My pain medication was stolen.
I left my pill bottle in another city.
My doctor is on vacation.
Your honor, I have a valid prescription for oxycodone.
Medical professionals who deal with patients pitching for pain-relieving narcotics hear the first three stories all the time. The fourth scenario, uttered by a defendant in the drug court in Racine, Wis., helped to inspire the staff at Wheaton Franciscan Healthcare – All Saints hospital in Racine to create an opiate-education program for all of its personnel who can prescribe narcotics.
"The best actors are patients who are trying to scam you," said Dr. David Galbis-Reig, head of the hospital's Opiate Stewardship Committee. "Our goal is to create sound guidelines and alternative treatments so that we aren't overprescribing these medications, or under-prescribing them."
Dr. David Galbis-Reig, head of the Opiate Stewardship Committee at Wheaton-Franciscan Healthcare – All Saints hospital in Racine, Wis., speaks with the hospital’s medical director. Dr. Mamta Pandey. She also is on the committee, which educates medical personnel on proper dispensing of narcotic pain relievers.
The hospital instituted a mandatory three-session program for all of its prescribers, including staff doctors, nurse practitioners and physician assistants. Galbis-Reig said All Saints is encouraging all doctors in its service region to attend them as well.
Abuse of narcotic painkillers is well-documented. So is death by overdose — a threefold increase from 1990 to 2008, according to the Centers for Disease Control and Prevention. In that same time, the number of opiate prescriptions written increased tenfold.
Cause for concern
Racine County, on Lake Michigan south of Milwaukee, has the fourth highest per-capita rate of prescribing opiates in Wisconsin, according to the state's Department of Safety and Professional Services. Galbis-Reig said he's not sure why that is so; nobody has studied it.
He said the spur to action was a report from drug court in Racine that defendants were claiming possession of prescriptions as a defense for testing positive for opiates.
"There were defendants basically taunting the judges. The county people approached us and said, 'You guys need to help us do something about this,'" he said.
Limiting prescriptions
Galbis-Reig got involved because he is director of medical services for inpatient mental health and addiction. Staff members created the Opiate Stewardship Committee in 2012 and began the mandatory training last year. Classes are to run through this year.
A major emphasis is upon the emergency department. Nationwide, that's often where scammers try to make their cases for opiate prescriptions. Some of them are addicted to the medications; others take their prescriptions or pills and sell them on the streets.
Galbis-Reig said the new protocol for the All Saints emergency department strongly discourages prescribing opiates, usually limiting prescriptions to 10 or 20 pills.
Narcotics tourism
Some hospitals have strict prohibitions against prescribing them from the emergency room. At St. Joseph's Hospital in Tampa, Fla., a member of CHE Trinity Health, the emergency room staff does not use OxyContin in treating patients and will write prescriptions only for cases of acute pain when lesser pain relievers aren't sufficient, and they do not approve refills of any opiates.
"We explain that that's a matter for their primary care physicians," said Dr. William McConnell, chief executive of the local doctors' group that staffs the emergency department.
In the national debate over opiates, Florida became notorious for what McConnell called "the narcotics tourism business." The state once was home to so-called pain clinics that freely prescribed the medications, sometimes to patients who arrived on charter buses. Florida was home to all but two of the 100 doctors nationwide who prescribed the highest amounts of oxycodone and hydrocodone medications. Government investigations led to closing most of the pain clinics and to the writing of new medication protocols at hospitals throughout Florida.
Signs of progress
McConnell said the staff in the St. Joseph's emergency department, the third busiest in Florida, has noticed a reduction in the number of patients who show up claiming to suffer from pain and asking specifically for opiates.
"I think the word is getting around that we won't send them home with a prescription," he said.
Florida changed its regulations governing painkillers and pain clinics in 2010. This July, the CDC reported that the death rate from prescription-drug overdose had fallen by 23 percent in Florida from 2010 to 2012.
Wisconsin began tracking prescriptions of certain potentially addictive painkillers in 2012. Like most states, it requires pharmacies to enter information about the prescriptions into a database that can be used to track patients who receive too many prescriptions, and doctors who write too many of them. Hannah Zillmer, spokeswoman for the Wisconsin Department of Safety and Professional Services, said information compiled so far indicates a nearly 30 percent decrease in what she called "doctor shoppers" — patients who obtain prescriptions from five or more prescribers in one month.
All the states except Missouri have some sort of database that operates in that fashion. Doctors and pharmacists can use the protected information to monitor abuse of the listed medications. This August, the federal government announced that it was increasing the number of medications covered by Schedule II of the Controlled Substances Act. (That schedule covers medically useful drugs, such as OxyContin, that have a high potential for abuse.) The new rule, to take effect this month, will add drugs, such as Vicodin, that mix hydrocodone with ibuprofen or acetaminophen. The new rules reduce by half, from a six months' supply to three months, the number of pills a patient can be prescribed at one time.
The fifth vital sign
At All Saints, Galbis-Reig said his main concern is the high potential for patients to become addicted to the powerful pain medications that offer less relief from pain the longer they are used. In a tone intended to portray the responsibility borne of prescribers, he said, "I can create an addict."
Opiates, of course, have been around for many years. Galbis-Reig said the abuse epidemic began in the early 1990s with influential institutions, including the Department of Veterans Affairs, elevating pain to the "fifth vital sign." Pharmaceutical companies, seeing the potential, jumped in with marketing campaigns promoting their medications. Before long, he said, thousands of patients were demanding that their doctors prescribe the drugs.
The solution, he said, has been for medical professionals to apply lessons from the overprescribing of antibiotics. "We often were treating viral problems with antibiotics because patients insisted that's what would make them better, and then we began seeing a rise in (illnesses with) resistance to antibiotics," he said.
Risk reduction
The All Saints program is taught in three sessions: an introduction to the prescription overuse and epidemic, the use of risk-reduction strategies such as drug tests and pain-management techniques, and instructions for using the state prescription drug-monitoring program. The course covers opiates and other powerful medications, including Valium and Adderall.
"We call it teaching doctors to decrease the risk to patients and to themselves," Galbis-Reig said. "We have tools in medicine to help figure out if someone is scamming us. We also have patients who aren't scamming, but who become addicted."
One problem for doctors has been the lack of objective measures for chronic pain and the tendency, however reasonable, for doctors to rely upon personal experience in prescribing medications. "We all remember our success stories," he said.
Requiring patients to sign pain-management agreements if they receive opiates is one good tool for detecting abuse. A patient who refuses to take a urine test mandated by an agreement may well be selling his or her medications, he said.
Galbis-Reig said he sees progress. "I see a change in the practices of prescribers, not so much in the mind-set of patients," he said. "We still have to encourage a cultural change in the system."
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