New effort by state could cause patients more pain

The state Hawaii Department of Health recently announced that it will begin to link deaths from prescription drugs to the physicians who prescribed them ("Doctors targeted amid rise in painkiller deaths," Star-Advertiser, May 5). This initiative is motivated by the growing number of deaths in Hawaii from overdoses of painkillers, mostly opiates.

Many of these deaths occur by accident when people mix opiates with other substances of potential abuse, especially alcohol. According to the U.S. Centers for Disease Control and Prevention, prescription opioids killed more Americans than illicit drugs such as cocaine and heroin in 2011.

Deaths from opiate overdoses are also part of a larger trend of increased rates of suicide associated both with stressors of the Great Recession and fallout from the 3 million American soldiers who have served and suffered in Iraq and Af­ghani­stan.

The pharmaceutical industry is mammoth and growing, now at approximately $350 billion in global annual sales. According to USA Today, nationwide, pharmacies dispensed a combined 69 tons of pure oxycodone and 42 tons of pure hydrocodone in 2010, enough to give "40, 5 mg Percocets and 24, 5 mg Vicodins to every person in the United States." According to the Wall Street Journal, prescription painkiller sales in the U.S. will continue to increase by 15 percent to $8.4 billion by 2017.

Not all opiates are dispensed to the right patients for the right reasons. A certain portion of those who visit a doctor with complaints of pain are simply prescription drug addicts with no valid medical problems beside addiction itself. Others seek to obtain prescription drugs to sell them on the street. While the overwhelming majority of physicians are highly conscientious when writing prescriptions for pain, there are a small number who lose their way, even succumb to addiction themselves and fail to adhere both to good medical practices and the law.

Several Hawaii physicians have lost the right to prescribe, while others have lost their license to practice medicine. A few are now serving time in jail. The intention of the current shared initiative on the part of the state Department of Health and the Department of Public Safety’s Narcotics Enforcement Division is to identify such physicians and take corrective action.

Legislation has just been passed, sponsored by Gov. Neil Abercrombie through his RICO team and state Sen. Josh Green, empowering the Hawaii Medical Board to suspend the licenses of outlier prescribers of narcotics in an expedited fashion, targeting the worst offenders, also known as pill mills.

The problem is that the majority of medical doctors are already extremely hesitant to prescribe pain medications for fear of legal repercussions. I had an opportunity this week to speak with Dr. Linda Rosen, chief of DOH’s Emergency Medical Services and Injury Prevention Branch, who is heading up this intervention. She is now working closely with the medical examiner to obtain a list of patients in Hawaii who died of opiate overdoses and, with the help of the state narcotics division, will link up these cases with the doctors who wrote the prescriptions. Dr. Rosen and I discussed our mutual concerns that this effort could have unintended consequences. With increased surveillance and scrutiny by law enforcement, more physicians might opt out of prescribing opiate medications for pain management.

This could enhance the access problem for honest patients in dire need of professional pain management services. According to one person under my care, "It’s not fair to the patients to punish doctors and make them afraid to treat people who have chronic pain." In fact, physicians also have liability when they fail to manage pain, and some have been successfully sued for failure to treat.

When prescribed responsibly, opiate medications are extremely useful in the management of severe pain, whether acute or chronic. On intake, time must be taken to complete a comprehensive review of medical records together with a thorough history and physical examination. Appropriate diagnostic tests must be run, they must be current and an effort should be made to correlate studies with subjective complaints of pain.

When pain is long term, eventually even the strongest person might succumb to major depression. Depression itself can magnify the perception of pain. As such, psychological evaluation is an important part of the pain work-up.

Once a diagnosis of chronic pain is confirmed, patients should sign a pain contract that includes an agreement to obtain pain medicines from only one provider and to submit to urine drug screens upon request. Urine screens should confirm presence of the pain medication being prescribed, and the presence of other drugs, including street drugs, must be ruled out.

Most important, the work-up should include a thorough evaluation of nonpharmacological treatment options. Studies have shown that severe chronic pain is best treated by a collaborative, interdisciplinary team of health providers. Manakai o Malama published the results of its three-year pilot performed at the request of HMSA in the Hawaii Medical Journal. The study demonstrated a sustained improvement in function and quality of life and a reduction in opiate utilization for the majority of participants.

Among the most challenging patients are those who have chronic pain combined with serious, ongoing mental health problems that place them at risk for suicide. In fact, chronic pain itself is a risk factor for suicide. Should a physician withhold medication from a person with severe pain who has also had a previous suicide attempt? It pre­sents a dilemma.

The pharmaceutical industry is a huge engine with the potential for both great benefit and great harm. Mounting deaths from opiate overdoses are among the unintended casualties and must be addressed. However, the decision to link opiate deaths to physician prescriptions is a double-edged sword.

———
Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.