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Pain Pills Now Leading Cause of Untimely Death

by Morgan True

WASHINGTON —  As the enormity of the prescription drug problem in the United States sinks in, efforts are coalescing at the national, state and local level to change the way Americans interact with these drugs — particularly opiate-based painkillers.

Detox Protocol

According to federal officials, accidental poisonings, largely due to prescription drug overdoses, are now the leading cause of premature death in the United States, outpacing auto accidents and gunshot wounds. Prescription drug abuse accounts for more overdoses than heroin and cocaine combined. Of the 37,000 people who died of a drug overdose in 2009, roughly 40 percent — more than 15,000 — were using prescription opiates, according to the Centers for Disease Control and Prevention.

In Massachusetts, nearly two people die every day from prescription drug overdoses, according to a Massachusetts Department of Health and Human Services report.

Marty Miller, 58, a former opiate addict who is now an addiction counselor at Worcester's AdCare Hospital, has seen the landscape shift dramatically since prescription drugs led him down a path to heroin addiction more than a quarter-century ago.

“I knew how to write a prescription for Dilaudid and morphine before I ever wrote a check,” Mr. Miller said.

“I see kids in their early 20s who have been to detox over 10 times — it's crazy,” said Mr. Miller, citing the proliferation of prescription painkillers as the dynamic that has caused the problem to reach epidemic proportions.

“If you think about the economy and the cost of health care, it isn't just the addiction, the overdoses, and the fatalities — which is heartbreaking enough — it's also a huge economic issue costing the country well over $50 billion,” said Gil Kerlikowske, director of the Office of National Drug Control Policy — a Cabinet-level position often referred to as the president's “drug czar.”

In 2000, retail pharmacies dispensed 174 million prescriptions for opiates; by 2009 that figure had climbed to 257 million, an increase of 48 percent in less than a decade. Among Americans — age 12 or older — who experimented with drugs for the first time in 2009, one-third started by using prescription drugs for non-medical purposes, according to Mr. Kerlikowske's office.

In an interview, Mr. Kerlikowske, a former Seattle police chief, said: “There's no silver bullet for dealing with this issue. It's a huge problem that just hasn't gotten as much attention by all of us that it should.”

But it's involved some high-profile celebrities.

“I decided to take OxyContin one afternoon thinking ‘I'll try this once and never do it again,' ” recalled Chris Herren, a former Boston Celtic. “I was 22, 23 years old, and I stopped when I was 32.”

“I had no intentions when I started taking OxyContin to be a full-blown addict and strung out for the next 10 years, but that's just the way it played out because that's how addictive they are.”

Since regaining his sobriety, Mr. Herren has reached out to share his story. He operates the Rhode Island-based Herren Project, which provides financial aid and support to addicts who are motivated to get clean.

But while addictive, opiate-based prescriptions also serve a recognized medical purpose — creating a dilemma that government, health care professionals and families are struggling to deal with.

A key component in combating prescription drug abuse calls for increased oversight by physicians and providers through prescription monitoring programs. PMPs monitor the prescription history of patients and identify behavior indicative of abuse.

There are approximately 17,000 prescribers in the Massachusetts system, with only a handful of “Mom and Pop” drug stores not included. Each time a prescription is written, it is put into a database, which tracks when and where it is filled — flagging individuals if they fill a certain number of prescriptions from different physicians or at different locations.

“If somebody has received that many prescriptions and filled them at multiple locations, that is cause for concern,” said Dr. Madeleine Biondolillo of the state Department of Health, who is responsible for coordinating the program. “It is possible this threshold will be met by people with legitimate use and need,” she said.

Only licensed prescribers and distributors of controlled substances can access the PMP without written permission from the Department of Public Health.

Law enforcement officials cannot access the Massachusetts PMP without clearing a significant amount of bureaucratic hurdles, making it more difficult to build cases against “doctor shoppers” – those seeking multiple physicians to fill a prescription for the same or similar conditions – or “pill mills,” prescribers who knowingly divert drugs for profit. But some argue that limiting law enforcement's access is necessary to protect privacy rights.

A handful of state and federal agencies, including the DEA, a specially trained drug diversion unit and the boards that regulate the prescribing professions, can obtain access to specific information pursuant to active investigations.

A key aspect of preventing abuse is providing physicians with information on alternatives to prescribing opiate painkillers, as well as reminding them to watch for signs of addiction and misuse.

“When we talk to physicians, or the deans of medical schools, you find that very little time is devoted to educating them about prescription drugs, things like tolerance, dependence and pain management,” said Mr. Kerlikowske.

Mr. Miller's recent experience at an emergency room after breaking his ankle is a case in point.

