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The passage of a new law, regarded as one of the toughest in the nation, makes Washington the first state to require dosing limits for doctors and others who prescribe these medicines. The law, RCW 2876, went into effect January 2, but those who have watched the epidemic spiral out of control still see significant challenges ahead.
Among the first is the dearth of pain specialists in the state. Under the new law, doctors and other prescribers with patients who need more than 120 mg a day must seek a second opinion from a pain specialist. But there are few of those professionals to go around.
Medicaid is already struggling to comply with the new law. Despite having thousands of patients currently over the threshold limit, the agency can only get one or two evaluated by a pain specialist a month, said Dr. Jeff Thompson, medical director of the state’s Medicaid program.
“Access is an issue,” said Dr. Gary Franklin, medical director of the state’s Department of Labor & Industries, adding that telemedicine consultation programs and other efforts to increase capacity are helping, but still don’t fill the need.
The new law makes Dr. Merle Janes of Valley Rehab & Emergency in Spokane angry. He said legitimate pain patients and doctors who prescribe for them are paying the price for the policy changes designed to nab addicts. People in real pain can’t get adequate relief, he says.
“It’s been a disaster for all these people,” Janes said.
Dr. David Tauben, a clinical associate professor and director of medical education in pain management at the University of Washington, agreed that not enough doctors are treating pain well.
“But this problem was happening well before the new law,” Tauben said. He’s optimistic that the new law will actually encourage more doctors to take on pain patients because they will have guidelines to follow to help keep them from running afoul of disciplinary agencies. The guidelines should remove ambiguity and help doctors communicate better with patients about the goals and limitations of pain treatment, he said.
Another obstacle to the success of the state’s new pain policy is the continuing lax oversight of prescribing habits.
“What we’re doing now is not working,” said Dr. Rosemary Orr, anesthesiologist at Children’s Hospital and Medical Center in Seattle. Orr lost her own son to an OxyContin overdose. She said she’s still amazed at the amount of pain medication she sees prescribed in her own profession.
A key limitation of the new law: While it gives state regulators a reason to discipline doctors, the statute does not require the state to check whether doctors or other medical professionals are breaking it.
That’s in contrast to the U.S. Drug Enforcement Administration, which monitors whether medical professionals with narcotic permits are following its rules. The new state program also falls short of Washington’s Medicaid program, which routinely tracks how much narcotic medication doctors hand out. Instead, the system set up by the new law relies on complaints from patients or medical professionals to trigger investigations.
As a result, the Medical Quality Assurance Commission, which investigates doctors and other healthcare professionals, can’t say how much of a problem excessive prescribing is for Washington doctors, dentists, advanced nurse practitioners, physicians assistants and other providers licensed to prescribe these powerful medications.
An InvestigateWest review of recent cases against medical professionals found only a handful over a three-month period. The majority of those disciplinary actions involve medical workers who are addicted themselves. A few, however, had been disciplined for excessive prescribing.
In July, for example, the Department of Health issued a statement of charges against an Everett osteopath for prescribing excessive amounts of pain medication to a dozen patients. Documents describe a pattern of prescribing to patients known to be at high risk for drug abuse. The doctor allowed his license to expire in September.
The state’s actions came after the doctor’s offices had been raided the previous year by DEA agents, an action that resulted in charges related to financial transactions the DEA indicated could be used to hide drug trafficking activity.
Doctors and others disciplined for drug-related issues are usually given chances to go into rehab, get additional training, or pay fines. In 2009, however, Spokane-area doctor Keith L. Hindman, went to prison for health care fraud and prescribing controlled substances for non-medical purposes.
The DEA, in contrast to the state, does carry out surprise inspections. The agency has shut down the top five prescribers in the state over the last several years, including a clinic in Vancouver, Washington that operated as a so-called “pill mill.” When the clinic shut down, many of its addicted patients flooded local ERs.
In August, the federal agency broke up an eight-member prescription drug ring operating between Washington and Alaska. Members were charged with conspiring to possess with intent to distribute the drugs, as well as money laundering.
For his part, Thompson of Medicaid sent a letter last summer to the top 20 doctors prescribing opiates to Medicaid patients, alerting them that they’d been flagged for the volume of their prescribing.
“That doesn’t mean they are good or bad doctors,” he said. “There is no definition. However, it does say, it’s worth looking at why they are so high.”
Prescription Monitoring Programs
One reason there has been little oversight of prescribing habits in Washington is that until this year there hasn’t been a systematic way to track the information.
Washington has been slow to adopt a statewide prescription monitoring program that would enter all patient prescriptions in one shared database. The legislature created such a program in 2007, but pulled its funding the next year. It never got up and running.
Currently, 35 other states have such programs in place, and the information has led to a reduction in prescription fraud as well as provided a way to identify doctors who have excessive prescribing habits.
The lack of such a program here frustrated Chris Johnson, policy director for the Washington Attorney General’s office. “We know from the war on meth that tracking sale of precursor drugs had helped curb the problem,” he said. “We figured the same approach could help stem the wave of prescription drug abuse.”
Johnson was part of a group that has now helped secure temporary funding to mount a prescription-monitoring program in Washington. But the program will be exhausted by June, he said.
And even this program has limitations. Prescribers are not required to consult the new database before writing a prescription. Participation is voluntary.
In Kentucky, where it is also voluntary, only about 20 percent of doctors used it, said Franklin.
Iowa is contemplating moving to a mandatory system because only 10 to 12 percent of its providers currently participate in the state’s prescription-monitoring program. New York is also considering legislation to require practitioners to use its reporting system.
It’s also unclear how Washington State will use the information it collects.
