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State Efforts Lag In Reversing Overprescribing Of Opioids
By Todd Feathers,UPDATED: 07/05/2015 08:20:51 AM EDT
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His hands moving methodically in blue latex gloves, Sgt. James Latham unscrewed the caps off dozens of orange pill bottles and dumped their contents into gallon plastic bags.

He piled the overflowing bags in cardboard boxes, which were in turn stacked next to a staircase in the Health Department. Three hours into Lowell's June drug-disposal day, Latham and a fellow officer from the Lowell Police Department's evidence unit had three large boxes stuffed with a kaleidoscope of little white tablets, red gel capsules, and purple triangles.

Conspicuously underrepresented were the OxyContins, Vicodins, Percocets, and other prescription painkillers linked to a dramatic nationwide spike in heroin use and a devastating opiate addiction epidemic that killed more than 1,000 people in Massachusetts last year.

"People who are addicted buy their stuff on the street, and it's out there (that)" you'll find the opioid pills, Latham said.

On the street, in the bathroom, in a cabinet, beside a bed.

The pills are so widely prescribed and often carelessly stored that, while heroin dominates the public's attention, more Americans are addicted to prescription painkillers than the cheaper, powder alternative.

The epidemic within an epidemic is driven by a variety of pressures on doctors to prescribe the pills, the lack of addiction-medicine training available, and in Massachusetts, by the general impotence of a state system set up specifically to prevent the problem.

Through interviews and reviews of state records, the Sentinel & Enterprise found:

* Statewide, the 168 million pills dispensed averaged out to 25 pills per resident.

* Medicare reimbursements for hospitals are dictated in part by how well patients feel their pain was eliminated, which creates an incentive for doctors to overprescribe potent painkillers despite the risk of addiction.

* Only two-thirds of Massachusetts prescribers are signed up to use the Prescription Monitoring Program, which monitors improper prescribing habits and drug-seeking behavior, and the state has no way to track whether prescribers actually use it.

* The PMP updates its database on a weekly basis and does not share data across state lines, giving addicts a wide window to solicit drugs from multiple prescribers without being caught.

Spreading use of opioids

The first opioid painkillers were originally developed to ease end-of-life suffering. But over the past several decades, the pills have increasingly been prescribed to help patients cope after minor surgeries, dental work or with muscle pain.

Nationwide, the number of opioid painkillers dispensed rose from 76 million in 1991 to nearly 207 million in 2013, according to the National Institute on Drug Abuse.

And some unknown percentage of those opioids -- stolen from a medicine cabinet, incorrectly prescribed or too addictive to stop taking -- became fuel for the epidemic. In the pockets of teenagers and construction workers alike, they trickled into alleyways, parking lots, high-school locker rooms, and other black-market bazaars, where the pills sell for $1 per milligram.

One out of every 15 people who take opioids for non-medical purposes will try heroin within 10 years, according to NIDA. And between 1999 and 2013, the number of Americans who have fatally overdosed on opiates of any kind has quadrupled.

"All of these drugs are very similar: they are highly addictive, and they are deadly if you take too much of them," said Dr. Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing. And over the past decade "as prescriptions began to soar, it led to a large increase in addiction and overdose deaths."

Genesis of problem: pain

Beginning in the 1980s, a series of studies and papers from physicians and medical associations, many of which received funding from pharmaceutical companies, urged doctors to do everything in their power to minimize pain in patients, including prescribing a class of painkillers -- opioids -- that were originally developed to ease end-of-life suffering.

By 2000, the Veteran's Health Administration had launched the "Pain as the 5th Vital Sign" initiative, and along with temperature, pulse, breathing rate, and blood pressure, doctors began routinely measuring pain on a scale of zero to 10.

The familiar chart, with a smiling face at zero that grows progressively sadder as it approaches 10, took up residence in doctors' offices across the country.

"Providers were worried about, 'Well wait a minute, maybe I'm not addressing this properly,' and that led to an increase in prescribing," said Dr. Kevin Hill, director of the Substance Abuse Consultation Service at McLean Hospital in Belmont.

In subsequent years, new research has blown apart the earlier studies that concluded opioid pills were not very addictive and debunked the efficacy of the Pain as the 5th Vital Sign movement. Doctors who were once leading proponents of opioids have recanted their statements and apologized.

But decades' of pain-treatment practices have proven slow to reform, and become institutionalized in the health-care industry in ways that make it difficult for doctors to adjust their methods.

Hospitals, for instance, can lose 1.5 percent of their Medicare reimbursements for a given year if they receive poor scores on a nationwide patient-satisfaction survey on which three out of the 27 questions are related to how well a patient feels their pain was managed. By 2017, up to 2 percent of reimbursements could be withheld due to poor survey scores.

In its much-anticipated report released in June, Gov. Charlie Baker's Opiate Task Force recommended that one question in particular on that survey, known as HCAHPs, be removed: "During your hospital stay, how often did the hospital staff do everything they could to help you with your pain?"

Medical professionals and treatment workers, inundated with new addicts who became hooked on pills after minor afflictions, said that pain is, in many cases, a good thing to feel because it is the body's way of sounding the alarm that something is wrong.

Treating short-term pain, they said, does nothing to cure the cause and serves only to obscure the body's self-assessment.

"God forbid we really work with (patients) and help them -- we medicate them," said Chris Connolly, Lowell's former public health nurse manager. "We don't look at them as human beings, we look at them like a business and we better get a good review."

The advent of online rating sites for physicians, like Healthgrades and ZocDoc, which are similar to Yelp for businesses, has added a new fear for physicians: that if they don't take the pain away, unhappy patients will criticize their performance online and scare away other customers.

