Editor's Note: In October 2004, the DEA removed the pain document described below from its Web site, saying it contained "misstatements." On Nov. 16, 2004, the agency published an interim statement in the Federal Register explaining its actions. The Pain and Policy Studies Group at the University of Wisconsin published a response to that statement on Nov. 24, 2004.

New guidelines could help doctors and patients make better decisions about using narcotics to relieve pain. Narcotics, also known as opioid drugs, are among the most effective treatments for moderate and severe cancer pain.

Created by pain management groups and the Drug Enforcement Administration (DEA), the new document outlines steps physicians should take to be sure they're prescribing these medications lawfully, and gives suggestions for patients to use when discussing pain relief with their health care team. The guidelines will be distributed to law enforcement personnel as well as physicians who are registered to prescribe opioids.

The goal, developers said, is to help physicians and law enforcers strike a balance between providing effective pain relief to people who need it without contributing to the growing problems of prescription drug abuse and criminal distribution (known as diversion).

RESOURCES: Read the new Prescription Pain Medication Guidelines developed by the DEA and pain experts.

"We have two serious societal problems -- the undertreatment of pain, and drug abuse and diversion -- that are intertwined through prescription pain medications. We address both problems in this document, and hope it will bring some clarity to the issue," said Russell Portenoy, MD, chairman of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York, and lead pain expert on the project.

Studies suggest that more than 40% of patients with diseases like cancer or AIDS aren't getting enough pain relief, Portenoy said. In part, the problem stems from concerns about becoming addicted to powerful opioid drugs; some patients and doctors are simply afraid to try them.

More recently, though, a sharp increase in prescription drug abuse and high-profile prosecutions of doctors prescribing opioids illegally have had a chilling effect on the medical community, said David Joranson, another member of the group that developed the new guidelines.

"We already knew that for years physicians have been concerned about being investigated if they prescribed controlled substances," said Joranson, who is director of the Pain and Policy Studies Group at the University of Wisconsin Comprehensive Cancer Center. "But now we hear that patients can’t find a physician who will prescribe opioids."

Some pharmacies, he added, won't even stock these medications because they fear being robbed by drug dealers or addicts.

The new guidelines should help address that situation by providing "some clarifications about what does or does not constitute questionable activity in the eyes of the DEA," said Patricia Good of the DEA's Office of Diversion Control. It also helps law enforcement officers understand what is considered sound medical practice, she said.

The endorsement of the DEA is "truly significant" said Mary Simmonds, MD, a medical oncologist and immediate past president of the American Cancer Society. She was not involved in developing the guidelines.

If doctors feel more confident prescribing opioids, patients are more likely to get the relief they need, she said.

In addition to describing the steps doctors should take when assessing pain and determining whether opioids are appropriate, the new guidelines give doctors some advice on spotting a person who is likely to abuse or divert drugs for criminal distribution. It also clarifies the differences between true drug addiction, and drug tolerance or physical dependence.

The distinction is important, said Joranson, because fear of addiction keeps so many people from getting proper pain relief. People who use opioids may well become physically dependent over time -- if they quit the drugs abruptly, they will experience withdrawal symptoms. But that's not the same as addiction.

"Addiction is a much more complex disease that occurs in vulnerable people due to genetics, biology, and environment," he said. "It involves maladaptive behaviors and a compulsive need to continue using [these drugs] for non-medical purposes."

Experts agree most cancer patients are unlikely to become addicted to opioid drugs, though they may become physically dependent or develop a tolerance to the medication, meaning they need higher doses to achieve pain relief.

"People think if they become tolerant they will eventually become addicted, or that there won't be a sufficient dose to relieve their pain," said Simmonds, "and that's not true.

"All these myths are in everybody's mind [making them] fearful of taking medication. But for moderate to severe pain, a non-opioid is not going to be potent enough, and there's no need to suffer."

Cancer pain is complex, Simmonds said. It can involve multiple types of pain in the same person for different reasons, and may even be combined with pain from other conditions, like arthritis. A patient may need to try different dosages or different medications, or combine medications to achieve relief.

The guidelines encourage patients to talk openly with their physician about their level of pain, and to seek out a doctor who takes these concerns seriously. Patients should tell the doctor if the medication isn't working or if it causes problematic side effects.

People seeking pain relief must also understand that doctors have certain procedures they need to follow in order to stay within the law. Requirements that may seem arbitrary or excessive to patients may, in fact, be dictated by law, Portenoy said.