a limb missing," he said.
"But the business of being in the military and the business of being in the war zone is hard, it's hard on human beings," Buckenmaier said. "We have these guys now in 40 pounds of body armour. They're often running around with rucks that are another additional 50 pounds."
Soldiers are returning from war with severe back strain, joint pain and other musculoskeletal injuries, as well as constant headaches from exposure to multiple blasts.
"When a soldier comes back broken, that impacts everybody," Buckenmaier said. "And until you've managed the pain adequately, they can't focus on anything else. We really become the basest, the most base that we can be as human beings," he said. "We're animals. All you can think about is escaping the pain."
Until the military began offering a combination of therapies, many people did just that by using opioids to excess, "because you could essentially send yourself into oblivion."
While post-traumatic stress disorder and traumatic brain injury have been called the "signature injuries" of war, Buckenmaier says there is a third: Pain.
No land army in the history of warfare has achieved the level of survival as seen in the war in Afghanistan, he said.
"We have a less than 10 per cent died-of-wounds rate, and I'm pretty sure the Canadian military is enjoying a similar statistic."
In the Second World War, 30 per cent of wounded troops died.
According to the Canadian Forces Surgeon General report in 2010, if a wounded CF soldier, sailor or airman makes it to the military hospital at the Kandahar Airfield with vital signs, they have a 97 per cent chance of making it back to Canada alive.
Advanced body armour, advanced trauma life support provided by medics on the battlefield and rapid evacuation of the wounded — all are factors behind the improved survival rates.
Still, more than 600 Canadian soldiers have been wounded in action in Afghanistan; more than 1,400 others have sustained non-battle injuries (such as injuries from traffic accidents or the accidental discharge of a weapon).
Many of these injuries will result in pain that is relentless, Lynch says. In addition, research in the U.S. shows that more than half of military personnel suffering physical pain from combat wounds are also plagued by depression, anxiety, panic disorder and other psychological problems — a phenomenon experts have dubbed "post-deployment multi-symptoms disorder," or PMD.
Blast-related injuries can dominate — wounds from IEDs and landmines and rocket-propelled grenades. The blast force can cause head-to-toe trauma, from "de-gloving injuries" — stripping of skin and soft tissue from bones — avulsion of limbs requiring amputation, shattered pelvic bones, genital amputation, bowel and bladder injuries, hand or finger amputation, punctured lungs and traumatic brain injury.
Soldiers can survive their wounds only to be left with complex regional pain syndrome — "nerve damage that causes pain that is excruciating," says Lynch, past president of the Canadian Pain Society, co-host of next week's pain summit. "Even the touch of a cotton ball can be painful, or the sound of a plane overhead or a newspaper rustling in the same room."
Until Canada pulled out of its combat role in Afghanistan, Lt.-Col. Markus Besemann received casualty and wounded reports regularly.
"Amputees are certainly the most graphic ones," said Besemann, head of the CF's rehabilitation program. But other severe injuries involve "multiple orthopedic trauma" — broken bones, shattered pelvis — nerve damage, head trauma, spinal cord injuries and internal organ damage from blasts.
Most military hospitals in Canada were shuttered in the 1990s, their role handed to the civilian sector. Military personnel who need specialized care are treated at civilian hospitals and rehabilitation centres, with followup care provided by their base health clinics. But not all have multi-disciplinary pain programs.
The Canadian Forces has two chronic pain management programs — one in Halifax, the other in Ottawa — that teach patients breathing techniques, mindfulness meditation and other exercises to help manage their pain. The plan, Besemann said, is to expand them to major bases across the country.
Patients are sent to the teams after everything that can be done medically is done, he said.
In addition, doctors specializing in rehabilitation medicine are being hired for bases in Gagetown, Edmonton and Quebec City.
He said soldiers needing complex care could be fast-tracked to civilian pain clinics within a matter of months.
Lynch says the decision on who should take priority should be made on the basis of urgency of need, "and not whether a person is a civilian or in the military."
"The whole system needs to be fixed," she said. "There is massive ignorance about the appropriate treatment for chronic pain."
Pain researchers, doctors and patient groups across Canada want a national pain strategy that would see more investment in training doctors — civilian and military — in pain and more specialized pain clinics.
