Prescription drug abuse, deaths target of new Washington law
Dameron got hooked on prescription pain medication after suffering a herniated disk while working in a dynamite factory. He’s one of thousands of Washington citizens who have gotten addicted to narcotic pain medications over the last decade. One doctor called the pain meds, which go by names such as Vicodin, Percoset and OxyContin, just a “fancy form of heroin.”
“I was addicted to pills, like, bad,” said Dameron. When he exhausted his supply, he would hit the ERs, telling doctors his back hurt. Eventually he was downing 20 Percosets a day. Once, he says, he got so desperate he broke his own little finger to get more drugs.
Dameron eventually wound up in drug court for forging prescriptions. He’s been living in a halfway house and hopes he’s kicked the pills for good.
Spokane County has one of the highest rates of deaths from prescription drug overdoses in the state, at 12.8 per 100,000 people. Statewide, the death rate is 7.1 deaths per 100,000 people, and in King County it’s 6 per 100,000.
Prescription drug abuse is at epidemic levels throughout the state and elsewhere in the country, despite lawmakers’ attempts to get a grip on it. Deaths from prescription drug overdoses in Washington have skyrocketed nearly twentyfold since the mid-1990s and now outstrip those from traffic accidents.
Washington has been one of the hardest-hit states, in part because of aggressive prescribing practices coupled with lack of oversight by the Department of Health.
An InvestigateWest analysis of U.S. Drug Enforcement Administration data shows Washington ranked fourth-highest nationally in per-capita prescribing of methadone in 2006 (the most recent year for which reliable data is available) and 11th for oxycodone – the two biggest killers.
“The higher deaths, and probably abuse, too, I believe has to do with higher supply or availability,” said Jennifer Sabel, an epidemiologist with the state Department of Health.
Even more disturbing, more than half of all prescription-drug-related deaths occur in the state’s poorest and most vulnerable population – people on Medicaid. A 2009 federal study showed the age-adjusted risk of death from prescription opiates in Washington was nearly six times higher for Medicaid enrollees than for those not on the program.
“Medicaid has about a death a day from prescription narcotics, and in the last two years it’s continued to escalate,” said Dr. Jeff Thompson, medical director for Washington’s Medicaid program.
New law outlines dosing limits
The cause of the epidemic has many roots, including a major shift over the last decade in how the medical community treats chronic pain. In addition, aggressive marketing of opiates by drug companies, the inability to track overprescribers, patient demand for quick fixes, the lack of insurance coverage for alternative treatments, and cost-saving moves by the state all have helped fuel the rise in death rates.
With a law that took effect this month, Washington state is making a bold attempt to reduce overdose deaths, by launching the first dosing limits for doctors and others who prescribe these medicines. The law has been heralded as one of the toughest in the nation, but loopholes and pitfalls in the system remain.
One of the biggest is a gaping hole in the state’s information-tracking system.
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 Providence Sacred Heart Medical Center in Spokane. Like Dameron, many addicted patients feed their habits by going to ERs or “doctor-shopping.” They fake or exaggerate injuries and illnesses to get doctors to prescribe pain meds.
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 pilot program that uses a shared database to track people who obtain pain meds in the ER.
“We’re walking a fine line here,” said Neven. “We don’t want to become policemen, and yet these are deadly drugs.”
The Spokane ER data-sharing network started in 2006 and 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.
The data-sharing network in Spokane is being watched as a model by other urban hospital centers.
Limitations of the law
Still, other challenges remain for reducing prescription drug abuse.
Under the new law, doctors and other prescribers with patients who need more than 120 milligrams a day must seek a second opinion from a pain specialist. But there are few of those.
Medicaid is already struggling to comply. Despite having thousands of patients currently over the threshold limit, the agency can only get one or two evaluated by a pain specialist each month, said Thompson.
“Access is an issue,” acknowledged Dr. Gary Franklin, medical director for the state’s Department of Labor and 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.
Janes was part of a group that attempted to sue the state, saying the new rules were unfairly harming legitimate pain patients. The suit, which was dismissed, challenged the guidelines for being “arbitrary, vague and overbroad” and charged that recent investigations by the Medical Quality Assurance Commission – the state’s disciplinary agency – were motivated by “opiophobia.”
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 treat pain patients because they will have guidelines to follow.
Another obstacle to the success of the state’s new pain policy is the continuing lax oversight of prescribing habits.
While the law 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.
Unlike the federal Drug Enforcement Administration, which does monitor whether medical professionals with narcotic permits are following its rules, or the state’s Medicaid program, which tracks how much narcotic medication its doctors prescribe, state licensing agencies don’t check on practitioner compliance with laws and regulations. The system relies on complaints from patients or other professionals to trigger investigations.
As a result, the Medical Quality Assurance Commission can’t say how much of a problem excessive prescribing is for Washington doctors, dentists, advanced nurse practitioners, physician 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 themselves addicted. A few, however, had been disciplined for excessive prescribing.
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 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, and 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 and 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 funds 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, Franklin said.
It’s also unclear how Washington will use the information it collects.
The administrators of the program will be reviewing the data to identify potential inappropriate prescribing patterns, said Chris Baumgartner, the program’s director. The system has the capability to pinpoint doctors and others who prescribe large amounts of opiates, but it hasn’t been decided yet whether the program 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.
The Medical Quality Assurance Commission has the authority to survey the database for prescription abuse but said it does not plan to do so.
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 become the nation’s de-facto illicit painkiller 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.
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, a Seattle-based nonprofit that provides resources for families and treatment for young people.
Methadone maintenance programs, which use 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.
A growing number of doctors are licensed to prescribe Suboxone – another opioid medication used for addiction that’s provided through a doctor’s office. But it’s expensive and its long-term efficacy has yet to be proved.
Meanwhile, the number of new addicts continues to grow as people get hooked younger and younger.
“The largest group of people entering treatment for prescription abuse right now is made up of young people between the ages of 18 and 24,” said Caleb Banta-Green, a research scientist at the University of Washington’s Alcohol and Drug Abuse Institute.
Addiction experts predict 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.”