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October 24, 2014

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SUNDAY CONVERSATION:

Trying to script a solution

Pervasive use of narcotic painkillers has expert panel debating how and why

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Steve Marcus

From left: Dr. Mel Pohl, the addiction specialist, notes that opiates treat not only pain but anxiety, providing an inducement for patients to continue using them. Leo Basch, a pharmacist and member of the Nevada Pharmacy Board, says culture changed in America in the 1990s when drug companies began advertising. Matt Alberto, the deputy chief of investigations at the Nevada Public Safety Department, says narcotics are being used in epidemic proportions. Dr. Michael McKenna, the Las Vegas pain specialist, says “the economics of medicine” sometimes factors into decisions doctors make about painkillers.

Prescriptions, Pain, and Profits

Highlights from the round table- Four experts in the fields of health and public safety discuss the rise of prescription painkiller use and abuse. The participants include: Matt Alberto, deputy chief of investigations for the Nevada Public Safety Department; Leo Basch, a pharmacist and member of the Nevada Pharmacy Board; Dr. Michael McKenna, a Harvard- and Stanford-trained pain specialist; and Dr. Mel Pohl, an addiction specialist. (Length: 5:35)

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The Nevada Public Safety Department confiscated these prescription narcotics during a criminal investigation this year. A recent Las Vegas Sun analysis found that more people died in Clark County in 2007 from prescription narcotic overdoses than from street drugs or gunshots.

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USE OF FOUR PRESCRIPTION DRUGS INCREASING

Since 1997, Nevada’s per capita use of four prescription narcotics has surged. Below is how that use has grown and how we compare nationally:

273% -- GROWTH IN HYDROCODONE USE

243 milligrams were distributed per capita in 2006, putting the state in first in rate of use nationwide.

306% -- GROWTH IN MORPHINE USE

110 milligrams were distributed per capita in 2006, putting the state in fourth in rate of use nationwide.

724% -- GROWTH IN OXYCODONE USE

206 milligrams were distributed per capita in 2006, putting the state in fourth in rate of use nationwide.

1,247% -- GROWTH IN METHADONE USE

47 milligrams were distributed per capita in 2006, putting the state in fourth in rate of use nationwide.

Experts blame Nevada’s skyrocketing rate of prescription narcotic use on hurried doctors who don’t adequately examine the patient’s history and source of pain, leading to inadequate treatment and the risk of addiction.

Some doctors are quick to prescribe the drugs to increase their patient volume at a time when they are being squeezed by low insurance reimbursements, the experts speculated.

Narcotic painkillers are often effective but not a cure-all, they said last week in a Sun roundtable conversation.

The four experts were assembled in the wake of the Sun’s report on the prescription narcotic crisis in Nevada. We’re the No. 1 users per capita of the prescription narcotic hydrocodone — also known as Vicodin or Lortab — compared with residents of other states, the Sun analysis found.

And we rate No. 4 nationally in per-capita use of three other prescription painkillers — methadone, morphine and oxycodone, best known by the brand name OxyContin.

The rate of narcotic painkiller use is rising every year, leading to increased crime and drug abuse.

Reflecting that trend, more people died in Clark County in 2007 from prescription narcotic overdoses than from street drugs or gunshots, our analysis found.

Some of the biggest dangers lie in our medicine cabinets. Adolescents who don’t understand the dangers of the drugs sneak pills and pass them to friends.

The Sun invited the four experts, each of whom has a different point of view, to discuss prescription narcotics. We asked a few questions, but mostly just listened as they talked among themselves.

The participants:

• Matt Alberto, deputy chief of investigations for the Nevada Public Safety Department, the primary police agency for prescription drugs.

• Leo Basch, a pharmacist and member of the Nevada Pharmacy Board, the regulatory agency for those licensed to prescribe and distribute the drugs.

• Dr. Michael McKenna, a Harvard- and Stanford-trained pain specialist in Las Vegas.

• Dr. Mel Pohl, an addiction specialist.

What follows is an edited summary of the conversation. We started with the biggest question we had:

How do you explain the skyrocketing prescription narcotic use in Nevada?

Dr. Michael McKenna, the pain specialist: The growing movement probably started in the 1980s and 1990s to address underserved, untreated pain in the United States. With that there has been a greater emphasis on education, so patients are demanding and expecting improved treatment.

Pain is very complicated. It’s a symptom of multiple diseases and there are multiple ways to address it. Unfortunately, the easiest way to address it is just to give pain pills. And there’s an economic incentive to do that. To adequately work up a patient — to order an MRI, to do the injections that would pinpoint the pain, to categorize the pain, to start the patient on a very regimented program of both long-acting and/or short-acting opiates and narcotics — these are all very expensive.

