Narcotics show their healing side Long-term use for pain found free of addicting effect

March 28, 1993|By Elisabeth Rosenthal | Elisabeth Rosenthal,New York Times News Service

In 1984, doctors told Patricia Paul, who suffers from a painful nerve condition called reflex sympathetic dystrophy, that she would need round-the-clock home care for the rest of her life and that she should forget about working ever again.

Since then, she has returned to college, graduated magna cum laude and raised a teen-age son. She now runs an award-winning program in New Jersey that trains handicapped people for jobs.

She attributes her dramatic turnaround to medical treatment that would have been unthinkable a decade ago: At her doctor's suggestion, she has taken large doses of narcotics, in pill form, every three hours for the past nine years.

"I used to sit in a wheelchair doing nothing," Ms. Paul, 47, said at her office at the Association for Retarded Citizens in Elmwood Park, N.J. "That medicine has given me the ability to live again."

Long considered hopelessly mind-numbing and addictive, and suitable only for the dying, narcotics are being prescribed with growing frequency by pain specialists who have made the surprising discovery that people who take them can continue leading normal lives.

Doctors who specialize in pain treatment say that unlike street addicts, who experience initial euphoria from drugs such as heroin, pain patients get no high from their pills -- they just get pain relief.

More important, they say that patients on daily stable doses of the drug quickly adapt to the lethargy these drugs normally produce, so that in a week they are able to work and even drive a car.

And so, more and more patients are being prescribed a variety of narcotics, such as morphine, methadone and Dilaudid, as a therapy of last resort to treat chronic, intractable pain.

"There is a growing literature showing that these drugs can be used for a long time, with few side effects, and that addiction and abuse are not a problem," said Dr. Russell Portenoy, a pain specialist at the Memorial Sloan Kettering Cancer Center in New York.

Dr. Portenoy and others say the worst side effects may be the scorn and discrimination that some patients suffer from their families, employers and even the medical world.

Ms. Paul said she decided not to seek custody of her children during her divorce several years ago because her husband had threatened to bring up her drug use in court.

When she developed a life-threatening blood clot in her lung while her doctor was on vacation, she at first refused to go to the hospital, afraid to tell another doctor about the drugs she must take; her friends took her in, almost comatose.

Until now she has lived, as she puts it, "in the closet," going to extremes to hide her medical needs.

"I hold a responsible job, and I'm respected in the community, and I'm sure I would lose all that if anyone knew," she said before deciding to speak openly with a reporter. "I want to dispel biases, but I'm afraid of recriminations. Imagine being a diabetic and being afraid to let anybody know."

Dr. Marcus Reidenberg, professor of clinical pharmacology at New York Hospital-Cornell Medical Center, said, "You can't tell these people are on narcotics, because their behavior is normal. But -- it's so unfair -- they meet with disapproval from within the medical profession and without."

Although doctors have used morphine for centuries to treat short-lived pain, such as that experienced in surgery, they have considered the drugs dangerous for longer use, capable of turning people into addicts, who would then crave escalating doses and waste away in a stupor.

But as cancer specialists began using narcotics to treat terminally ill patients with severe pain in the past decade, they noticed that many lived on for years with their faculties apparently intact and without any sign of addiction.

Although body chemistry changes in the presence of narcotics, and the patients do experience withdrawal when they discontinue the drug, they do not display the behaviors that many specialists feel are central to addiction: compulsive use and continued use despite harm.

Many pain specialists now think that narcotics are not inherently addictive drugs, although, like alcohol, they may lead to addiction in people who are predisposed; this small group of people may have an unusual genetic makeup that makes them vulnerable to becoming addicted.

This new view appears to be supported by basic science research that has found that animals who try cocaine -- which is a stimulant -- will do virtually anything to get another dose, while those given liquor or narcotics -- which fundamentally are sedatives -- show much less interest in getting more.

"Opiate addicts are fundamentally different from average medical patients" taking narcotics, Dr. Portenoy said, noting that in patients, narcotics produce a depressed rather than elated mood. "Among pain specialists, the controversy about whether opiates cause addiction has waned, and now we debate the benefit in terms of comfort and function."

Still, some prominent pain specialists who say they no longer worry about addiction say there are other good reasons to avoid narcotics.

Dr. Charles Chabal, an anesthesiologist and pain specialist at the University of Washington at Seattle, said patients given pills every three to four hours might develop a poor "treatment attitude" and become less persistent in their efforts at rehabilitation. It "sends the message that we as a medical profession are in charge of your pain and we can take your pain away," he said.

"I'm not worried about patients becoming addicted, but we have to worry about whether we are impairing memory or motor coordination, and no one really knows," he added.

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