The end of pain

NOW THERE'S A PILL THAT CAN SAFELY EASE EVERY AGONY FROM CANCER TO A BAD BACK, SO WHY ARE DOCTORS AND PATIENTS AFRAID OF IT?

Before she started taking morphine two years ago, Cinderella Allen looked like a drug addict: puffy, pale, and watery-eyed. Bedridden for a year and a half from knife-sharp back pain, she found it a chore just to get up and shower. "I was always in pajamas," she says. "For a rare treat, once every month or two, I would get dressed up and put on makeup, just to feel human again."

Allen, 41, is a cheerful woman with a self-deprecating sense of humor and a gravelly laugh. But after seven spinal operations to counter the combined effects of degenerative disk disease and a car crash, she had reached the end of her rope. Night after night, unable to sleep, she took up residence in front of the living room television set in her suburban Maryland home. The routine was deadening, and nearly deadly: She popped prescription pain relievers, chain-smoked cigarettes, and occasionally nodded off-waking to find embers smoldering in her nightgown. "My husband was having fits," she says ruefully. "I was burning everything up. He was disgusted with me, because I was so disgusted with myself. But there just wasn't anything I could do."

Allen's doctor had reached his own limit. Fearful that Allen was taking too much Percocet and Valium, he refused to provide more. "You are going to have pain the rest of your life," he told her. "You'll have to live with it." As a stricken Allen wept, her husband grew irate. "She can't live with it," he said. "Something has got to be done." Reluctantly the doctor told them about a specialist in Baltimore who treats chronic pain patients with the world's most powerful pain reliever: morphine.

Today, thanks to the orange pills she swallows three times a day, Mien looks and acts nothing like a junkie. With the other prescription drugs cleaned from her system, she works part-time as a manicurist, handles paperwork for her husband's contracting business, shops, cooks, cleans -- and has to remind her husband from time to time that she does need a hand.

"It's like a magic pill," Allen says with her husky laugh, aware that her story sounds, appropriately, like a fairy tale. "It gets rid of the pain, and you don't feel like you've taken anything. There's no high to make you want to have more. But all of a sudden the pain disappears. It just drifts out of your body."

It's not news that morphine, a drug long synonymous with addiction and death, is enjoying a revival. Given the narcotic's ability to relieve pain in up to 95 percent of cancer cases, doctors now routinely prescribe it to patients seeking peace in their final months. And injections are common after surgery, as the drug can mask discomfort until healing alleviates it.

But some experts want to take the revival one step farther. They believe morphine and its chemical kin, methadone, can and should be used to treat many of the 34 million Americans who suffer from chronic pain --that is, any pain unrelated to cancer that lasts longer than six months. Such people could be on the drugs for decades.

The approach shocks doctors, worries narcotics agents, and frightens would-be patients. For most people, morphine, a derivative of the opium poppy, still conjures up images of wounded soldiers hooked up to makeshift IVs, becoming hollow-eyed addicts. But pharmacological advances have given the drug a whole new face, advocates say. New morphine pills are not addictive. They produce no high. And they control chronic pain -- which is now thought to be dangerous in itself -- more safely and effectively than any other painkiller.

One leading proponent is neurosurgeon James Campbell, who runs the pain clinic at Johns Hopkins Hospital where Allen was treated. Campbell started prescribing morphine and methadone for chronic pain several years ago when he realized that many of his patients were opting for risky operations that were less likely to ease their pain than drug therapy.

The time-release pills Campbell recommends, called long-acting opiates, work much like nicotine patches: The drugs enter the bloodstream gradually, providing steady relief but no euphoria. A dose lasts from six to 12 hours, avoiding the peaks and valleys of short-acting opiates such as oxycodone, used in the popular prescription painkillers Percocet and Percodan, or hydrocodone, the opiate in Vicodin.

Such an approach would appear to be a major advance for those with chronic pain, most commonly from head, back, or neck injuries; arthritis; or nerve damage. But because Campbell prescribes the drugs without preset doses or time limits, for everything from auto injuries to headaches, he's been attacked.

Campbell makes an unlikely Dr. Feelgood: Mild-mannered, school masterly, and partial to bow ties, he comes across more like Jimmy Stewart. He's a bit surprised to find himself portrayed as a drug pusher by critics. But he is deeply troubled that millions of people with chronic pain rush from doctor to doctor for relief, rarely finding one who will acknowledge their torment, much less relieve it. Withholding useful drugs from desperate patients, Campbell says, is both inhumane and medically misguided. "Chronic pain robs people of their desire to live," he says quietly. "If you're not controlling pain, then you're not practicing good medicine."