“I'm in the hospital and the physician's assistant says, ‘All right, I'm going to write you out a prescription for Percocet,' ” he recalled. “And I say, ‘No I'm sorry I can't take those. I'm a recovering heroin addict,' and she says, ‘Well you're gonna need them.' ”

The physician's assistant was right, and when he woke at 2 a.m., the pain was excruciating.

“You know what? I got through it. Was it painful? Yeah,” Mr. Miller said. “But for me, as a recovering addict, it would've been a lot more painful if I'd taken that bottle home.”

Not everyone in a similar situation is as forthcoming about his or her addiction — and, even Mr. Miller, though he had explained his condition, still had health care professionals urging an opiate prescription. He said addicts often negate their responsibility by using the rationalization that, “a doctor gave it to me so it's OK.”

As part of the effort to bolster physician education on this issue, the Worcester Division of Public Health and the Worcester Medical Society have hosted courses, with the most recent one in mid-March. Physicians who attended received continuing education credit, while learning ways to curb reliance on opiates for pain management and to help patients navigate the pitfalls that can lead to addiction.

“We need to educate physicians on how to recognize patients that might be manipulative. We also need to help them learn to treat pain effectively, and look for non-opiate options for treating pain,” said Dr. B. Dale Magee, former Worcester public health commissioner.

But the effort to improve education must also extend to the general public, Mr. Kerlikowske noted.

“You don't think about how many powerful painkillers exist in people's medicine cabinets, but just to give you a hint: Real estate agents are telling people to clean out or lock up their medicine cabinets, because there are people that will go to open houses just to see what's in the medicine cabinet and go get something out,” he said.

The Drug Enforcement Administration, in conjunction with local law enforcement agencies, sponsors take-back days, when individuals can turn in their old prescriptions to be disposed of by law enforcement. The next take-back day hosted by the Worcester Police Department is April 28.

Although there is currently no federal program for directly educating the public on the dangers of prescription painkillers, the Office of National Drug Control Policy does sponsor the Drug Free Community Support Program — which provides grants for coalitions of local public health departments, law enforcement agencies and educators.

The Worcester area presently does not receive funding through the federal program, but, there are plans to apply for the fiscal year 2013, according to public health officials.

Rep. William Keating, D-Bourne, recently introduced legislation aimed at making prescription painkillers tamper and crush resistant. The proposal, embraced by a number of pharmaceutical companies, is aimed at abuses such as snorting and injecting crushed pills.

“The technology just continues to get better and better in terms of getting tamper proof and abuse proof protection on those drugs,” said Mr. Keating, a former district attorney.

The abuse of prescription painkillers cuts across socioeconomic lines, exposing the vulnerability of a diverse swath of the Massachusetts population – which, while holding private health insurance, can't afford additional care when the decision is made to seek treatment.

“The biggest complaint that we get is from people who have commercial insurance who don't feel like they have access to this whole continuum of treatment services,” said Michael Botticelli, director of the Massachusetts Bureau of Substance Abuse Services.

While the state can provide in-patient services or access to a halfway home to the uninsured or those receiving Medicaid, there is little recourse for the underinsured. Prolonged stays at private treatment centers can costs thousands, and the same is true of accessing a halfway home.

Mr. Herren points the finger at private insurers, declaring, “The way the insurance companies are set up today, addicts, and especially opiate addicted patients don't get much respect, and you're lucky to get a detox for 4 days.”

He added, “When I went into detox after using opiates for 10 years they gave me seven days to get sober. To me, that's unacceptable. This is an illness, and it's a disease, but we're treated as 'Hey you made a choice, get in there, clean up and get out.' It doesn't work that way.”

Susan Pisano, a spokeswoman for America's Health Insurance Plans – the industry's national trade association – noted that that federal law mandates benefits for mental health, including addiction services, “be no less favorable than coverage for physical illness in terms of things like deductibles and limits.” It is a state's responsibility to make sure there are laws in place that comply with the federal mandate, she added.

In Massachusetts, insurers that offer mental health benefits are required to cover treatment of alcoholism and chemical dependence. The state requires providers cover up to 30 days of inpatient care and $500 for outpatient services, as long as the treatment is deemed “medically necessary,” according to the Massachusetts Trial Court Law Libraries website.

Mr. Miller said most opiate patients come into rehabilitation having used that day. They are given increasingly smaller doses of methadone over the course of the next five days.

“When you walk out the door they give you 5 milligrams of methadone,” he explained. “From my own experience, the next day, you feel anxiousness and there's queasiness in your stomach.” The latter, he said, is akin to withdrawal — although less acute — and, as a result, many opiate-addicted patients relapse soon after detoxification.

The result is a Catch-22 where addicts are guaranteed 30 days of inpatient care as long as it's “medically necessary,” a determination based on whether a patient is still receiving methadone. But patients are then usually cut off methadone after just five days.

As Mr. Miller put it, “Once their methadone is done, they're done.”

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