Making Life With Cancer a Bit More Bearable : UCSD Program Closely Manages the Use of Pain-Killing Drugs

Dr. Rollin V. Oden prescribes a daily morphine dosage of 1,500 milligrams for Debbie Peacock, a 35-year-old cancer patient. The federal government says a dosage that high is enough to kill the average healthy person.

Oden, who runs the pain management program at UC San Diego Medical Center, says he is just being a good doctor--one who is dedicated to improving the quality of life for patients who have little hope left.

But what’s important to Peacock, a nurse who has had cancer for four years, is that she doesn’t have to suffer. Peacock says she feels better since coming under the care of Oden, partly because he has found a way to alleviate her pain through medication, and partly because Oden explains to her his choice of drugs and their effects.

“He’ll just sit down and talk with you,” said Peacock, a victim of breast cancer that has spread to other parts of her body. She has gained 90 pounds during the last year as a result of chemotherapy treatments and medication.

Patients Fear Pain Will Be Unrelieved

“Pain is always real,” said Oden, an anesthesiologist with a specialty in managing the cancer pain of terminal patients, most of whom fear they are going to suffer from pain that can’t be relieved.

Despite the strong dosage of narcotics, Peacock is not addicted to her medication, Oden said. Rather, she has developed a tolerance and physical dependence on the narcotics to quell her constant pain. But Oden stressed that she would not need the drugs if the pain went away.

“The chance is less than one in 10,000 that a patient would still want the drug” if they no longer suffered from their pain, Oden said.

Oden, 38, takes a two-pronged approach that he considers unique to dealing with cancer pain. And the tools he uses, Oden said, are available to every physician willing to learn about them, if physicians would only overcome the prevailing reluctance to prescribe them.

Oden listens face to face--sometimes for as long as an hour--as patients tell him about their pain. Then he prescribes treatment that might include oral narcotics, such as morphine, in a regimen unique to each patient.

A tall, bearded man with a warm handshake and gentle manner, Oden says communication and interaction with the patient are essential. He is always available to his patients by means of a beeper and it comforts them to know that they can always reach someone who knows about their medication “if the pain gets out of control,” he said.

Some of Oden’s patients at the clinic, which is less than a year old, are referred to him by other UCSD physicians who won’t prescribe strong narcotics. He said this is sometimes because they don’t believe patients suffer to the extent they claim. Other times they may underprescribe narcotics--which Oden prescribes all the time without batting an eyelash--for fear of close scrutiny.

Oden, who teaches and does clinical research in addition to seeing about 18 pain outpatients per week and inpatients at the medical center, said he is concerned that many California doctors fail to take advantage of available pain killers to alleviate the pain of their patients.

Oden said he is not afraid to prescribe oral narcotics, which can contain 80% of patients’ pain, because he keeps in close communication with his patients--close enough that he learns to understand them and their illnesses, especially when they are taking high doses.

But Oden admits that sometimes what a patient may identify as physical pain is really a result of a separate anxiety and depression. But by talking to the patient, he has found that he can sift these out and adjust their medication in the appropriate manner.

Oden argues that the potentially illegal diversion of prescribed narcotics should not be allowed to “stand in the way of prescribing drugs to patients who need drugs” to manage their pain.

Pain Medication Diverted

“I know I am going to get duped sometime,” said Oden, who recalls a situation about 18 months ago while he was in Washington state where a patient was diverting some of his narcotics to roommates. Oden said he contacted the federal Drug Enforcement Administration, which agreed that despite the illegal diversion, Oden should continue to prescribe the needed medication while keeping a close watch on the patient.

But Oden is uncertain of the real reason and effects of the fact that only 20% of licensed California physicians prescribe outpatients medication stronger than Tylenol with codeine. He is not sure if the other 80% fear being monitored for prescribing narcotics, or they don’t want to bother filling out the triplicate forms required by the state. He also said there is little data on the connection between the low percentage of doctors prescribing strong drugs and proper management of patients’ pain.

Oden, a graduate of UC San Diego Medical School, learned about pain management when he was a fellow and later a faculty member at the University of Washington, which he described as “the granddaddy of pain treatment centers.”

Soon after his return to San Diego with his wife and 4-year-old daughter, Oden initiated the clinic within the UCSD Cancer Center.