Tracing its roots to the rise of the modern pain movement in medicine, the opioid analgesic epidemic has come about during a dramatic rise in prescriptions of powerful painkillers like Oxycontin and Percocet by medical professionals, many of whom are not well-educated about the risks of these drugs.
Clinicians are often confronted in a way they were not as recently as 15 years ago with patients who desperately seek prescriptions for pain—some legitimate, many not. Doctors and nurses are hardly naïve to patients lying to get drugs. But because of the medical establishment’s decision to elevate pain as a health problem—“the fifth vital sign”—and because of the number of people who complain of chronic pain, medical professionals have become sometime unintended drug peddlers.
Internal medicine and emergency room doctors frequently see patients who complain of pain and yet often have only minimal training in pain medicine. According to the American Society of Interventional Pain Physicians, 80 to 90 percent of physicians in the U.S. have received no education in the use of controlled substances. On top of this, much of their information about opioid analgesics has come from the pharmaceutical companies that make painkillers, posing a significant conflict-of-interest.
“In most cases, doctors contribute innocently because they haven’t been trained properly on how to prescribe in a responsible way, how to identify a drug addict and help them,” Dr. David Kloth, a pain management physician from Connecticut and spokesman for ASIPP, told the U.S. Congress in 2011.
This lack of knowledge can have serious consequences, says Bridget Brennan, New York City’s special narcotics prosecutor.
“The emergency doctor who prescribes a month’s supply of opioids doesn’t ever see that patient again. They don’t see what I see. They don’t know it’s morphing to the criminal side,” she says. Her office has seen a sharp uptick in prescription drug-related crime in the last several years.
To be sure, studies have found that most doctors rarely prescribe prescription opioids.
In New York City, among those doctors who prescribed opioids, nearly half wrote one to three opioid prescriptions per year in 2010, according to New York City Department of Health and Mental Hygiene data. Those who wrote the bulk of prescriptions—31 percent—represented only 1 percent of prescribers. These “very frequent” prescribers wrote on average 1,159 prescriptions per year. These usually are the medical professionals who are prescribing to addicts—such as alleged pill mill operator Stan Li from part one of this series— or even writing prescriptions for drug dealers.
Although her office has been going after doctors in this latter group, Brennan says that the brunt of the effort cannot be made by law enforcement but by the medical establishment, who need to be educated about vigilant prescribing practices, and in some cases be limited on what they can prescribe. Examples include new emergency room guidelines in New York City for doctors prescribing painkillers or Washington State’s requirement that patients receiving high doses of painkillers must be referred to pain specialists for an evaluation if their condition is not improving. Another idea is to permit only pain specialists to prescribe opiates, rather than all medical professionals. For instance, in the Kaiser Permanente group, only oncology, pain management, and hospice physicians can prescribe oxycodone.
Pain specialists tend to be more aware of the potential for misuse and abuse, as well as the availability problem, according to Dr. David Walega, an assistant professor of anesthesiology and practicing pain specialist at Northwestern University.
“As a general rule, most good pain specialists are going to prescribe medications under stricter conditions—not that they’re trying to withhold care—but we monitor patients much more closely,” he adds.
In his practice, he and his colleagues require patients to sign a “narcotic contract,” in which patients agree to a battery of conditions including that they can only get prescriptions from a doctor in that practice, they cannot call for an early refill and they cannot make up excuses for why they need a prescription early.
“I lost my prescription, my kid flushed it down the toilet, my valet stole it, my dog ate my prescription. We’ve heard everything,” Dr. Walega says.
His practice also does a kind of background check on whether the patient or someone in his or her family has a history of addiction.
“We’re not like Miss Marple in an Agatha Christie novel. There’s only so much time and resources and energy we can commit to getting information, but the more we can get a spouse or family member to come in with that patient and verify the story, the better,” he says.
There are now prescription drug monitoring programs—electronic databases that allow prescribers to monitor patient prescriptions statewide, in order to make sure they are not “doctor shopping”—getting painkillers and other drugs from multiple doctors. However, in many states these programs are underfunded, and they have so far failed to make an impact on drug overdose mortality rates, according to a 2011 study.
“The fact that they exist doesn’t necessarily mean they are effective. California has the oldest prescription database, but there is no funding for it,” says Erin Daly of Oxy Watchdog, who lives in San Francisco. Last year, the state reduced the staff of its prescription monitoring program to one person.
Few people in medicine advocate for a total ban on prescribing prescription opioids for legitimate, significant pain, as determined by a patient and their doctor.
“In some ways, this is an unintended consequence of an intent to treat pain better,” said Dr. Robert Rolfs, deputy director of Utah’s Department of Health, in the New England Journal of Medicine.
Although medical associations, governments, and sometimes pharmaceutical companies are increasing their efforts to regulate who gets prescribed opioid analgesics, the burden of painkiller addiction in many communities, especially in rural areas and suburbs is already significant. In some places there is now an ecosystem where drugs intended for legitimate pain relief purposes are peddled by dealers to desperate addicts.
Edited by Jordan Lite and Dana March.