But for soldiers, there are other challenges in seeking care: The "tough-it-out" mentality embedded within the military can make soldiers fearful that their careers will end if they report that they're in pain.
"I guess it's inbred in their training to suck it up," Besemann says. "They often come back and tell me that: I was basically taught as an infanteer I have to just suck it up and get on with it."
Many delay seeking care until their pain becomes chronic, he said.
"People are desperately wanting to maintain their careers, and so they'll push through pain. . . . And those are significant challenges, trying to convince people, 'Look, you need to come to us earlier, rather than later.' "
Pain isn't a threat to a career, he said, "so long as the condition they have is treatable."
Yet a recent Postmedia News series on Canada's combat mission in Afghanistan told how the number of soldiers being "medically released" jumped from a low of about 675 a year in 2002 to almost 1,200 a year in 2006.
Many of these were forced out, their injuries from Afghanistan leaving them unable to fulfil the military's requirement that all personnel be physically able to go into combat. Then-chief of defence staff Rick Hillier would later promise to exempt any soldier wounded in Afghanistan from that requirement — a promise some have complained is inconsistently applied.
Campbell, of Edmonton, says for serving soldiers with pain, "the career is on the line, and every soldier knows it." For those with back pain, knee pain, shoulder pain: "You walk it off, you suck it up, and you do what you've got to do."
The difference for him is that, "I'm done."
"I'm never going to be an infantry officer again. I'm finished. My career is over," he says. "What's holding me back from saying: 'Hell, I hurt. I want it fixed.' "
It took two tourniquets on each leg to stop his severed femoral arteries from bleeding him out. He was lucid — and in "indescribable agony" — the entire time it took soldiers to run with him on a carpet stretcher, through irrigation ditches and with gunshots and grenades exploding around them, to a secure area where an evacuation helicopter could safely land.
Campbell spent two months at Edmonton's Glenrose Rehabilitation Hospital — a rehab centre that a 2008 Senate committee report on national security and defence said stands out in Canada "like a 2009 Lamborghini on a car lot dotted with too many 1970 Ladas."
After Campbell was discharged home, the phantom pain was so severe he couldn't sleep most nights. His military psychiatrist referred him to a University of Alberta Hospital specialized pain clinic, where his doctor suggested methadone.
"Campbell remembers thinking: "The pain is so bad that I need a heroin treatment for it?"
The drug, he says, has been a "life changer."
It allows him to sleep; it helps keep him from thinking about the pain.
For Campbell, the road to rehabilitation has been long. "You don't ever fully recover from wounds like mine," he says.
His pain, he says, is exacerbated by the struggle for fair compensation from the government of Canada.
"One moment you're in combat, then the next thing you know you're in a hospital bed, and you've got no legs," he said. "The last thing you remember was that whole horrible incident you hope was just a nightmare.
"Except once the drugs wear off, you realize, 'this isn't a nightmare. This is real.'
"And the nightmare never really lets up."
Tuesday, April 17, 2012
Monday, April 16, 2012
On the wall at the foot of my bed, a poster displays the Faces Pain Scale, a series of earless, genderless everymen arranged, from right to left, in increasing degrees of agony.1
"The faces show how much pain or discomfort someone is feeling," the caption explains. "The face on the left shows no pain. Each face shows more and more pain and the last face shows the worst pain possible. Point to the face that shows how bad your pain is right NOW."2 The blurb adds, helpfully, that your face need not resemble the cartoon visages in the Pain Scale.
It's August 2011. I'm lying in a room at New York-Presbyterian Hospital, waiting to undergo surgery for a small-bowel obstruction, an intestinal blockage resulting from postoperative adhesions caused by my 2008 surgery for my first small-bowel obstruction, itself the result of my 2006 surgery for a rare and virulent cancer. Abdominal surgery begets scar tissue. Which gives rise to adhesions. Which sometimes cause bowel obstructions. Which may necessitate surgery. Which begets more scar tissue, which...
I'm feeling nigh unto death, driven half-mad by my nasogastric tube, a tube running up my nose and down my throat, pumping a bilious green froth of stomach acid and half-digested goop out of my belly, into the canister behind my headboard.
