COLUMN ONE : How Much Painkiller Is Enough? : Health care workers are often on guard against giving too much medication. A landmark case against a nursing home has sent a warning not to provide too little.

Death came fairly easily to Henry James. What preceded it was nightmarish--four months of agony that would send a warning to any doctor or nurse who dared to ignore a patient’s suffering.

At 74, James, a retired house painter from Murfreesboro, N.C., was found to have cancer of the prostate. Doctors removed his testicles, but the surgery came too late. The cancer had spread to his leg and spine.

The pain was excruciating. But the way nurses at Guardian Care of Ahoskie treated James made it even worse. As soon as he arrived at the nursing home in February, 1987, they began cutting his doses of prescription pain medication. In place of powerful narcotics, they gave him mild headache medicines; they substituted a placebo and claimed it was morphine. Some days they gave him nothing at all.

Rebecca Carter, the nursing supervisor, explained why to James and his family. He was a big, strapping man in danger of becoming a drug addict. If he took morphine now when he didn’t even look like he was suffering, what would he take when the pain really got bad? There was something else she wanted James and his family to know. Since James was a recipient of Medicare and Medicaid, her tax dollars were going toward his drug habit. She didn’t like that.

Without adequate pain relief, James’ personality changed. Polite, cheerful and uncomplaining when he entered the nursing home, he became testy and withdrawn. Soon he stopped socializing with other residents and even his own family. Eventually he did nothing but lie in his bed, sweating and moaning under the weight of his suffering.

His family tried to help until James died four months later. They met with the director of the home. They contacted James’ doctors. They filed a complaint with a state regulatory agency. Eventually they went to court.

On Nov. 20, 1990, a trial began in a North Carolina courtroom. After 3 1/2 days of testimony, a jury took only 59 minutes to render a verdict: Guardian Care and Hillhaven Corp. of Tacoma, Wash., the owner and operator of the nursing home, had been negligent in failing to provide Henry James with adequate pain medication. The nursing home was ordered to pay his estate $15 million--$7.5 million in compensatory damages, $7.5 million in punitive damages. Although the jury found that Carter also had been negligent, she was not ordered to pay damages.

She and the other nurses vehemently denied any negligence or wrongdoing. The case was closed when Hillhaven Corp. paid the estate an undisclosed sum, agreed on in an out-of-court settlement last January.

There had never been a case like it. For the first time, a health care provider was held liable for failing to provide adequate relief for a patient in pain. The original verdict was said to be the largest medical malpractice award ever handed down by a jury in North Carolina and one of the largest rulings against a nursing home anywhere in the country.

“There have been a number of cases where doctors and nurses have been accused of giving too much medication. . . . Now, they are being held responsible for giving too little,” said Robert T. Angarola, a Washington lawyer and former White House counsel on drug-abuse prevention.

Betty Ferrell, an associate research scientist at the City of Hope Medical Center in Duarte, called it “a verdict every pain expert in the country has been waiting for.”

Although the verdict was unique, what happened to James was not.

“The latest statistics by the World Health Organization show that as much as 80% of all cancer pain is undertreated,” Ferrell said. “There are many reasons for this apparent neglect--ignorance about pain, prejudice about pain medications, fear on the part of doctors and nurses that if they prescribe or administer too many pain medications, especially narcotics, they will run into trouble with medical boards and drug regulators.”

“Until now,” she said, “the U.S. government has not even had uniform standards for the treatment of pain.”

The first such guidelines, drafted by the Agency for Health Care Policy Research and scheduled for release soon, will spell out the basic pain services that medical institutions should offer patients in acute discomfort during an emergency and after surgery. A second set of guidelines, scheduled for release in 1992, will deal with cancer pain. Eventually, U.S. health officials hope to set uniform standards for treating all forms of chronic pain.

With enough compassion and the right kind of training, pain experts contend, doctors and nurses can drastically reduce or even eliminate most forms of physical suffering. Yet, as the Henry James case so powerfully illustrates, patients continue to suffer.

Guardian Care of Ahoskie is part of a reputable nationwide chain of nursing facilities. It is an immaculate 131-bed facility in one of the more prosperous towns in rural northeastern North Carolina.

For 16 years, Rebecca Carter has run the nursing staff at Guardian Care with an iron fist. Passionate about her profession, she wears her white uniform nearly everywhere, even to social gatherings at the local woman’s club.

A 1950 graduate of a Baptist nursing school in Virginia, Carter, like many in her generation, has little formal training in pain management. Like all nurses, however, she says she knows about pain.

During the trial, Carter testified about her husband’s experience with cancer--his colostomy, the removal of one of his lungs, the surgery on his liver. Through it all, he never asked for morphine; nor would she have given it to him. Carter herself had suffered cancer of the breast. After a mastectomy, she had not needed morphine. “I had my surgery on a Friday; on Sunday I took two Tylenol,” she said. Two weeks later, she was back at work.

She was frankly appalled, she told the jury, by the quantity of pain medication James was taking when he entered the nursing home: 7.5 ccs (150 mg.) of morphine every three to four hours. No one could say it was a small dose. No one on Carter’s staff or any of the town’s pharmacists had ever heard of giving so much painkiller for any kind of physical distress, Carter said. In fact, Carter told the jury, none of the local pharmacies even stocked the form of liquid morphine that James was taking.