The administrators of the program will be reviewing the data to identify potential inappropriate prescribing patterns, said Program Director Chris Baumgartner. The system has the capability to pinpoint doctors and others who prescribe large amounts of opiates, but hasn’t decided yet whether it will automatically produce and distribute reports on those individuals to various licensing agencies for investigation.
Other states have found that such proactive reporting results in reducing prescription drug abuse.
In the meantime, law enforcement, including the DEA, will have limited access to the information. Agencies are allowed to query the data base only if they have an active investigation underway. Similarly, Medicaid can see records about its patients, but not about its prescribers.
The state’s Medical Quality Assurance Commission has the authority to survey the database for prescription abuse, but said it does not plan to do so.
Joshua Dameron, a Spokane laborer, got addicted to Dilaudid after a herniated disc.
Photo credit: Jesse Tinsley/The Spokesman-Review
The Emergency Connection
Another gaping hole in the state’s information system is the inability to track patients from emergency room to emergency room. Many addicted patients feed their habits by cruising ERs and “doctor-shopping.” They fake or exaggerate injuries and illnesses to get doctors to prescribe pain meds.
Joshua Dameron, a Spokane laborer, got addicted to Dilaudid and other types of pain pills after he suffered a herniated disk while working in a dynamite factory.
“I was addicted to pills, like, bad,” said Dameron. He would cruise ERs, telling doctors his back hurt. Eventually he was downing 20 Percosets a day. He says he once got so desperate, he broke his own little finger to get more drugs.
He eventually wound up in drug court for altering prescriptions. He’s been living in a half-way house and is hoping he’s kicked the pills for good.
“I never want to go through that again,” he said.
Most emergency rooms are not equipped to assess whether someone has already been seen across town in another ER, said Dr. Darin Neven, medical director for the Consistent Care Program at Sacred Heart Medical Center and Children’s Hospital in Spokane. Like Dameron, many addicted patients feed their habits by going to multiple ERs.
The trend is so bad that some ERs, including those throughout the Swedish Medical Center system in Seattle, no longer hand out prescriptions for oxycodone, one of the most commonly abused pain pills. It has also prompted the emergency rooms in Spokane to band together and mount a program that uses a shared database to track people who obtain pain meds in the ER.
The emergency room data sharing program, which started as a pilot in 2006, has now spread to four emergency rooms in Spokane and 19 others across the state. Neven, along with Lee Taylor of the Spokane County Medical Society, has applied for a grant to expand the program to all the ERs in the state.
To date, the program has flagged 633 "frequent users" of the ERs and helped enroll them in programs to better manage their pain and addictions, said Neven.
The doctors’ concern is for their patients. Doctors don’t want the people they serve turning up dead. And yet it happens too often.
“We’re walking a fine line here,” he said. “We don’t want to become policemen, and yet these are deadly drugs.”
The Spokane emergency-department data-sharing network, among the first of its kind in the country, is being watched as a model by other urban hospital centers.
Too Many Drugs, Too Little Treatment
Even as the system for collecting data improves, two other significant obstacles to reducing prescription drug addiction remain.
The first is the sheer volume of pills in people’s medicine cabinets, which have de facto become the nation’s illicit pain-pill dispensary.
Teenagers and even younger children pilfer their parents’ medicine cabinets for drugs, which get passed around or sold on school campuses and the street, said Mark Thomas, acting special agent in charge of the DEA’s Northwest division. According to the latest national survey, more than 70 percent of people who abuse prescription drugs get the pills from friends or family, not a doctor or other prescriber.
To curb this problem, the DEA has begun a campaign of Take Back days during which people can drop off their unused medications at local police stations and other secure locations. In October, 2011, the Northwest region of the DEA collected 11 tons of pills, nearly half of them from Washington. These programs also help keep drugs out of landfills and other places where they can pollute streams, rivers and other waterways.
Public health experts say an even better approach would be to establish an ongoing and routine way for people to safely dispose of their surplus pills.
King County has been trying for years to get a take-back program in place that would allow people to drop their unused pills off at convenient, safe locations to get them out of the house. Drug companies, however, have resisted these programs, and for the past three years have managed to derail legislation that would have created them.
Stepping back further, the underlying problem is that there are not enough treatment options for drug addiction.
“We know about 10 percent of people, including kids, who need treatment get it,” said Gina Grappone, director of Science and Management of Addictions (SAMA), a Seattle-based nonprofit that provides resources for families and treatment for young people.
Methadone maintenance programs, which are one of the oldest and most effective ways of treating addiction to narcotics, have long waiting lists, and are simply unavailable in many parts of the state, said Ron Jackson, executive director of Evergreen Treatment Services. The stigma of being dependent on methadone, in some cases for the rest of your life, also serves as a major deterrent to treatment, as does the logistical nightmare of having to travel to a methadone clinic on a daily basis in order to receive methadone.
There is a proposal to build a new methadone clinic in Bremerton to serve about 350 people, but even that won’t fill the demand, Jackson said.
One solution is to provide more office-based treatments, such as Suboxone. A growing number of doctors are licensed to prescribe Suboxone – another opioid medication used for addiction. But it’s expensive, and its long-term efficacy has yet to be proved, said addiction experts.
Meanwhile, the numbers of new addicts continue to grow as more young people get hooked.
In fact, researcher Caleb Banta-Green of the University of Washington’s Alcohol and Drug Abuse Institute predicts that the number of deaths from prescription drugs, which fell slightly in the past year, will see a surge in the years to come as this large group of younger addicts ages and becomes debilitated by the drugs.
Deaths from opiates tend to pick up in the mid-40s because the long-term abuse of these drugs is hard on the body, said Banta-Green:. “People are dying 30 years earlier than they should.”