(Few readers will know firsthand the horror of the NG tube, or, more exactly, of its insertion. Handing you a cup of water, the doctor prods a plastic tube up one of your nasal passages, down your throat and into your stomach, exhorting you todrink, drink, DRINK! to ease the tube's passage and suppress your gag reflex. The violation is over in seconds, but for those seconds the retching, suffocating nightmare is unendurably awful, like drowning on dry land. And for the days or weeks that the tube lives in you, like some parasitoid alien organism, you gag a little every time you swallow, the tube rasping against your throat.)
In my agony, I take some small comfort in knowing that the Faces Pain Scale is there for me, even if I don't look like a constipated mime.
In 2006, I was diagnosed with squamous-cell cancer of the urethra, a rare form of the disease. I spent that summer at the Memorial Sloan-Kettering Cancer Center, riding the sickening swells of a chemotherapy so toxic it left me limp and nauseous for the first of the two weeks between each session, poisoned by the cure that felt as if it was killing me.
By summer's end, it had shrunk my tumor, but not enough. Thus, my date with the O.R. at New York-Presbyterian—foreordained from the moment my surgeon saw my first MRI—would be more harrowing than I'd hoped. "Of course, it was dispiriting," I told my friends, in one of the periodic e-mail updates I called cancer-grams. "I had hoped that the tumor would shrivel up and die, nuked by the chemo." That said, I noted,
The most painful part of having my hopes dashed was the deadpan affect with which my Sloan-Kettering oncologist delivered the news that my chemo had failed, adding that, in his considered opinion, I should have my everything removed as an offering to the Angry God of Cancer, in the desperate hope that this thing will never come back. "Radical penectomy," he snapped, tonelessly. Then, without so much as a handshake, he swept out of the room, white coat flapping. That, I gathered, was the end of our doctor-patient relationship.
I'll always remember him as a man who put the "care" in "caregiver," with a bedside manner whose saintly compassion and twinkly-eyed avuncularity recalled Joseph Mengele at his best.3
Mercifully, my surgeon was as profoundly humane as my Sloan-Kettering doctor was bloodless. Dr. James McKiernan struck a delicate balance between an unfeigned compassion, leavened with a hilariously bent wit, and an unassuming mastery of his field. He was by all accounts preternaturally skilled with a scalpel. A radical penectomy, he reassured me with an eyeroll, would not be necessary.
In October 2006, Dr. McKiernan carved away my cancer in an epic operation. Since then, I've undergone MRIs and CAT scans at ever-greater intervals. So far, no bogeys have appeared on the radar screen; hitting the five-year mark without incident, as I have, means that the statistical likelihood of a recurrence is astronomically small—cause for celebration indeed, since of those patients who are favored, by the blithely cruel God of Random Chance, with my vanishingly rare cancer, 70 percent experience a recurrence. And virtually all of them are killed by it. This thing is a slate-wiper.
Saturday, April 14, 2012
When Mets pitcher R. A. Dickey partly tore the plantar fascia in his right foot last May, he turned to a treatment that in recent years has become a go-to elixir for professional baseball and football players: Toradol, an injectable anti-inflammatory drug.
"It certainly helped, especially in the first months after the injury," said Dickey, who received injections in his buttocks before about 12 starts. "I don't think it's a panacea, but it helps you get where you have to go."
But some medical experts are concerned about the ways sports teams are using Toradol because so little is known about its possible long-term effects on athletes.
No data are available on the use of the drug by athletes, so it is unclear how frequently Toradol injections are provided and for what ailments, and whether players are told of the potential side effects — all of which has caused tension and a growing awareness among sports medicine experts. Concerns over its widespread use in baseball compelled at least two team doctors to stop using it, according to a medical staff member of a major league team who spoke on condition of anonymity so as not to implicate his team.
"It puts those of us who do sports medicine in a tough position," said Dr. Jessica F. Butts, a physician focused on family and sports medicine at Indiana University Health. "The decision to play is a tough one. There are some things that are black and white, but there are a lot of sports injuries that are in a gray zone, especially in professional sports and college sports, where so much is on the line."
Dr. Gary Green, the medical director for Major League Baseball, said discussions about Toradol came up every year and "there's certainly differences among physicians about how it's administered." But, he said, "it's not a controversy, but a difference of opinions." The drug has "a good analgesic impact," he said, and the side effects are well known.
