Pain Control Access at Stake in Congressional Bill

Stepping into ambiguous terrain, Rep. Pete Stark (D-CA) is
introducing a bill to monitor prescriptions of all
potentially addictive medications. The impact of Stark's
proposal on the treatment of HIV and AIDS could be either
positive or negative. It may help alert AIDS specialists to
the proper use of tranquilizers and opioid pain killers, or
it could impose stifling legal restraints on efforts to
alleviate suffering among those affected psychologically and
physically by the disease.

HR 5051, or the Prescription Accountability Act, would create
ten model computer networks managed by state health
departments. The states' computers would record all sales of
controlled substances, flagging those that appear to be
violations of the law.

Limitations on the system mean that the grounds for detecting
abnormally large or frequent prescriptions are rather crude:
Unusual sales will be spotted largely on the basis of patient
age and physicians' specialty.

Addiction medicine expert Westley Clark, M. D. fears the
outcome: "The issue is what happens when the law and the
individual patient don"t fit, and a third party is monitoring
and contends the matter."

In contrast, Alex Stalcup, M. D., an HIV specialist and
pioneer in measures for relieving chemical dependencies,
lauds the physician education portions of the bill. The bill
contains provisions for a national commission to develop
informational programs concerning the treatment of chronic
pain. A national telephone hotline also is to be established.
On the state level, HR 5051 mandates "practice parameter" and
patient care panels, which would include physician and
patient representation, to address the undertreatment of pain
and establish what is legally acceptable.

"Doctors are hungry for knowledge about pain management and
especially desire education from someone outside the drug
companies," Stalcup said.

Stalcup noted, however, "Guidelines apply to the mean, but in
HIV we haven"t established that mean. There is a great need
for individualized treatment plans."

Painful Complexities

The issues involved in prescribing psychoactive drugs to
people with HIV can become very complex. One illustration is
Stalcup's patient Karen, a one-time heroin addict. Karen came
to Stalcup for medical assistance in breaking her Valium
dependency. She had been taking the Valium under a doctor's
supervision to ease the side effects of the antidepressant
Elavil. And she was taking Elavil to reduce the pain from her
AIDS-related peripheral neuropathy.

Stalcup prescribed Dilaudid rectal suppositories for her pain
and proceeded to help her stop the Valium. Dilaudid is a
morphine derivative, and Stalcup was in a legal gray area
when he prescribed it to an ex-addict, even though such
suppositories are not easily abused.

The doctor thinks the use of Elavil is fine for dealing with
neuropathy. "It helps make pain matter less," he said,
"Patients can distance themselves from the sensation and then
use less opiates."

Valium is not a good idea, though. According to Stalcup,
tranquilizers are greatly overprescribed.

He commented, "They"re good for the acute anxieties that
arise during HIV, when terror is palpable, but we should be
very cautious with them. Detoxification after long-term use
creates free-falling anxiety, confusion, shakes and
concentration problems for up to a year."

Cost-Cutting Medicine

An aide to Rep. Stark said that the Congressman's primary
motivation is curbing Medicaid fraud. "Illegal diversions of
drugs for street sales or personal use cost the government a
lot of money. They keep benefits from law-abiding patients,"
said the aide, who does not want to be identified.

Stark himself said on the floor of the House, "In short, this
effort is nothing more than an expansion of existing federal
law for Drug Utilization Review beyond the Medicaid
population to the population as a whole."

The individual states' DUR Boards, set up to find ways to cut
Medicaid costs, will lay out the basic guidelines for
controlled substance prescriptions under the proposed law. HR
5051 also suggests that the prescription tracking database be
stored within the state-operated Medicaid Management
Information System computers used to monitor Medicaid
reimbursement.

Economy is the basic watchword for the whole prescription
recording process. That process relies on pharmacists' pre-
existing computers, and Stark argues it imposes no burden at
all on doctors.

The economic implications upset Dr. Clark. He observed that
undertreatment is much harder to catch than overtreatment,
especially when the supervising body has a financial interest
in cutting medical costs.

Comment

The Stark bill does mandate a very cumbersome secret
encryption system to meet privacy concerns. The code will be
known only to a special commission directing the program. But
the privacy safeguards may not make much difference since
much of the same prescription information is available
elsewhere on Medicaid and insurance company computers.

HR 5051 does not confront the growing stockpile of accessible
personal information, nor does it challenge the tendency to
limit freedom of medical care in the name of cost-cutting or
the "war on drugs." It just tries to smooth the rougher
edges.

Stark's aide is in a hurry, though. He said, "Computerization
of medical records already exists. Do you want the systems
run by the district attorney or the health care
administration? We say health care, and let's not wait while
the health people study the issue. The police kick down
doors."

Of course, the police could still kick down doors once they
are notified by the board overseeing the prescription
monitoring system. Or a licensing board could invade a
doctor's practice in an equivalent manner.

"Doctors are very paranoid about the state looking over their
shoulder and getting hauled in," noted Stalcup.

As long as the government maintains its present rigid
position regarding psychoactive drugs, it may be impossible
to rationalize prescription policies for addictive drugs.

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