Carter said she had warned James of the dangers--that he would become addicted, that he could become so tolerant to the medication that it would stop working altogether. She and the other nurses were able to cut his pain medication, Carter explained, because Dr. Roy G. Flood, James’ physician, had prescribed it in the usual way--every three to four hours or as needed for discomfort.

The nurses had not deemed the medication necessary. Yes, Carter told the jury, James objected at first, but eventually he stopped complaining. Once he even said a glass of orange juice without any medication made him “feel good.”

Pain experts from the National Institutes of Health and other nursing facilities who were called by the plaintiffs to testify as expert witnesses said they were shocked by reading James’s medical record.

The nursing records showed he was denied six, seven, sometimes eight doses a day. In all, the experts calculated, he had gone from 240 doses of morphine in January to only 41 in February.

“I think he must have been in misery,” testified Dr. Steven Krasnow, a National Institutes of Health oncologist who has published more than 40 research papers on cancer treatment. “There’s no way that the doses he received at Guardian Care could have controlled the pain.”

Although as many as 40% of cancer patients do not suffer significant pain, James was not one of the lucky ones, Krasnow told the jury. Bone cancer is almost invariably agonizing, much like having the spine and legs crushed again and again.

To say that he was in danger of becoming tolerant to the medication was “ridiculous,” Krasnow said. The nurses’ behavior, he said, showed a complete lack of knowledge about how narcotics work. When doses of painkillers are increased gradually and methodically, as they were in James’ case, there is “no upper limit” to how much a patient can receive.

Ann Carpenter, a quality-control nurse for Beverly Enterprises, the largest nursing home chain in the world, testified that the nurses were “careless” and “cruel” in giving so little medication.

Even before the trial began, the North Carolina Department of Facility Services, the state agency that oversees care of Medicaid and Medicare patients, had determined that the nurses violated a number of state regulations. They violated standard nursing practice by not assessing James’ pain or believing him when he complained. They violated the patient’s rights by not bringing his pain under control. The nursing home paid a fine.

Meanwhile, Flood, James’ physician, told the jury he thought James was getting his medication in a timely fashion. He did not know headache medicine was substituted for morphine; he had never authorized using a placebo. The patient’s family had complained, Flood acknowledged, but Carter, whom he had known for years, assured him everything was as it should be. When Flood talked to James, he said, the patient had not complained. In April, Flood himself was hospitalized. He did not know what happened to his patient after that, aside from learning James had died in June after returning to the hospital.

To say James was in danger of becoming a drug addict was “like calling him a name,” said Susan Schafer, a nurse who has specialized in the treatment of pain in the elderly at Harvard Medical School and the National Institutes of Health.

In spite of what Guardian Care nurses believed, the most reliable studies on narcotics have shown that they are not addictive when given to patients in pain with no previous history of addiction. A powerful narcotic may give a drug abuser a psychological high, but all it does for patients in pain is to curb their discomfort. Even if James became dependent on drugs, what difference could that have made for a 75-year-old man with less than six months to live, Schafer asked.

Although James stopped complaining, it is unlikely he ever stopped suffering, she said.

A person in chronic pain may stop talking about his condition for several reasons, Schafer told the jury. It could have been exhaustion. It could have been his temperament and background. Maybe James was the kind of person who wanted to please, who wanted to be accepted.

“Patients routinely underreport pain,” June L. Dahl, a pain expert and professor of pharmacology at the University of Wisconsin, reported in recent studies on pain management.

“Many patients fear that if they focus too much attention on the subject they will alienate (their care-givers) or take (their doctors’) precious time away from their diseases,” Dahl said. “Patients do not want to admit their pain is worsening because it may mean their diseases are worsening. If you deny you hurt, you can deny you have cancer.”

It is not just patients who try to ignore pain. Many health care professionals acknowledge that they have developed a high tolerance for physical suffering, at least for the suffering of their patients. Even when they feel compassion, doctors and nurses often have the same aversion to narcotics that the public has.

Experts acknowledged that James’ prescription had been for a hefty dose of a powerful and potentially dangerous drug. But, they also observed, James’ oncologists at the medical center in Norfolk, Va., had studiously followed the “three-step ladder” to pain management developed in the 1980s by the World Health Organization. The oncologists started with mild, over-the-counter analgesics, progressed to stronger prescription medications and eventually turned to narcotics, the most powerful painkillers.

By taking preventive doses of morphine every three hours James had been able to lead a reasonably comfortable life. He could watch TV. He could play with his great-grandnieces and nephews. He could chat with his family and neighbors.

Some observers at the trial wondered if his nearly normal lifestyle was part of the problem. Perhaps James looked and acted so well that the nurses didn’t believe he was as sick as the doctors said.

The jury apparently was not interested in justifications. James had suffered, they said in their unanimous verdict.