Toradol, a brand name for ketorolac, is among a family of drugs called nonsteroidal anti-inflammatory drugs. Doctors put it in the same class as ibuprofen (like Advil) and Aleve. But unlike those drugs, Toradol can be injected, as well as taken orally, and can act more quickly. It is most commonly used in emergency rooms and post-operation wards to help patients manage short-term inflammation and pain, but athletes are turning to it to deal with inflammation and pain.
The use of Toradol, which is made by a number of drug manufacturers, was at the center of a lawsuit filed in December by a dozen retired N.F.L. players who said the league and its teams repeatedly and indiscriminately administered the drug before and during games, thus worsening injuries like concussions. (The league disputed the claims.)
The suit claimed that the use of Toradol was rampant in the N.F.L., with players lining up in their locker rooms before games to receive injections, a process the players called a cattle call. According to the complaint, no warnings were given and there was "no distinguishing between different medical conditions of the players, and regardless of whether the player had an injury of any kind."
Dr. Scott Rodeo, the associate team physician of the New York Giants, said that in the National Football League, Toradol "became prevalent to the point where players expected it and used it prophylactically." Some players, he said, "barely think of them as medicine."
Dr. Rodeo said Toradol first surfaced in football locker rooms in the mid-1990s. He said he was aware of the side effects, including how the drug could lead to increased bleeding, as well as gastrointestinal damage. There is also an ever-present risk of infection from an injection.
But when the drug is given occasionally to young, healthy players, the risks appear to be low, he said, adding that up to 40 percent of the Giants players received a shot on game days.
Dr. Rodeo and other doctors noted the risks associated with cumulative doses of Toradol, like kidney damage, one reason some doctors are curtailing its use. Others want to avoid a slippery slope, in which a player who uses Toradol on game days asks for additional shots after the game or on practice days. Many sports leagues largely let team physicians decide how and when to prescribe the drug, which leaves an opportunity for misuse.
"The limit I'm worried about is, does it dull the pain so much that it dulls the body part they've injured?" said Dr. Carla C. Keirns, a medical ethicist at Stony Brook University, adding that athletes could be prone to reinjury because the warning signs of pain are muted.
In baseball, it is most popular among starting pitchers because the repetitive movements in pitching can cause damage as the season progresses. The risk of abuse and experiencing side effects is reduced because they pitch every fifth or sixth day.
The medical staff member of a major league team who spoke on condition of anonymity said Toradol was first used by baseball players about a decade ago and quickly soared in popularity. At one point, perhaps two or three of a team's five starting pitchers used Toradol regularly, the staff member said, but in recent years the prevalence has waned, and now one or two starting pitchers might receive regular injections.
Because team physicians do not regularly travel with their teams, players on visiting teams may have to ask the home team's doctor for injections. Problems can arise if the home team's doctors are reluctant to dispense Toradol, said Dr. Andrew Gregory, a team physician at Vanderbilt University who works with the United States Olympic volleyball team.
"If we say no, they can claim we're trying to help the home team," Dr. Gregory said. "But we don't know about the visiting athlete and his history."
Although Toradol is not a banned substance or classified as a narcotic, many players, trainers and coaches remain skittish about discussing it.
Pitcher Jered Weaver of the Los Angeles Angels called Toradol "an in-clubhouse thing" and declined to say whether he had used it. Reliever Brad Lidge of the Washington Nationals said he had not used Toradol, but knew there were potential long-term consequences. Some other pitchers interviewed in various clubhouses declined to answer questions about the drug.
Newsday first reported the use of Toradol among Mets pitchers.
About 10 years ago there was a movement against the use of anti-inflammatory pills among professional basketball players after Alonzo Mourning, the Miami Heat's All-Star center, was found to have a kidney disorder. He said he believed that long-term use of anti-inflammatories contributed to his disease, though medical experts said the pills did not cause kidney disease.
Dickey is among the players who believe Toradol is more effective than taking over-the-counter pain pills. He said he believed the injections helped keep him on the field to pitch 2082/3 innings last season, despite his injured foot. Some doctors, though, said athletes might believe Toradol to be more effective only because of the way it is commonly administered.