"If you're a solo practitioner and you want to grow your practice, you need to keep people happy," Hill said. "Somebody comes in, they feel like they have back pain and it's hard to diagnose ... If you don't prescribe to them you run the risk of having a bad review on these sites."

Underlying those pressures on physicians is a general failing in American medicine to educate medical students and doctors about proper prescribing policies and addiction, said Dr. Kevin Kunz, executive vice president of the American Board of Addiction Medicine.

Unlike medical fields such as anesthesiology or allergy and immunology, addiction medicine does not have a specialty board approved by the American Medical Association's Council on Medical Education, a vital step in developing continuing education programs and certifications for doctors, although Kunz said he hoped that would be rectified within the next two years.

Without those programs, many doctors are unprepared to deal with patients aggressively demanding drugs, or to advise well-meaning patients on when and how to stop taking them.

"We can do heart transplants, for God's sake ... but we can't get a doctor to prescribe the right drug and know when to take you off it?" Kunz said. "They have to know, when they have in their hand a prescription pad, exactly what it means to write for a controlled substance."

A broken tracking tool

Because pain can be so hard to diagnose and opiate addicts hard to differentiate from patients with chronic pain, 49 states have developed tools called Prescription Monitoring Programs, which track the number of prescriptions an individual has received for a controlled substance, and who gave it to them.

PMPs allow state review boards to monitor for irresponsible prescribing habits and serve as tools for doctors to make better prescribing decisions and identify addicts who are faking ailments for drugs.

In 1992, Massachusetts became one of the first states to institute a PMP. But in recent years, while the state's opiate epidemic exploded, the program lagged.

The program does not share data across state lines, and unlike many other states It takes at least seven days after a prescription is dispensed for the information to be recorded in the PMP system where doctors can see it. This delay gives potential addicts and drug dealers a window to collect pills from multiple prescribers without detection.

"The problem with these programs is that they're late," said Dr. Peter Connolly, a medical adviser to Lowell's Health Department. "It comes back to me weeks later and says you gave Percocet to this guy, but he already had it from three other people."

Until 2011, prescribers could not search the Massachusetts PMP online. They were not legally required to enroll in or use the program until 2013. Now, whenever a person renews his or her license to prescribe controlled substances like opioids, they are automatically enrolled in the PMP and legally mandated to check it before prescribing opioids to a patient for the first time.

But as of February, only two-thirds of all doctors, dentists and other prescribers in the state had signed up to use the program. The drugs dispensed by the remaining third are never recorded in the PMP, undermining its effectiveness.

And once they are enrolled, few prescribers actually use the program to research their patients before giving them drugs. During a four-month voluntary survey last year, only 7 percent of prescribers reported checking the PMP before writing a prescription, according to a report from the state Department of Public Health.

The DPH report acknowledged that many prescribers have no need for the PMP, because they do not regularly use opioids in their practice.

But besides periodic, voluntary surveys, the state has no way to monitor whether prescribers are using the PMP as they are legally mandated to do, said Deborah Allwes, who oversees the program.

"The more prescribers use it, the more effective it has the potential to be," said Peter Kreiner, principal investigator with the Brandeis University PDMP Center of Excellence. But "nobody is checking the PDMP to see who is checking under various conditions."

The PMP, which operates on less than $1.5 million per year, is progressively improving, Allwes said. The governor's opiate report called for the system to update every 24 hours, like many other states do, and share data across state lines.

So far, Maine is the only state with which Massachusetts has a formal agreement to share PMP data, Allwes said. But the two systems are not compatible, so officials here must wait for Maine to update its system. Kentucky, a consistent leader in PMP innovations, will likely follow Maine, but partnerships with other New England states remain out of reach. Vermont's Legislature specifically prohibited its PMP from sharing data.

Some, like Frank Singleton, Lowell's former health director, said that just fixing the program's technical issues is not enough.

Even when the system is able to identify problematic trends, enforcement is left up to a panel of doctors and dentists, whom the state will not identify. The panel reviews cases and chooses whether or not to refer them to the relevant medical licensing board, which reviews the cases again before deciding whether to discipline the prescriber or notify law enforcement.

The lack of transparency and reluctance of medical professionals to punish their own renders the PMP toothless, Singleton said.

Of the 38 prescribers the state identified last year as displaying questionable prescribing habits (the definition of which the state does not make public), none were disciplined, according to the DPH report.

"Asking physicians to guard the PMP is asking the fox to guard the hen house," Singleton said.

A cautionary trend

The difficulty for doctors, and those monitoring them, is that prescribing is seldom black and white.

There are many patients whose quality of life is drastically improved by the drugs. Then there are others, like Nikky Gray of Lowell, who never wanted the drugs in the first place.

Gray said her doctor wrote her an opioid prescription for a chronic spine problem "just in case" she needed the extra relief, despite the fact that she told him she would never use the pills and hated how they made her feel. The doctor did, however, warn her about how addictive the pills could be, she said.

On drug-disposal day, Gray, trailed by her grandson, brought in the unused bottle of painkillers and handed them to Latham. She feared someone might dig through her trash and find them if she threw them out, or worse, that her grandchildren or their friends might come across them and decide to experiment.

"If I can drop it off and get rid of it, it's such a relief," she said. "I never want to risk getting addicted to anything ... I've got great grandkids and I'd have nightmares if I lost my grandchildren like that. I couldn't bear it."

Almost all the medical professionals interviewed for this article had a similar story of their own: receiving a prescription for just in case, or a bottle of 30 pills when five would do.

"There's pressure to give you the cheapest drug," Connolly said. "There has been no pressure to make sure we use the safest drug or the drug least likely to cause addiction."

But "the tide is turning a little bit," he added. "Maybe you should not give somebody 50 Percocet because they came into your office and banged their thumb."


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