We live in a society where publicly traded insurance companies fund medicine. The insurance companies want to be profitable. I’ll tell you it’s a lot easier to write a prescription for 120 pills of Lortab once a month than it is to order an MRI, send a patient to a specialist and get him an interventional procedure that would eliminate certain diagnoses.

Dr. Mel Pohl, the addiction specialist: Just to dovetail on Dr. McKenna’s comments, we used to use opiates strictly for cancer pain. The philosophy was that people were dying so it doesn’t really matter if we gave them medications that might potentially cause problems.

But really, medicine in general has responded probably in the past 10 or 15 years by saying, “Well, you really can’t withhold medications that improve the quality of people’s lives.” So opiates are more available, painkillers are more available for a lot of different sources of pain. I think that’s a good move.

The downside of this is that the more opiates are available the more potential problems we can see — the side effects of these opiates. These opiates are not a panacea for pain. As Dr. McKenna also said, pain is a symptom of a complex number of different diseases. And to think that we can simply take pain away, eliminate it, is unrealistic.

Leo Basch, the pharmacist: I believe there’s a change of culture in the United States where people are more accepting of prescription drugs. In the 1990s, we had direct-to-consumer advertising (by pharmaceutical companies), which tells the American public that it’s OK to take pills, it’s OK to take medicine and it’s OK to specify to your doctor what medicines you want. So that defines the culture that we find ourselves in today.

Matt Alberto, the law enforcement investigator: Pain relievers provide more than pain relief. They may get anxiety relief or other symptoms relieved. Yeah, they feel good. And we live in a state that is kind of built on feeling good, free alcohol and gambling and that kind of stuff. And so maybe we have a population with a larger addiction component or that “make me feel good” component.

In man’s history, if there’s a way to please himself he is going to find it and experiment with it. Prescription pills — pain pills — are another way to do that.

Basch: And we probably do see a fair proportion of tourists coming in, transient in the state, and they’ll see a doctor and get a script from there and that adds to it.

Pohl: People want to feel better and they’re of the mind-set that if I could take a pill, that’s going to make me feel better.

Opioids make the pain go away on a physical basis, but they also affect emotional pain. So if someone’s angry, or frustrated, or fearful or anxious and they take an opiate, they feel better. And that’s a pretty strong inducement to repeat that ingestion, and it’s a setup for abuse.

As a culture, I’m not sure how to wedge in there with my colleagues and our culture. “Just say no” didn’t work in the Reagan administration, but on some level it requires thinking differently as a physician. I’m a family physician by trade and I used to have my hand on my prescription pad like a trigger. I was just ready to pull it out in practice: What am I going to prescribe for this condition?

I think that’s a mind-set, and prescription narcotics are only one of many tools in a toolbox. I would hope that perhaps there is some sort of paradigm shift in the profession and the culture so people don’t just think they don’t have to fix the way they feel. They have to deal with the way they feel.

McKenna: One of the comments I read in one of the Sun’s articles was that it is a lot easier to write a prescription than it was to work up the pain. You know, in my field there’s a certain standard of care where you need to do an evaluation, a thorough evaluation. And part of that evaluation is a psychological evaluation to see if that patient is at risk. Each patient is individualistic regarding their physiology and their ability to metabolize medicines. You need to characterize pain and then address it in a multi-modality fashion that may include anti-depressants, anti-seizure medicines. There’s multiple ways to treat it depending on the type of pain.

In addition, I think it’s very important to have a diagnosis. I mean, “low back pain,” is not a diagnosis. If you can make a diagnosis, then you can treat that diagnosis and at least have a chance to decrease the amount of medications that are required and actually come up with adequate treatment. There’s criteria that are set up.

Do you think most medical providers take the time to do an adequate work-up of patients?

Basch: I see the patient after they have been to the physician, and I respect physicians for what they do, but a lot of the patients are saying they’re rushed right through, that they don’t get their questions answered and they realize that a lot of that has to do with their insurance companies pushing the doctors to have a shorter visit time. And that’s probably compounding the problem. It is probably simpler to write the prescription and not give the full work-up.

Alberto: It’s profitable. It’s easier for a doctor, not necessarily a pain specialist, to see 100 patients a day for 15 minutes and go, “What’s your problem?” The patient says, “Well, I was in a car accident 10 years ago and my lower back pain has never gone away.”