"Any athlete you ask, they will guarantee that the injection is better than the oral pills, but that hasn't really panned out in the research," said Dr. Tanya Hagen, the director of the University of Pittsburgh Medical Center Shadyside Primary Care Sports Medicine Fellowship. "The needle is mightier than the pill."
Sunday, April 08, 2012
SEATTLE — It was the type of conversation that Dr. Claire Trescott dreads: telling physicians that they are not cutting it.
But the large health care system here that Dr. Trescott helps manage has placed controls on how painkillers are prescribed, like making sure doctors do not prescribe too much. Doctors on staff have been told to abide by the guidelines or face the consequences.
So far, two doctors have decided to leave, and two more have remained but are being closely monitored.
"It is excruciating," said Dr. Trescott, who oversees primary care at Group Health. "These are often very good clinicians who just have this fatal flaw."
High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States. And over the last decade, the number of prescriptions for the strongest opioids has increased nearly fourfold, with only limited evidence of their long-term effectiveness or risks, federal data shows.
"Doctors are prescribing like crazy," said Dr. C. Richard Chapman, the director of the Pain Research Center at the University of Utah.
Medical professionals have long been on high alert about powerful painkillers like OxyContin because of their widespread abuse by teenagers and others for recreational purposes.
Now the alarm is extending from the street to an arena where the drugs had been considered legitimate and safe: doctors' offices where they are prescribed — and some say grossly overprescribed — for the treatment of long-term pain from back injuries, arthritis and other conditions.
Studies link narcotic painkillers to a variety of dangers, like sleep apnea, sharply reduced hormone production and, in the elderly, increased falls and hip fractures. The most extreme cases include fatal overdoses.
Data suggests that hundreds of thousands of patients nationwide may be on potentially dangerous dosages. And while no one questions that the medicines help countless patients and that most doctors prescribe them responsibly, there is a growing resistance to their creeping overuse. Experts say that doctors often simply keep patients on the drugs for years and that patients can develop a powerful psychological dependence on them that mirrors addiction.
But changing old habits can be difficult — for doctors and patients alike.
The most aggressive effort is under way here in Washington, where lawmakers last year imposed new requirements on doctors to refer patients taking high dosages of opioids — which include hydrocodone, fentanyl, methadone and oxycodone, the active ingredient in OxyContin — for evaluation by a pain specialist if their underlying condition is not improving.
Even before the new provisions took effect, some doctors stopped treating pain patients, and more have followed suit. Christine Link, 50, said that several doctors had refused to refill the prescription for painkillers she had taken for years for a degenerative joint disease.
"I am suffering, and I know I am not the only one," she said.
Washington State officials acknowledge some of the law's early deficiencies, including its sometimes indiscriminate application, and they are seeking to address them. But there is no retreat on the goal of moderating opioid use, and the movement extends well beyond Washington.
The federal Centers for Disease Control and Prevention has urged doctors to use opioids more judiciously, pointing to the easy availability of the drugs on the street and a mounting toll of overdose deaths; in 2008, the most recent year with available data, 14,800 people died in episodes involving prescription painkillers.
The Departments of Defense and Veterans Affairs are trying new programs to reduce use among active-duty troops and veterans. Various states are experimenting with restrictions, including Ohio, which is considering following the Washington model.
"We are trying to prepare our state for what we hope is the inevitable curbing of the use of opiates in chronic pain," said Orman Hall, the director of Ohio's Department of Alcohol and Drug Addiction Services.
The long-term use of opioids to treat chronic pain is relatively new. Until about 15 years ago, the drugs were largely reserved for postoperative, cancer or end-of-life care. But based on their success in those areas, pain experts argued the medications could be used to treat common kinds of long-term pain with little risk of addiction.
At the same time, pharmaceutical companies began to promote newer opioid formulations like OxyContin for chronic pain that could be used at greater strengths than traditional painkillers. Sales of painkillers reached about $8.5 billion last year, compared with $4.4 billion in 2001, according to the consulting firm IMS Health.
Along with Purdue Pharma, the maker of OxyContin, other producers include Johnson & Johnson and Endo Pharmaceuticals.
Dr. Russell K. Portenoy, who championed the drugs' broader use, said the new data about the potential high-dose risks was concerning. But he added that the medications were extremely valuable and that their benefits needed to be factored into policies like the one in Washington State.
