Pills a potent problem
Officials seek to balance patient needs, alarming rise in abuse
Saturday, November 5, 2011
By the Numbers
6.13: Percentage of Washington residents who used pain relievers for nonmedical purposes in 2008 (Ninth highest in the country).
55: Percentage of Americans who obtained pain relievers for nonmedical use from a friend or family member for free.
1.4: Percentage of 18-to-25-year-old Americans who are dependent on pain relievers.
2,500: The number of U.S. teenagers every day who use prescription drugs to get high for the first time.
2006: Since then, deaths in Washington from unintentional drug overdoses have surpassed auto deaths.
12.3: Percentage of Washington deaths in 2007 due to unintentional drug overdose.
Sources: National Survey on Drug Use and Health (2010 survey); Washington State Department of Health; Centers for Disease Control and Prevention
The methamphetamine epidemic that plagued Clark County in the past decade has taken a backseat to another public health crisis: prescription drug abuse.
The number of people seeking care at Lifeline Connections, Clark County’s largest treatment center, for opiate addiction has surpassed methamphetamine and most other drugs, making it second only to alcohol.
In the 2011 fiscal year, more than 17 percent of people who sought treatment at Lifeline Connections used opiates or synthetics, including oxycodone and hydrocodone, as either their primary, secondary or tertiary drug of choice. More than 7 percent identified the drugs as their primary choice, compared with nearly 36 percent who primarily used alcohol.
Physicians acknowledge the issue. Law enforcement recognizes the trend. But nobody seems sure how to rein in prescription drug abuse.
"There’s a tear in the fabric of our community somewhere, and I’m looking for it,” said Sgt. Shane Gardner with the Clark County Sheriff’s Office.
But the problem isn’t unique to Clark County.
Last year, 6 percent of the American population used prescription pain relievers, tranquilizers, stimulants or sedatives for nonmedical purposes. That’s 16 million people misusing prescription drugs — more than four times the number a decade ago, according to the Substance Abuse and Mental Health Services Administration.
Washington has some of the highest rates of abuse in the U.S. More people in this state die from accidental prescription drug overdoses than motor vehicle crashes.
Washington lawmakers, however, believe they may have found a way to put a dent in those statistics.
The strategy: take a tougher stance on prescribing opiates.
In 2010, Washington lawmakers passed Engrossed Substitute House Bill 2876, calling for new prescribing rules. State Rep. Jim Moeller, D-Vancouver, who has worked as an addiction counselor for more than 25 years, sponsored the bill.
The bill directed the five governing boards and commissions for Washington practitioners to adopt uniform rules concerning the management of chronic pain not caused by cancer. None of the rules apply to palliative (last year of life) care, hospice or end-of-life care. They also don’t apply for management of acute pain from an injury or surgical procedure.
Representatives from each board formed the core group responsible for developing the rules. Dr. Mimi Pattison, chair of the Medical Quality Assurance Commission, was a member of that group. For a year, the group met regularly and researched laws in other states and turned to the Federation of State Medical Boards for guidance.
Each commission approved the rules, which go into effect for physicians and physician assistants on Jan. 2. For all other fields, the rules went into effect July 1.
The new rules require a patient evaluation and complete history of pain treatment, a written treatment plan and a written agreement for treatment. The rules also require prescribers of long-acting opioids or methadone to have completed at least four hours of specialized training.
One of the bigger changes is the requirement of a pain specialist consultation. Prescribers with a patient who reaches an established threshold (120 mg of a morphine equivalent per day) must seek a pain specialist consultation under the new rules.
"I think we’ve gone to great lengths to write rules that we think are going to improve the opioid prescribing for chronic noncancer pain in Washington,” Pattison said.
In addition to improving prescription of opioids, lawmakers and physicians hope the rules will help rein in prescription drug abuse and diversion.
Dr. Gilbert Simas, the medical director at Lifeline Connections, said in the past five years the center has seen a significant increase in the number of people seeking treatment for opiate addiction. The largest increase has come from 17- to 21-year-olds, Simas said.
Most people seeking treatment were prescribed pain relievers following a traumatic injury. When the prescription runs out, the addicts begin stealing the drugs from family or friends and then move on to selling belongings and stealing to purchase the pills, Simas said.
They fear the long, painful process of withdrawing from opiates. That’s when they turn to Lifeline, he said.
Part of the problem is the lax attitude toward pain relievers, said Dr. Jeff Bowden, primary care physician at Legacy’s Battle Ground clinic. At least half of the younger generation believes prescription drugs are safer than street drugs. Most parents aren’t doing anything to dispel that misconception, he said.
"I can’t tell you how many parents are giving teens a Vicodin for a twisted ankle,” Bowden said.
"That lax attitude doesn’t end with the younger generation. More and more adults show up at their doctor’s office wanting prescriptions for pain medication," Pattison said.
"The public now has the expectation of getting opioids for all pain,” she said.
Another part of the problem is the easy access.
Pain relievers are readily available in most high schools. People can see multiple physicians in different offices and receive prescriptions from all of them. Last year, U.S. physicians wrote 130 million prescriptions for Vicodin.
In 2010, enough prescription pain relievers were prescribed to medicate every American adult around the clock for one month, according to the Centers for Disease Control and Prevention.