It's Wednesday -- pain clinic day -- at Johns Hopkins, and Campbell darts from examining room to examining room, seeing a steady flow of patients. Alonzo Breeden, badly injured five years ago when a bandstand fell on him and a metal shard punctured his stomach, saw 13 doctors before he was referred here. Campbell operated on his stomach three months ago, and Breeden says his pain is now manageable: two or three on a scale of ten, as opposed to six or seven at the time of the accident. Campbell, with a firm handshake, assures Breeden that he can resume a normal life without pain medication.

Down the hall, in the room where Andrea Franko waits with her boyfriend, it's a different story. A small, delicately pretty woman in a white knit sweater and pearls, Franko nervously pulls a baby blanket off her arm to let Campbell examine it. The bones in her hand are gnarled, and the muscle tone is gone. "It feels as if my arm is on burning coals," she says, fighting tears. "I feel nothing but pain in my hand. If my eyes were closed, I'd have no idea that you were touching it."

After surgery on her neck, arm, and hand following a car accident, Franko's hand began to atrophy, and 12 additional operations only increased her suffering. The former secretary can no longer work or use her hand for the simplest tasks; at times she's had to open bottles with her teeth.

Because Franko is a new patient, Campbell offers no assessment until he completes a full exam. After a long pause, he looks her in the eye. "I'll tell you one thing I'm very confident of," he says. "We can control your pain. We can get it down from eight to three, four, maybe even two."

Franko brightens slightly. "That would be nice," she says. "But how about my fingers?"

Campbell draws a breath. "We have very poor results getting restoration of hands in brachial plexus repairs," he says, referring to a complex of nerves that supplies the chest, shoulder, and arm. The nerves may be cut -- irreparably.

"So it's possible I'll never be able to use my fingers?" Franko asks, panic splitting her voice. "What am I going to do?" Her boyfriend encircles her with his arms. Campbell and the nurse look away to give the couple a moment to absorb the blow.

Franko will probably be in pain for the rest of her life, but by finding her way to Campbell, she may have avoided a worse fate. Several major studies show that physicians consistently underestimate patients' pain, often dramatically. One study of patients in moderate to severe pain found that doctors and nurses never even asked half of them how much their conditions hurt. Campbell believes that's because pain cannot be quantitatively measured. "There is no blood test, no X-ray, that can tell us how much pain a person is having," he says. "If we don't measure things, doctors tend to underestimate their magnitude, because we're oblivious to it."

The result: A survey of 204 pain patients found that they had sought treatment from an average of ten health care providers, yet half the patients said the strongest medication prescribed still left them in agony. These people often become caught in a cycle of depression, inactivity, and hopelessness. Half of those surveyed had considered killing themselves.

Suicide isn't the only risk from unchecked pain. "It appears that the dictum 'Pain does not kill,' sometimes invoked to justify ignoring pain complaints, may be dangerously wrong," asserts John Liebeskind, a psychologist at the University of California at Los Angeles. Studies show that pain can delay healing after surgery and -- at least in animal studies-spur the growth of malignant tumors. Pain also appears to leave a cellular memory that sensitizes the spinal cord, making subsequent pain worse.

Opiates can play a key role in blocking the memory of pain. Pain doesn't become a physical sensation until the pain message, which originates in injured tissue or nerves, is sent to the spine and then the brain. General anesthesia puts the brain to sleep, so you feel nothing, yet that doesn't keep the spinal cord from recording the pain. Opiates, on the other hand, mimic the body's pain-fighting endorphins: They blanket the spine's pain receptors, preventing the message from arriving. In other words, opiates don't numb pain. They literally keep it from happening. That's why doctors now commonly inject morphine directly into the spine before operating.

Campbell argues that chronic pain patients deserve the same relief, and that long-acting opiates are the best drugs for the job. He cites a growing number of studies indicating that the drugs reduce pain and improve mobility, usually without serious side effects. In the first few days or weeks of treatment, most patients experience sleepiness, nausea, and constipation. Except for constipation, the symptoms generally subside, and many patients report no side effects at all. Opiates are not free of risks. Taking too much at once can trigger respiratory failure and death. But doctors can eliminate the risk by slowly ratchetting up the dosage over a few weeks.

Campbell doesn't ordinarily initiate drug therapy until he rules out surgery and also refers the patient for physical therapy and psychological evaluation; people with a history of addiction or emotional problems are ruled out. Then he'll try both short-acting and long-acting opioids to see which combines the greatest relief with the least bothersome side effects.

That can be a challenge. For Cinderella Allen, short-acting oxycodone simply never provided sufficient relief. But when her neurologist, Campbell's colleague Marco Pappagallo, started her on methadone, she hated it. The drug caused her to doze off in mid-sentence while dining with friends, to nod off at traffic lights, and to sleep through an entire performance of the Nutcracker. Only after Allen tried morphine did it become clear that opiates would work for her.