"I don't think opioids need to be thought of any differently than any other therapies," said Dr. Portenoy, chairman of the pain medicine and palliative care department at Beth Israel Medical Center in New York. "It is just that right now, they have got our attention."
A pain expert here in Seattle, Dr. Jane C. Ballantyne, said she once agreed with Dr. Portenoy, but she now finds herself in the role of former believer turned crusading reformer.
"We started on this whole thing because we were on a mission to help people in pain," she said of the medical profession's embrace of opioids. "But the long-term outcomes for many of these patients are appalling, and it is ending up destroying their lives."
The clues were buried in the dullest of places: thousands of workers' compensation claims.
In 2006, a state official here, Dr. Gary Franklin, called together 15 medical experts to discuss some troubling data found in the records.
Thirty-two injured workers who were prescribed opioids for pain had died of overdoses involving the drugs. In addition, in just a few years, the strength of the average daily dose of the most powerful opioids prescribed to patients treated through the workers' compensation program had shot up by more than 50 percent. The number of patients taking the drugs in large quantities had grown to 10,000.
Doctors often increase opioid dosages because patients can adjust, or develop tolerance, to the drugs and need greater amounts to get the same effect. Pain specialists, including Dr. Portenoy of Beth Israel, had argued that it was safe to increase dosages so long as doctors made sure that patients were improving.
But the Washington data suggested that doctors were not monitoring patients; they were simply prescribing more and more. Such practices are common, said Dr. Trescott, the official at Group Health in Seattle, because treating pain patients, who are often also depressed or anxious, is time-consuming and difficult.
"Doctors end up chasing pain" instead of focusing on treating the underlying condition, she said.
That is what happened several years ago to a former nurse, Mary Crossman, after she was found to have lupus, an autoimmune disease that can cause severe joint and muscle pain. Her doctor put her on OxyContin and methadone and then raised the dosage every six months or so after she developed tolerance to the lower dosage.
Five years later, she was taking dosages so high that another doctor who examined her was shocked. "She said, 'I don't want you to die,' " Mrs. Crossman recalled.
In 2007, the Washington State panel approved a guideline that urged doctors to refer patients on large dosages for evaluation if they were not improving. Two professional groups representing pain specialists had already taken a similar step. But the Washington action had an important difference that soon proved contentious: it set a dosage level meant to prompt the referral.
As with most medical guidelines, doctors in Washington largely ignored the panel's suggestions, a later survey found — until last year, when the guidelines became law.
That bill moved so quickly through the State Legislature that its opponents were caught off guard. The maker of OxyContin, Purdue Pharma, tried and failed to stop it. Several national pain experts, including some with ties to the drug industry, also sought to block it, saying the new provisions would cause chaos by restricting patient access to care.
Even some supporters of the new law agreed that there was little evidence to support the dosage threshold, which was the amount of any opioid equivalent in strength to a daily dose of 120 milligrams of morphine. Nonetheless, they believed that drastic change was needed.
"I thought the new law was a necessary evil," said one Seattle-area physician, Dr. Charles Chabal.
A Cycle of Abuse
The state law has transformed the clinic at the University of Washington into a pain treatment center of last resort — and Dr. Ballantyne, the pain expert, into an appeals judge of sorts because she sees patients referred for evaluation under the law. On a recent day, she was seeing a stream of castoff patients, including Ms. Link, who sat hunched in a wheelchair, suffering from a degenerative joint disease.
"They all said that I can't treat you, you need to see a specialist," Ms. Link said of her other doctors.
Before the widespread use of opioids, the University of Washington's medical school was known for an approach to chronic pain that emphasized nondrug treatments like physical therapy and counseling. Some specialists like Dr. Ballantyne, who moved here a year ago, are now determined to revive that tradition.
"If doctors understood how hard it is to get patients off of these drugs, they would not prescribe them to begin with," she said.
Born and educated in England, Dr. Ballantyne was in charge of pain treatment for more than a decade at Massachusetts General Hospital in Boston before taking a post in 2008 at the University of Pennsylvania, in Philadelphia. She and her husband, who is also a doctor, bought an old house there to renovate, but when the University of Washington called, she jumped.
