The state Department of Health is beginning an extensive study to attempt to link deaths related to prescription drugs with overprescribing physicians.
The study is driven by a dramatic increase in fatalities primarily due to overdose of painkillers, also known as opioids, an alarming trend that has grown in recent years both locally and nationwide.
Poisoning has become the leading cause of injury death in Hawaii, with 120 deaths in 2011 compared with 86 in 2007, according to the Health Department.
"The sad thing is we’re starting to see prescription drugs in our schools, and we’re seeing kids at younger ages utilizing these drugs," said Keith Kamita, chief of the state’s Narcotics Enforcement Division. "There’s more people who utilize drugs who might not have an overdose, but they have an adverse reaction. These are narcotics; they’re more deadly than illicit drugs because of their strength and their purity."
The number of children between the ages of 10 and 19 admitted into hospitals for drug overdose jumped 42 percent to 172 in 2012 from 121 in 2007, while admissions for seniors between the ages of 60 and 69 soared 74 percent to 204 from 117, according to the Hawaii Health Information Corp.
The Health Department is seeking to use the Narcotics Enforcement Division’s electronic drug monitoring database that tracks patient prescriptions to link death records and autopsy reports to prescribers to get a clearer picture of where people are getting the prescriptions and what type of drugs are being abused, said Linda Rosen, chief of DOH’s Emergency Medical Services and Injury Prevention System Branch.
"It’s very alarming, the increases we’ve had over recent years. These are extremely powerful drugs, and taken a little too much too frequently in combination with other drugs, they can lead to death," she said. "We don’t know where they got this stuff in most cases. It appears there’s an association between increasing deaths and increasing number of prescriptions being written across the country."
Former Kauai physician Harold Spear III is the most high-profile case of illegal prescribing in recent years. The former Hanapepe doctor is serving a 12-year prison term for prescribing painkillers and other drugs to patients without even seeing them.
U.S. District Judge David Ezra concluded in March 2012 that Spear dispensed dozens of controlled substances, including the painkiller methadone, to a Hawaii patient on several occasions, outside the course of usual medical practice and not for a legitimate medical purpose.
"A doctor who facilitates the large-scale distribution of controlled substances, especially highly addictive pain medications, in a manner not warranted by legitimate medical needs, does a disservice to both those patients and the surrounding community that suffers the collateral consequences of drug addiction and drug-seeking behavior," U.S. Attorney Florence Nakakuni said at the time of sentencing.
Over the past decade, state officials have prosecuted at least half a dozen Hawaii physicians for illegal prescribing, Kamita said. Penalties range from five to 10 years in prison and fines of $5,000 to $10,000 per felony.
Linking the records will expedite narcotic investigations and help curb abuse, Kamita added.
"We might see the overprescribing side, but we don’t know the result. It completes the link, especially when there’s a death," he said. "So we can prosecute physicians or individuals who assisted or provided drugs to the person who passed away."
A recent report by the U.S. Centers for Disease Control and Prevention showed the national number of drug poisoning deaths involving opioids such as oxycodone, methadone or hydrocodone more than quadrupled, from 4,030 to 16,651, from 1999 to 2010. Opioids accounted for 43 percent of the 38,329 drug poisoning deaths in 2010, up from 24 percent of the 16,849 drug poisoning deaths in 1999, the CDC said in March.
Over the past decade, the most prevalent type of drug abuse has turned from street drugs like heroin to prescription painkillers, and there’s been a significant increase in use by the adolescent and college population, said Lisa Cook, head of a holistic healing center for drug abusers.
"Maybe once in a while you would have someone who was addicted to prescription painkillers," said Cook, executive director of Ku Aloha Ola Mau, which provides medication-assisted treatment to 600 patients annually in Honolulu and Hilo. "Nine out of 10 intakes are now for prescription drug (addiction). The folks who are using prescriptions are pretty young, between 20 and 26 years old."
She said young people are throwing what are known as "pharm parties," in which youths raid family members’ medical chests and throw the medications in a bowl "like Russian roulette" so they don’t even know what they’re taking.
"(Abuse) is amazingly five to seven times higher than it was five years ago among adolescents," said Dr. William Haning, a professor and associate chairman for the education department of psychiatry at the University of Hawaii John A. Burns School of Medicine. "An awful lot of addictiveness has to do with availability. Their access to drugs, strangely enough, is greater to prescription drugs than many of the street drugs. "
The use of prescription drugs is accelerating at a faster rate than street drugs, he said.
What’s more, the prescription drugs being diverted are almost always painkillers that are much stronger and thereby more likely to result in a fatal overdose, Haning added.
"There’s no room for error," he said. "If I just use Valium to get high, it may take 10, 20 or 100 times that dose to kill myself. If I use Vicodin, Percodan or oxycodone (painkillers) or one of those to get high, the effective dose needed to kill me may be as little as two to four times as much. You can’t screw up."
The growing problem has become alarming for health insurance companies.
Hawaii Medical Service Association, the state’s largest health insurer, has several programs to prevent abuse, misuse or unintentional overdose of medications, including multiple levels of authorization and quantity limits required for certain addictive drugs. The health plan also has a safety monitoring program in which pharmacists monitor claims daily to identify physicians and dispensaries for possible unlawful distribution and work with law enforcement to pursue violators, said HMSA spokeswoman Elisa Yadao.
The national trend prompted health insurer UHA, also known as University Health Alliance, to put in place an opioid policy last year that set thresholds for reasonable amounts of prescriptions for members, excluding cancer patients.
The health plan also began monitoring pharmacy benefit data to see who was receiving "industrial doses of narcotics" and found more than two dozen physicians who were prescribing an "extraordinary amount of morphine-related medication," said George McPheeters, chief medical officer of UHA, which covers 50,000 members. UHA individually contacted members and doctors to require urine drug testing, X-rays and care plans with a goal of reducing the amount of prescription painkillers.
"It’s not an appealing task for an insurance company to undertake," McPheeters said. "On the other hand, we knew so much of this drug was being prescribed it boggled the mind. Nobody could be taking dozens of high-dose narcotic pills a day."