What ultimately determines whether Campbell prescribes opiates isn't the ailment. It's the patient. "If my patient tells me that his pain is an eight or nine on a scale of ten, I take that pain seriously."

He clearly takes Andrea Franko's pain seriously. Before leaving her, he hands the nurse a hastily scribbled prescription for methadone, which is used mostly to treat heroin addiction.

"I won't have a problem with my pharmacist in Pennsylvania, will I?" Franko asks.

"You shouldn't," the nurse tells her. "We'll write 'for pain,' so they know you're not an addict."

Most doctors are convinced Campbell's approach will only lead to disaster for patients. In a recent study of medical board members --people who discipline doctors deemed errant-only 12 percent believed that prescribing opiates for chronic pain was medically acceptable. One-third said they would investigate the practice as illegal.

"Physicians think that anybody taking morphine for pain control is in essence an addict," says Campbell. "But this is really a misuse of the word addiction."

At issue is a distinction far from semantic: the very real difference between addiction and physical dependence. People who take morphine for pain are indeed physically dependent on the drug. If they stopped taking it abruptly, without tapering the dose, they would suffer withdrawal symptoms, including nausea, sweating, stomach cramps, anxiety, chills, rapid heart rate, and muscle spasms. Such dependence accompanies the use of many nonnarcotics, including steroids, some blood pressure pills, and antiseizure and antianxiety medications.

But addiction involves a compulsive craving for increasing amounts of a drug over time, regardless of medical need or harmful consequences. Ten years ago Russell Portenoy, a neurologist at New York's Sloan Kettering Hospital and a pioneer in the use of opiates to control cancer pain, noticed a funny thing: His cancer patients had not developed such desires even after years of opiate therapy.

"Unless you believed that having cancer imparted some protection from these terrible drugs, there was something wrong with the perception about the drugs themselves," Portenoy says. In three studies involving almost 25,000 patients with no history of drug abuse, only seven became addicted.

The drugs' abuse potential seems to correlate with how quickly they get to the brain. Injection is the fastest route, providing the rapid peaking addicts want. By contrast, long-acting drugs, because they enter the bloodstream slowly, provide no rush -- nothing to crave.

There is another reason why few pain patients become junkies: Most are nervous about using pain-killers at all. Sixty percent of people surveyed in a recent Harris poll were reluctant to take their prescribed pain medication, mostly because they feared addiction. "We find that patients who take opiate medications want, if anything, to get off the drug," Campbell says. "They don't develop a compulsive, drug-seeking syndrome."

Tell that to the federal Drug Enforcement Administration. The agency employs 450 investigators and a massive computer system to monitor every opiate prescription in the nation, including those for long-acting pills. The target? "Scrip doctors," who write fraudulent prescriptions and give them to crooked pharmacists, who sell the drugs to street dealers.

The DEA estimates that such "diversion" accounts for a third of all illegal drug traffic in this country. Other experts disagree, putting the share at no more than 5 percent. Still, the agency arrests more than 200 doctors and pharmacists each year and takes civil action against 600 others. To avoid trouble, most doctors surveyed say they either won't authorize refills for opiates or they prescribe doses too low to attract notice. Many opt for weaker drugs.

The legal risks are serious. William Hurwitz, a Washington, D.C., internist, temporarily lost his medical license in 1991 after agents from the DEA and city police raided his clinic. His offense: prescribing up to 500 milligrams a day of oxycodone for a patient suffering from degenerated hip bones. A dose that high, while appropriate for severe pain, raised a red flag. Then, this past May, the Virginia Board of Medicine suspended Hurwitz's license after two of his patients died. The board alleged that he was "a substantial danger to public health and safety" for prescribing drugs to addicted patients.

Hurwitz, a beloved figure among chronic pain patients, insists that one death was an intentional overdose by a woman bent on suicide and the other was caused by food poisoning and gastrointestinal bleeding unrelated to the drugs he'd prescribed. Meanwhile, his controversial suspension has left his 220 patients scrambling. If they can't find doctors who will risk treating them, they will run out of medication and undergo withdrawal.

Robin, one of Campbell's patients, knows the danger. A 46-year-old landscaper and antique collector who prefers that her full name not be used, she turned to morphine after two decades of misery. She's an attractive woman with a youthful ponytail and a dancer's proud bearing. A car accident she had while in her twenties triggered a steady march of pain from her neck down her shoulder and arm. "It was like an ice pick stabbed in my upper neck," says Robin, strolling down a winding dirt road near her Pennsylvania farmhouse. "I walked like a rigid board. I had fantastic posture, but it hurt."

She had five operations on her spine and arms to repair nerve damage, but the pain always came back. Finally, Campbell urged her to try M S Contin, a long-acting morphine pill. "I heard it as M S Contin," Robin recalls. "If I had known it was morphine, there wouldn't have been a chance of me taking it." By the time she realized what it was, the drug had kicked in. "There was no high. No zoom. No 'Oh, gee!'" she says. "But it did go to the pain."