“The only thing I never fully understood about the case,” Tom Henson, a lawyer for the plaintiffs, said afterward, was how the jury settled on the amount. “I have often wondered if those 7.5 millions weren’t somehow an effort on the jury’s part to make up for all the 7.5 ccs of morphine Mr. James missed during those final awful months of his life.”

Looking back, it seems “inconceivable” that anyone in the health care profession could have been so seemingly callous to physical suffering, “and yet we know it happens to other patients in other settings all the time,” said Ferrell, who is now serving on the government’s panel of pain experts.

“The real tragedy,” she said, “is not that something so awful happened to one person but that it happens to all kinds of people all the time in all sorts of settings.”

All forms of pain can--and do--go undertreated not only in nursing homes but also in doctors’ offices and at major medical centers around the country, she said.

It has long been recognized that part of the problem is a lack of education. The vast majority of doctors get little formal training in pain management. The same is true of nurses. In a recently published survey of four-year nursing programs, nursing students on average received only 1.4 hours on beliefs and misconceptions about pain and 3.9 hours on the use of pain medications.

The nation’s effort to stem the illegal drug trade also seems to have affected pain treatment. “Increasingly,” doctors and nurses “are afraid” to prescribe and administer adequate doses of pain medication “for fear they will be investigated by medical boards or drug agents,” said Dr. Harvey L. Rose, a family practitioner from the Sacramento suburb of Carmichael. In 1981, Rose was charged by the California Medical Board with prescribing too many painkillers to patients in intractable pain. The accusation was eventually dropped on a technicality and ever since Rose has lobbied for better drug education programs and less restrictive drug statutes.

Rose is not alone. Numerous specialists throughout the country have found themselves in similar situations because of vigilant enforcement of anti-drug statutes and regulations.

New York, for example, has a requirement that patients treated with narcotics for extended periods be registered with the state as “addicts.” Nine states, including California, require doctors who prescribe narcotics to use special triplicate prescription forms. Copies are kept on file in the doctor’s office, the pharmacy and the state’s medical regulatory agency where they can be used for investigations.

David Joranson, a pain expert at the University of Wisconsin Medical School, has found that states with triplicate requirements have experienced a 50% drop in the use of narcotic pain medications. In California, only one in five doctors has applied for triplicate prescription pads, which means the vast majority of the state’s doctors cannot prescribe strong painkillers, even when their patients need them.

The issue of pain control is so confused it has become the No. 1 “ethical dilemma” facing nurses today, according to recent surveys conducted by Anna Omrey, a specialist in nursing ethics at UCLA.

“You would think,” Omrey said, “it would be the ‘sexy’ questions, like organ transplants or euthanasia.” Yet what nurses continually confront are questions surrounding pain: How much suffering is too much? How do you prove under-medication? What are the dangers of over-medication? Who decides?

Doctors and nurses have pushed for new laws to clarify the legitimate use of drugs. Earlier this year, a law went into effect in California that says a physician cannot be disciplined for prescribing controlled substances to patients whose pain cannot be relieved any other way.

A group of health care professionals known as the the Wisconsin Cancer Pain Initiative has introduced more comprehensive pain-control education programs and has been lobbying to eliminate what are said to be antiquated pharmaceutical regulations. The Wisconsin group has spawned similar groups in nearly 20 other states, including North Carolina.

But, most pain experts agree, there is still much that needs to be done.

Today, three handsomely framed citations hang inside Guardian Care’s elegant lobby. One, from an Alzheimer’s association, gives special recognition to Guardian Care for “easing the burden” of the elderly. Another commends the Ahoskie home as the “outstanding” facility of the chain’s nursing homes throughout the North Carolina. The third and most impressively framed honor--given by a nursing association in 1988, the year after Henry James’ death--names Rebecca Carter as “nurse of the year.”

Carter still works at Guardian Care. She will not talk about the lawsuit or the settlement other than to say “nothing whatsoever has changed.”

“We still give drugs the way we always have,” she said. “The doctors still prescribe in the same way they always have.”

At the trial, Catherine Faison, James’ great niece, said: “As far as Guardian Care was concerned, when he died, it was a closed issue, it’s over.

“It’s not over for me,” Faison told the jury. “I can’t sleep at night when I think about the fact that he had to lay over there and suffer. . . .

“I think about him laying there hurting, saying ‘I want my medication,’ and not being able to get it. I don’t want to suffer like that. . . . I don’t think anybody would. Somebody needs to say you can’t do it.”

Pain: The Bottom Line

Based on decades of studies by the World Health Organization, the U.S government and American universities, here are some statistics on the tragic world of pain:

* One in three U.S. families has someone in persistent pain.

* Four of five Americans will get at least one disabling bout of back pain before the age 55.

* Nearly 75% of the American population suffers from periodic headaches.

* Cancer pain is a major health problem; moderate to severe pain is experienced by approximately 40% of patients in all stages of cancer and by about 75% of patients with advanced cancer.

* There are about 26,000 surgeries annually or about one for every 10 Americans. Studies show that at least 40% of those patients receive inadequate pain relief after their operations.

* Only about half of pediatric patients get analgesics after surgery.

* 30 billion aspirin tablets are are taken every year for pain.

* Full-time employees lose an average of five workdays per year due to pain.