Physician education can lessen prescription drug abuse
YAVAPAI COUNTY - In today's society of the quick fix, we want our food prepared quickly, our investments rewarded instantly, and our pain to go away.
Opioid pain relievers have satisfied that desire, but is the cost too high? And have physicians forgotten or overlooked the dangers of these drugs, and their potential long-term impact on their patients and on society?
In terms of scope and danger, the rise in popularity of prescription pain medication as a drug of abuse is reminiscent of a recent and ongoing concern.
"I believe it's a severe problem, the same sort of proportions we saw with meth a few years ago," said Yavapai County Juvenile Justice Center Director Scott Mabery. "You can get as high or worse on these things as you can with marijuana or coke or any of those other drugs."
Education has had a noticeable effect on the use of methamphetamine, at least in the case of students. A 2010 Arizona Youth Survey indicated that less than 1 percent of grade 12 students in Yavapai County had ever used meth, compared with 6.1 percent in 2006.
Conversely, more than 25 percent of those 12th-graders reported they had abused prescription pain relievers at least once.
In 2006, the question was not even asked.
The initial effectiveness of the opioid pain relievers, and the medical profession's shifting views on their use, plays a large role in today's status of the drugs as readily available and ripe for abuse.
"Fifteen or 20 years ago, some of the medications that are the biggest risk, especially the hydrocodone and oxycodone derivatives, were not recommended for long-term use," said Lisa Wynn, executive director of the Arizona Medical Board. "But studies have since found that they do work long-term for pain management so they are prescribed more now."
Many doctors have adopted a responsible course of action, enlisting patients into "pain contracts" that include an agreement to receive prescription medication from just one source, and even to submit to urinalysis as protection against overuse and possible adverse drug interactions.
But sometimes, things get away.
"Sometimes doctors will just get in a hurry and not be watching out for the red flags," Wynn said. "In the most severe cases, it's someone who is acting criminally, knowingly prescribing to someone they shouldn't be."
The latter occurrence is rare, Wynn added, but "it does happen."
It's understandable that a compassionate doctor would continue to prescribe pain medications for someone who is hurting, even after common sense indicates the pain from an injury should have abated. In doing so, though, that doctor could be putting his patients' long-term health at risk.
Dr. Fred Johnson is the emergency department director at Verde Valley Medical Center. He believes that the issue of prescription drug abuse can be broken down into two classes of people, those who overuse the drugs for chronic pain and those who use them for recreational purposes.
Those in the latter class, taking the drugs without medical supervision solely for their euphoric properties, are dancing on the precipice of illness and death. The others, the chronic pain sufferers, are often unknowingly headed down a path toward depression and potential financial ruin.
Prescription drug abuse is not just a healthcare issue, according to Johnson. "This is the major healthcare issue. It is a destroyer of lives."
The brain is a complex organ that works in simple, predictable ways when it reacts to the substances the body consumes, Johnson said. In the case of the opioids, the initial effectiveness, combined with the euphoric aspect, leaves the patient with a blissful feeling of pain-free well being.
But the brain, accustomed to a steady state of activity, reacts at once to the euphoria and assimilates the drug's actions, maintaining its activity state, but only while the drug is present. Consequently, the brain loses its innate ability to deal with life's normal aches and pains.
"This can go on for decades," he said, "long after you've eliminated the original source of pain."
Take the drug away, Johnson said, and the brain sinks into a depressed state, creating a longing for the lost euphoria.
Add in a source of stress and the brain activity drops even further, sometimes leaving the patient chronically intolerant to pain that often is difficult to diagnose.
"Because we don't understand it and patients are begging for help," Johnson said, "we run every kind of test we can think of. Some of these people lose their jobs, lose their insurance and end up on the public healthcare system."
Through his work with Matforce and talking one-on-one with doctors, Johnson is on a mission of sorts to advocate extreme caution in the use of these powerful medicines.
"I think you're going to see the prescribing of prescription narcotics decline sharply if we do our job right," he said, harkening back to the words of Hippocrates.
"Our oath, our creed," he said, "is to first do no harm."
The demand for these drugs for recreational purposes has led to the creation of a very clever class of addicts.
"I can't tell you how artful these people are," Johnson said at a recent Matforce meeting. "If you had a book of all the excuses, it would be this thick."
And Dr. Harald Gutgsell, who has run a pain management clinic in Prescott for 10 years, agrees that constant vigilance and proper medical testing and procedures, is necessary to ensure that the drugs are used appropriately.
"You have to look to see if what this person is telling you is the truth" through physical examinations, MRIs and the like," Gutgsell said. "Without all that, nobody will get anything."
Still, the drugs leak through the cracks and fall into the province of law enforcement, whether they're stolen from mom and dad's medicine cabinet or obtained by more risky means.
"Most of what we're seizing is what people get from their doctors and they're selling it on the street," said Partners Against Narcotic Trafficking Director Sgt. James Gregory. "They get these prescriptions and they can sell the drugs for four or five times what they paid for them."
How they get the drugs is largely through fraud, forging or changing prescriptions or even, in one case, stealing a doctor's entire prescription pad and making up their own.
Hard numbers of cases involving prescription drugs are difficult to determine because of local charging tendencies. Most often, unlawful possession of prescription drugs, a statutory misdemeanor, is charged as felony possession of narcotic or dangerous drugs, thus lumping the medications together with street drugs for statistical purposes.
Coming across the drugs in someone's possession is just business as usual, Gregory said. But getting to doctors who illegally prescribe is another matter altogether.
"It's a lot easier doing street drugs than going after doctors who over-prescribe," he said. "We haven't had a whole lot of cases because they're very hard to develop."
Most investigations of that nature begin when "you start getting complaints from a relative, a friend, or you arrest someone the doctor has prescribed to."
Gregory added that he has yet to see any cases involving drugs purchased from illegal Internet pharmacies, but the federal Drug Enforcement Agency certainly has.
Ramona Sanchez of the DEA said that, while doctor-shopping and prescription fraud are the primary means of obtaining legal medications illegally, the Internet is a haven for rogue pharmacies, often operating in India or Southeast Asia.
"A lot of those are challenges for the agency because you can't tell physically where they're at," Sanchez said. "They export the drugs to a third party, sometimes in Canada, and it takes a long time to trace it back."
Adding to the fundamental harm of mere access to the drugs is the high likelihood that the medications themselves are often counterfeit.
"That brings it to a different level," Sanchez said, "because you don't know where it's coming from, who makes it or anything." With that uncertainty comes an added danger, the lack of quality control that could turn a user's standard dose into a life-threatening adventure.
Pain medications can be purchased legally through the Internet, she added, but legitimate online pharmacies will always require a prescription and a detailed medical history.