The drug has controlled her discomfort successfully for four years now, but because morphine is a Schedule II drug, monitored by the DEA, she must call her doctor for a new prescription every month. The necessity has, at times, been harrowing. Three years ago Robin and her husband were on vacation in the Bahamas when Hurricane Andrew hit, flooding their cottage and drenching much of that month's supply of pills. Robin was terrified.

"If I don't take that pill, not only is the pain excruciating, but I will go through withdrawal," she says. "It was my first experience knowing the dependence I had on that damn little pill."

When Robin got home and called to renew the prescription early, her doctor balked and instead had Robin come into the office for a physical. Suspicious at the obvious change in the doctor's demeanor, Robin scanned her medical file when left alone in the examination room -- and was stunned to read that her doctor thought she was lying about the damaged pills. Robin confronted the woman when she returned. "You think I'm abusing drugs."

"Well, you have to admit it's a strange story," the physician responded. Only after Robin convinced her to call Campbell to learn more about morphine did she reauthorize the prescription. Robin's eyes blaze at the memory of being treated like a junkie.

Should morphine and methadone become frontline chronic pain treatments? The question has pain experts slugging it out. A blunt critic of Campbell's approach, John Loeser, a neurosurgeon who runs a highly regarded pain clinic at the University of Washington School of Medicine in Seattle, believes many pain patients do far better without opiates.

Half of Loeser's patients have chronic lower back pain. Many have had several operations, tried a variety of other unsuccessful treatments, and suffered bouts of depression before arriving at his door. Yet, he says, he and other doctors who combine physical therapy, psychological counseling, and vocational training get 50 percent of lower back pain sufferers on their feet again. "The burden of proof is on those who wish to argue that any other kind of treatment is as good as that," he says.

Campbell doesn't yet have studies to compare his treatments to Loeser's. But even if he did, the two measure success with different yardsticks. While Campbell seeks to lessen pain until it's manageable, Loeser is not convinced pain is a bad thing. His main measure is whether a patient becomes gainfully employed.

"Success is when the patient says, 'I still have pain, but I'm able to work, I have greater function, and I need to see the doctor less.' There's got to be more than somebody saying, 'I like this stuff, and I like how it feels.'"

Loeser prescribes opiates in some cases, but in his experience, he says, they dull patients' thinking and force some to use rising doses to stay ahead of the pain, which makes it difficult for them to take control of their lives.

His charge that opiates cause "cognitive deficits" is unconfirmed. A study of 20 patients done at Johns Hopkins found no evidence of mental clouding after six months of use. Other studies support Loeser's view, so it's still an open question.

Also uncertain is the claim that patients develop tolerance for the drugs. Pain experts agree that patients need gradually higher doses for the first months and then stabilize at a dosing plateau. Campbell argues that increasing tolerance is rare. But Loeser contends the problem is being swept under the rug.

"Yes, some patients are successfully managed over the long haul with opiates," he says. "But some patients rapidly get into trouble, take more of the drug, and become more and more dysfunctional. And then there's a large number of patients who are somewhere in the middle."

Portenoy, whose research helped make morphine legitimate, is also cautious. "We're living at a time when the science behind the therapy is still poor. We shouldn't be treating these drugs as though they're ibuprofen.

"But," he adds with satisfaction, "there has been a sea change in people's thinking."

While doctors and researchers debate the wisdom of opiate use, Cinderella Allen and Robin find themselves on somewhat shaky ground. Allen dreads having her new freedom snatched away by the act of a single doctor or lawmaker. "You get a taste of being able to live a normal life again," she says, distress showing in her eyes as she strokes her dog and hushes her chattering parrot. "If somebody took that away, I think that would be the end of me."

Robin, who has never told anyone but her sister and husband that she is on morphine, worries about the reverse: that she'll never get off the drug. She pauses to look over the rural valley where she lives, her gaze lingering on the two swans floating in the pond below her house. Her pain has been increasing, and her doctor has advised her to up the dose. For now, she's resisting. But she doesn't know what the future will bring, and a life tied to a painkiller holds as much fear for her as a life of pain.

"Morphine has given me my life back," she says after a long silence. "But I don't have independence. The truth is, the medication controls my pain, but it controls me, too."

PHOTO (COLOR): "PHYSICIANS THINK ANYBODY TAKING MORPHINE TO CONTROL PAIN IS AN ADDICT," SAYS NEUROSURGEON JAMES CAMPBELL. "BUT THIS IS REALLY A MISUSE OF THE WORD ADDICTION."

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By Alexis Jetter

Alexis Jetter lives in Vermont and has written for Vogue and the New York Times Magazine.

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