Dr. Ballantyne, 63, once embraced the wider use of opioids. Her transition to skepticism began about a decade ago, when she noticed that hospitalized patients taking high dosages screamed when they were examined — as if the drugs had increased their sensitivity to pain.
She decided to research long-term data about the drugs and published a medical journal article in 2003 with her findings. It concluded that high doses might not be safe or effective.
Other experts accused her of undercutting years of effort to erase stigmas about the drugs. "They'd say, 'How could you do something like this after all we have worked for?' " Dr. Ballantyne recalled.
Since then, other researchers have published papers about the drugs' medical dangers. Studies have shown, for example, that the drugs greatly suppress the production of sexual hormones.
"It is not just our sex lives that go away; it is our ability to get things done," said Dr. Chapman, of the University of Utah.
Dr. Portenoy, the expert in New York, agreed that doctors needed to be aware of such risks. But he said that the dosage threshold used by Washington officials was arbitrary and that the state had failed to put a system in place to evaluate the law's impact on patients.
"You would always want to look at outcomes to see what you did either harmed or helped," said Dr. Portenoy, who consults with opioid producers.
A patient advocacy group, the American Pain Foundation, which receives much of its financing from drug makers, has continued to oppose the law, calling it "inhumane." And even some supporters believe it needs reworking.
Dr. Ballantyne said she also feared that the problems encountered by patients seeking treatment could cause an adverse reaction to the law. But she said she hoped that the quandary for patients like Ms. Link, who was given a new painkiller prescription, were "teething pains" that would be remedied.
She has little patience, however, for those who believe that the opioid problem can be solved simply by screening out those patients who might abuse the drugs.
"I think that after 20 years of a failed experiment that there are not many people supporting this except for the die-hards and the pharmaceutical industry," she said.
A Lost Generation
About a year ago, Mary Crossman, the former nurse with lupus, was at a neighborhood cookout with her husband when she noticed something odd: she was more relaxed, talkative and sociable than she had been in a long while.
Not long before, her doctor had suggested reducing her use of the painkillers OxyContin and methadone. The doctor, who worked at Group Health, said they would reduce the drugs slowly but warned Mrs. Crossman that she would initially feel more pain and increased anxiety.
Mrs. Crossman, who is 58, was scared but agreed to try. When her lupus flared up, she took more drugs, but over all, her daily dosages steadily came down. Today, she no longer takes methadone, and the amount of OxyContin she takes each day is 80 percent lower than it was a year ago.
Looking back, she said the high dosages helped mask her pain. But the pain relief came at a price; she now feels more mentally alert.
"There are days when I still hurt a lot, but over all I'm doing O.K.," she said.
Big health care systems like Group Health, which treats 420,000 patients at 25 clinics throughout Washington, can oversee how doctors prescribe drugs and provide patients with alternative treatments. Over the last four years, Group Health has cut the percentage of patients on high opioid dosages in half, the system says, and reduced the average daily dose among patients who regularly take opioids by one-third.
The system is now examining how those changes have affected patients. Studies elsewhere suggest the benefits of lower opioid use may be significant for many patients. For example, Danish researchers have published a study indicating that chronic pain patients getting nondrug treatments recover at a rate four times as high as those on opioids.
"These drugs don't seem to be even doing what they are supposed," said Dr. Per Sjogren, a pain expert in Copenhagen who led the study.
The obstacles to lower opioid use remain formidable, however; both insurers and public agencies must be willing to pay for other treatments, which can be costly.
"You can't just take things away," said Dr. Roger Chou, an associate professor at Oregon Health and Science University in Portland. "You have to give patients alternatives."
There is also political and professional resistance to adapting requirements like those at Group Health to taxpayer-financed programs like Medicaid.
The Food and Drug Administration indicated in 2008 that it might require that doctors receive several hours of mandatory training in the use of opioids as a condition of prescribing them. But in 2010, the agency backed away from that stance in the face of opposition from some medical and patient advocacy groups. In addition, although the Obama administration announced plans last year to introduce legislation containing such a mandate, it has yet to do so.
Few programs are in place to deal with patients now on high opioid dosages who are not benefiting from them.
If the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle.
"I think we are dealing with a lost generation of patients," she said.