Soft tissue pain is really hard to diagnose. The doctor says, “OK, well what do you usually get?” And then the patient tells the doctor, “Well I usually get oxycodone, Lortab,” and so on. The doctor writes three prescriptions because of the theory that the patient would know what’s best for them, and they walk out the door in 15 minutes.

You know there are a lot of practices where patients don’t have insurance and pay cash. You come in, no appointment necessary, you meet the doctor and walk out the door with three prescriptions. And that doctor has cleared $100 for 15 minutes worth of work.

The doctor gets caught up in doing that rather than sending them to a specialist who will go through all the proper steps, realizing that while these medicines have a benefit to society and the treatment of patients, they have a really high potential for abuse.

Most doctors care about treating their patients, but they end up creating addicts and then these addicts have to feed that habit and they’re going to do other things to do it. So we perpetuate the entire problem.

Pohl: Addiction is really only one of the problems with opiates and it’s a serious problem — maybe it’s 10 percent of the population, maybe it’s 20 percent of the population, the studies vary. We need to be mindful of the fact that some people are at risk.

Another problem is that a lot of people taking their opiates are in substantial pain. I’m not sure that these people are necessarily addicted. They continue to take the drugs, despite consequences, because they don’t know anything else to do.

And, in fact, there are some studies that say opiates cause more pain — “hyperalgesia” — which means more pain from the opiates.

So what I really caution colleagues who are prescribing opiates is, they’re wonderful medications, they treat pain very effectively, probably in the majority of people for whom they are prescribed, but there’s a substantial percentage of people who take an opiate and it does not help.

In those people, there should be an exit strategy from the beginning. The patient would be better off the opiates and using alternative interventions for their pain.

McKenna: I agree completely with that. But it’s really complicated.

The key again is adequate evaluation of the patient. If the opiates are not working, then you need to address the problem in a different way. There’s new evidence that taking patients off medications for their pain and then starting on spinal medications can be very effective. However, it’s very expensive. Again it comes down to the economics of medicine. It’s a lot cheaper to just throw drugs at the problem without adequately evaluating and addressing the problem.

What bothers you most about the skyrocketing rate of narcotic painkiller use in Nevada? Is this is a crisis?

Alberto: Yeah, we’re in a crisis. Prescription narcotics are at epidemic proportions at this particular time. It’s expanded the black market drug trade where a lot of traditional drug dealers who might have only sold marijuana or cocaine or a couple of drugs, they’ve expanded the market into prescription pills because they’re so profitable out on the street and there’s such a high demand for them.

Pohl: I would point out in terms of the epidemic that this is the No. 2 drug of abuse among 12- to 25-year-olds — particularly 18- to 25-year-olds — second to marijuana. This is the drug people are looking for. This is the drug that people are taking. This is the drug people are abusing and some of them are getting addicted. And the source is not dealers on the street; it’s parents’ medicine cabinet. Over 60 percent of these kids, the data suggest, are getting their medications at home. And I think that this is a true epidemic.

In the treatment center where I work, a substantial portion of our people are younger than 25 and opiates are their drug of choice.

Alberto: Unfortunately, we’ve seen kids as young as 9 years old that have admitted to taking prescription pills and they get it exactly like Dr. Pohl said, from Mom or Dad’s medicine cabinet or purse or dresser or wherever they keep them. And even one time that pill could have a disastrous effect on you. That’s why parents need to secure their pills from their kids just like they would secure a gun.

Pohl: And then they go to a party and do what’s known as “pharming.” They go out and pour Mom’s pills and Dad’s pills into a bowl, grab a few, and as all of us can confirm, those are potentially lethal combinations of pills.

McKenna: My biggest fear, and I’ve got three teenage kids, is that medications that I write will end up at a high school party and some kid will take it and have an untoward consequence. And that scares the heck out of me.

The thing that really bothers me when patients are using me to obtain medicines and diverting them into the population. Those are the situations that you do a drug screen and they don’t have drugs in their systems. By definition they are not taking it so it’s going somewhere else. I mean oxycodone is a good example: 80 milligrams three times a day, for a month’s worth has a street value of probably $12,000 to $15,000. You can make a pretty good living by obtaining these medications by fooling your physician.

I think that does represent a crisis. I think that this is a very important issue to be discussed so that we realize that there needs to be some very significant precautions taken when prescribing these.

Basch: I agree with Dr. McKenna that there is a crisis. There needs to be public awareness. I think it’s a public health issue, particularly when the medicines are hitting the street and people are taking them without a doctor’s order. And I’ve had people tell me over the years that they can get the medications on the street, probably easier than they can from the physician.

