Every week, a group of physicians and pharmacists convene in a meeting room at St. Patrick Hospital's Spine and Pain Center to discuss how to better manage the risk of treating pain patients with narcotic painkillers.

Dr. Randale Sechrest and his colleagues at the Spine and Pain Center are in the business of treating chronic pain as a disease process, and opioid painkillers are an oft-used tool, particularly for patients with acute back pain or who suffer from terminal illnesses.

"It (chronic pain) is a disease process that is destroying people's lives," said Sechrest, medical director of the center. "That's the party line."

At the same time, Sechrest and his colleagues are hyper-aware of the growing addiction problems associated with opiates, and frequently see their own patients' pain-treatment therapies spiral out of control.

Using every tool available, the center's collective goal is to strike a balance by providing compassion and adequate drug therapy for patients with legitimate pain issues, while limiting the potential for abuse and misuse.

The moment a doctor suspects a patient is taking opiates excessively, the patient is re-evaluated.

In extreme cases, the treatment ends abruptly, and the patient is referred to a chemical dependency treatment center.

"We don't turn people off cold turkey unless they are diverting and selling," Sechrest said. "They have a legitimate disease process and it's not ethical for us to turn them loose and let them withdraw on their own."

To that end, the Pain Center has overhauled its treatment methods by developing rigid risk profiles for every patient. Physicians then monitor each patient's opiate intake, relying on drug screens, regular patient-doctor meetings and pill counts to discern aberrant behaviors that suggest misuse or abuse of the prescribed drugs. About half of the time, Sechrest said, the assessment reveals some sort of potential risk factor in treating a patient with opiate painkillers. With that information in hand, the treatment is then tailored to the individual patient, who may still be prescribed pain pills, but is more closely monitored.

Sechrest says the assessment and monitoring components are critical to a pain patient's recovery.

"We've launched this experiment that may have one of two outcomes, and then we never monitor the experiment itself," he said. "We need to prescribe an appropriate amount of opiates and then watch the patient."

Part of the problem is that there is a dearth of physicians willing to treat chronic pain and monitor a patient's therapy regimen of opiate painkillers, Sechrest said. He's seen a precipitous decline in the number of physicians in Missoula who are willing to treat chronic pain because they fear criminalization. The medical community as a whole has ramped down on pain treatment, he said.

"There are 30 to 40 percent fewer doctors treating chronic pain now than there were five years ago," he said. "We're stuck in the middle of these pincers, with one side saying pain is a huge issue and the other side screaming about addiction. How do we find a balance?"

If a patient of the Pain Center requests an unscheduled refill because they say the medication was lost or misplaced, Sechrest's staff casts a wary eye, but will allow the patient to refill the prescription once.

"Everyone has one opportunity to have their dog eat their medication or forget it in a hotel room," Sechrest said. "Unfortunately, that kind of thing happens all the time."

Sechrest also evaluates patients for mental health issues because it's the most effective tool for assessing a patient's risk profile, which helps gauge their potential to abuse the drug.

Because opiates have no ceiling, addicts push their drug intake higher and higher until they are often taking doses that would kill a person not accustomed to the drug.

"We get patients who are literally taking handfuls of opiates that are all prescribed," Sechrest said.

"It's a short leash," he says of the treatment plan. "It has to be."