Pain is difficult to measure and many times physicians rely largely on trust with their patients when determining whether to write a prescription, Bowden said. When the patient builds a tolerance, physicians can either increase the dosage or leave their patient in pain — neither of which are ideal options, he said.
"There’s no question that things got out of control with opioid prescribing in terms of opioid dosing,” Pattison said.
For what may be the best example of out-of-control prescribing in the state of Washington, one needs to look no further than Vancouver’s Payette Clinic.
The Payette Clinic, the former pain clinic that now operates under the name Walnut Grove Medical and Mental Health, was the subject of a yearlong Washington Department of Health and Drug Enforcement Administration investigation that found nurse practitioner and clinic co-owner Kelly M. Bell was prescribing “extremely high doses of opioids.” As part of the resolution of the case, Bell and her staff had to surrender their credentials to prescribe controlled substances.
The fallout sent ripples through the community.
The DEA reported about half of the clinic’s 800 patients were addicted or physically dependent on narcotics. Patients inundated area hospitals, pain clinics, urgent care centers and drug treatment centers. Some committed crimes to get the drugs. Others turned to opiates like heroin to feed their addiction.
"That wasn’t pain management,” Gardner said of the clinic. “That was maintaining peoples’ addiction or increasing the addiction.”
In addition, many patients from the clinic were diverting the drugs, according to officials. Diversion is attributed to the death of an Oregon teen who overdosed after smoking an oxycodone pill originally prescribed to a Payette patient.
The Payette Clinic brought the issue of prescription drug abuse to the forefront for Moeller, who went on to advocate for tougher prescribing rules.
Many local physicians believe the tougher rules will help improve opiate prescribing practices.
"I think after reading it, it’s in line with what should be the standard of care,” said Simas, who is an addiction specialist. “I’m happy to see we’re holding physicians accountable.”
The requirements will help balance the pendulum swinging between underprescribing pain and overprescribing pain, said Dr. Ben Platt, a pain specialist for PeaceHealth Southwest Interventional Pain Clinic.
"Overall, I feel they are a good thing, and, if interpreted correctly, they should not hinder pain care and should lead to better care for patients,” Platt said.
However, he said, the rules have generally been misinterpreted by many care providers and have caused significant undertreatment of pain.
The misunderstanding has also prompted some physicians to stop seeing pain patients, said Dr. Bob Djergaian, director of physical medicine and rehabilitation at PeaceHealth Southwest Medical Center. Already several patients have been referred to the medical center’s new pain rehabilitation program by physicians who are no longer treating pain patients, he said.
Pain patients generally require more time and attention from physicians. The extra stipulations are enough to prompt some physicians to stop prescribing the narcotics, Djergaian said.
Some prescribers are also concerned with the unwanted attention prescribing may bring and fear the medical board will pursue and penalize physicians who continue to prescribe, he said.
Pattison said the medical board will not police physicians. However, if complaints are filed against a prescribing physician, the board will investigate just as it does any other complaints against physicians or physician assistants. The rules are flexible enough to allow the medical commission to base each case on its individual circumstances, Pattison said.
Many consider the new rules to be another tool in the tool box.
Some local physicians and medical groups are implementing additional procedures to help prevent misuse and diversion of pain relievers.
Physicians at Legacy clinics won’t refill pain medication prescriptions on the first visit. They also require patients to sign a contract agreeing to appear for visits and only use one pharmacy to fill prescriptions. The clinics also use urine analysis to ensure patients are not taking more than prescribed, Bowden said.
In addition, Bowden tells his patients upfront that he will not continue to treat chronic pain by writing prescriptions.
In January, the state will launch a prescription monitoring program for pain medication and other controlled substances. Physicians, pharmacists and law enforcement officers will be able to access the secure database that tracks the prescriptions.
The Clark County Sheriff’s Office has also implemented new policies in response to the growing misuse of prescription drugs. During all death investigations, officers collect all medications prescribed to the deceased person, Gardner said.
The sheriff’s office also funds a drug take-back program. Unwanted medications can be dropped off at the west and central precincts and office headquarters. In addition, the sheriff’s office works in conjunction with the DEA to host take-back events. The most recent event was Oct. 29. Officers collected 179 pounds of unwanted controlled substances.
Clark County’s Drug Action Team is also working to educate parents and encourage them to lock up their medicine cabinets and safely dispose of unwanted medications, said Toni Eby, team coordinator.
"We need people to take it a lot more seriously what’s in their medicine cabinet,” she said.
More work to do
Local officials hope the new rules coupled with the prescription monitoring program and local efforts to tackle misuse will help reduce the number of people hospitalized and dying from prescription drugs.
"Have we done everything? I don’t think so. There has to be more we can do,” Gardner said.
Gardner and Bowden agree the key will be to get patients to not want to use drugs to escape their reality.
"I don’t know how to fix it,” Bowden said. “I don’t know how to get people to not want it.”
The bigger challenge may be in finding balance; to prevent prescription drug abuse but not neglect the needs of patients with chronic pain.
"We’ve got a big job ahead of us on how to address patients’ legitimate pain concerns. I don’t doubt that,” Moeller said. “At the same time, we have to cognizant. We don’t always improve function by giving more pills.”