How should lawmakers and members of the public address this crisis?

Basch: I would go out on a limb and say that people getting large amounts of these narcotics should see a specialist. As Matt pointed out, many people will walk away from a 10- or 15-minute doctor visit with three prescriptions and I would put that up to four, the three he mentioned, the oxycodone, the hydrocodone, the Lortab and Xanax. That’s sort of the cocktail that people will come to the pharmacy with — and they’re getting that from a primary care physician.

And if they’re needing that medication on a monthly basis, then they have some pain issues, they probably ought to see a specialist that can monitor them.

Alberto: That would be a good start. I think also there should be some regulations required even at the pharmacy level. A lot of pharmacies originally made it their own practice that you had to present picture identification to pick up a Schedule 2 controlled substance painkiller like oxycodone, and it was recorded by the pharmacy. That was pretty much across the board. Maybe those requirements should also be made for Schedule 3 drugs like hydrocodone. You have to present picture ID and it has to be recorded by the pharmacist to maintain that prescription.

McKenna: Regarding the Pharmacy Board’s prescription drug database, this is something that’s one of the pitfalls right now. Congress passed a law that is supposed to make this a national program. Right now a patient can go from Nevada over to Arizona and I don’t have any way really to find out what’s going on in Arizona.

But if we have a national database, that’s going to be good for my practice because there are patients — because there’s enough money involved — who really want to go to multiple doctors for drugs to make money. They go to Utah, Arizona, California, Nevada and each doctor in each state has a difficult time following that patient.

The other thing that would be important, and I don’t know if this is legally possible: If a patient is identified as someone with a history of criminal activity with medicines, somehow make that information available to the physician. A patient can get discharged from one doctor because he’s been misusing medicines and go to another one and another one and another one. And you can go probably four or five years seeing different physicians.

Basch: On the pharmacy side, we see legitimate prescriptions and we see the illegitimate, the homemade prescriptions that I think all of us are aware of that come across the pharmacy counter. And it’s sometimes difficult to tell whether a prescription is real or a fraudulent prescription. However, recently the federal government required Medicaid prescriptions to be on a tamper-proof prescription pad and if we had that for controlled substances in Nevada that would pretty much eliminate the phony prescriptions that are passed at pharmacies. So if we were to require — by regulation or statute — that prescriptions for controlled substances be written on a tamper-proof prescription pad, that would almost eliminate the street drugs that are obtained by phony prescriptions.

McKenna: All of these suggestions are great, but they all cost money. Our health care system is profit-driven system where insurance companies are publicly held. And with that we have choices that may be cost effective but not provide the best of care.

To send every patient in pain to a primary care physician and then a board-certified pain specialist and then to get the adequate tests involved in it, increases the cost of medicine. There’s a counter incentive and we can come up with all the greatest ideas in the world, but that’s one of the limitations I’ve found.

What are the things that could bring about a paradigm shift in Nevada?

Pohl: I wish I knew. I talk to colleagues about this all the time. The vast majority of physicians in this country really want to help people. I think they’re at a loss. They just don’t know what to do. I mean it’s tough to counsel people, it takes more time, it takes more energy and it’s not really the indigenous part of our training, so I think it goes back to medical school training and it goes toward attitudes and additional education and then some sort of bomb goes off in the culture. I mean we see a guy on prescription medicine mow two people down in the bus stop. Maybe these things will grab people’s attention, I don’t know.

McKenna: I think education is important. I think the Sun’s whole series is going to educate the public. There probably will be a lot of physicians reading it and there’ll probably be a lot of lay people reading it.

I just want to emphasize that pain is real. People are suffering. So I think the stuff we talked about is important, public awareness is important, but there are legitimate uses for these medications and they can be used safely just going through the adequate evaluation and follow-up steps. The one thing I would hate to see this forum do is do nothing but provide negative comments on what’s appropriate for medical reasons because they can be very effective.

Pohl: And as an addiction specialist I would concur. I think opiates work exceedingly well for the proportion of people who take them as prescribed and don’t abuse them and lock them in their medicine cabinets. There’s another part of the culture that we’ve been talking about that have trouble with either abusing them or overusing them or diverting them or becoming addicted to them and those people need some sort of intervention. Certainly someone with an addiction needs treatment for their addiction, they need to be off the medications because the treatment for addiction is not taking medication. And even though they have pain, they need to find alternative ways to deal with that pain. But I would certainly concur that opiates are not the devil.

Sun reporter Mary Manning transcribed this text. (See past Sunday Conversations)

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