Pubdate: Sat, 20 Feb 2016
Source: Day, The (New London,CT)
Copyright: 2016 The Day Publishing Co.
Contact:  http://www.theday.com/
Details: http://www.mapinc.org/media/293
Author: Judy Benson

OPIOIDS HARDER TO GET, MONITORED MORE CLOSELY

Prescribing Habits Have Changed, Doctors Say; State Touts Database

A lot of Dr. Jeffrey Miller's patients come to him in severe pain 
after car accidents, traumatic falls and sports injuries.

But over the 22 years the orthopedic surgeon has been practicing in 
New London, he's seen a marked change in attitudes within the medical 
community, from patients themselves and from health care regulators, 
toward how that pain is treated - a change that has become even more 
pronounced with the recent heroin crisis.

"Twenty years ago, the message physicians were getting was that we 
weren't treating pain well enough, and that patients had a right to 
be pain free," he said Thursday. "We had to show that we were 
treating pain to document that we were practicing appropriately."

At that time, medications like Oxycodone, Vicodin and Percocet were 
becoming widely available, and doctors were being pressured to 
prescribe them readily, he said.

But now, as the highly addictive nature of these narcotic painkillers 
has become more widely known and their abuse often cited as a pathway 
to their chemically related illegal and cheaper cousin - heroin - 
fewer patients complain when he prescribes only very small amounts or 
none at all.

"Now, it's much easier for me to say to a patient, 'that's all I'm 
going to give you,'" Miller said. "Overall, I'm prescribing fewer of 
these pills to fewer numbers of patients."

In the aftermath of the recent spike in heroin and prescription 
opioid overdoses and deaths in the region, families of addicts, 
addiction recovery experts and former addicts have often cited easy 
access to prescription pain pills - whether obtained legally, stolen 
or purchased on the black market - as a main culprit in the crisis.

That finger-pointing, however, may be somewhat out of date, not 
recognizing the steps that have been taken to better monitor and 
curtail prescription narcotics abuse, doctors and others say.

"More than 18,000 prescribers are now registered on our prescription 
monitoring and reporting system," said Jonathan Harris, commissioner 
of the state Department of Consumer Protection, referring to the 
state's online drug registry. "This is a crucial tool in the war 
against opioids."

A 2008 state law created the registry, but it wasn't until Oct. 1 
that doctors, advanced practice registered nurses, dentists and other 
health care providers who can prescribe medications were required to use it.

Now, prescribers are obligated to check the registry before patients 
are given more than three days' worth of narcotics, to make sure they 
haven't just gotten some elsewhere.

Called the Connecticut Prescription Monitoring and Reporting System, 
it shares data with 18 other states, and New York will be added soon, 
Harris said.

"There are discussions going on about getting more states involved," he said.

Because use of the system is new, the level of compliance isn't yet 
known, he said, though his department is actively promoting it.

In addition to requiring physicians check before prescribing a more 
than 72-hour supply of narcotics, the monitoring law passed last year 
also requires doctors to review the patient's record every 90 days if 
they are using narcotics for prolonged treatment.

"We are trying to get people to follow the law and make this a 
crucial part of their practice," he said.

Dr. John Paggioli of the Eastern Connecticut Pain Treatment Center, 
said the registry is helping him identify patients who are "doctor 
shopping" for pain pills, and that overall he is prescribing fewer 
narcotics in favor of injected steroids, nerve blockers and other 
alternatives for pain relief.

For the past few years, he's also been using an in-office urine test 
system that gives him immediate results showing traces of 10 
different drugs, including alcohol and narcotics.

If he needs further information, he'll send the sample to an outside 
lab to quantify the amount of the substance.

He also checks hospital emergency room records routinely before 
prescribing narcotics.

"There are a lot less narcotics going out to the street from doctors' 
offices," said Paggioli, who practices out of offices in Norwich, 
Waterford and Putnam. "Doctors have become more careful because of 
the addiction problem."

For those patients who need prescription narcotics, Paggioli said, he 
emphasizes keeping their supplies locked up, particularly if 
teenagers live in or visit the home.

"Some teenagers will become addicted. It's a genetic predisposition," 
he said. "The public has to safeguard their supply from their own 
family members."

But tightening up on the availability of prescription narcotics has 
had an unintended downside, according to Dr. Samuel Silverman, 
psychiatrist at Rushford Center and president of the Connecticut 
Chapter of the American Society of Addiction Medicine.

Rushford is part of the Hartford HealthCare network, which also 
includes The William W. Backus Hospital in Norwich.

Too many people got used to being able to get prescription narcotics 
whenever they needed - or wanted - them, he said.

Doctors, often pressed for time, chose the quickest remedy, and, in 
may cases, the only one insurance companies would reimburse for, he said.

The demand didn't ebb when doctors started getting stingy.

"Heroin filled the vacuum," Silverman said. "Prescription medications 
were harder to get, and heroin is cheaper."

At the same time, heroin production in Mexico was increasing, as 
marijuana farmers were switching to growing opium poppies as a more 
lucrative alternative after illegal pot started losing customers to 
legal supplies available in Colorado and other states.

The current heroin crisis, he said, is the result of a confluence of 
these forces - overprescribing in the past that established the 
demand, coupled with the ramping up of the heroin supply.

The street value of prescription narcotics ranges from $30 to $80 per 
pill, while a bag of heroin currently sells for about $5.

"There's enough dysfunction to go around," Silverman said.

At least now, he said, the issue is finally getting the attention it 
needs, and efforts are being made to expand treatment capacity and 
make anti- addiction drugs more available.

"Three years ago, no one was talking about this," he said. "Now, the 
people with the money and clout are finally becoming aware that this 
is a problem that wasn't getting addressed."

Greater awareness has reached virtually all sectors of the medical 
community, including dentists, said Dr. William MacDonnell, dentist, 
anesthesiologist and past president of the Connecticut State Dental Society.

Now, he said, dental practices that once automatically gave 
prescriptions for narcotic pain pills for a toothache or after dental 
surgery follow a different routine.

That may include longer acting anesthetics in addition to 
prescription-strength versions of Advil and Tylenol.

"The new gold standard for treating moderate-to-severe pain is to 
give 400 to 600 mg of ibuprofen every four to six hours, alternating 
with acetaminophen every three hours," said MacDonnell, who also 
teaches at the University of Connecticut Dental School. "We're trying 
to get away from prescribing narcotics as the first line of defense. 
Half or more or our patients don't really need narcotics."

Patients increasingly skittish about using prescription narcotics to 
control pain also are turning to alternative medicine, including 
acupuncture and natural remedies, for relief, said Ana Reudiger, a 
naturopathic physician at Natura Medica in Mystic.

Often, she said, patients come to her before an upcoming surgery for 
pain management techniques and treatments.

Dr. Mark Kraus, chairman of the Connecticut State Medical Society's 
Addiction Medicine Committee, is also a proponent of greater use of 
non-medical methods for pain relief, including moist heat, massage, 
physical therapy, acupuncture and electrical stimulation.

More medical schools are adding requirements for classes in addiction 
and pain management, noted Kraus, a Cheshire internist and assistant 
clinical professor at the Yale School of Medicine, and physicians' 
groups including the state medical society are offering continuing 
education workshops on these topics.

In April, the group is hosting a talk by Dr. Seddon Savage of the 
Dartmouth Center on Addiction, Recovery and Education titled, 
"Interdisciplinary Approaches to Opioid Prescribing."

Instead of blaming overprescribing of opioids for the heroin problem, 
Kraus said a more productive approach would be to understand 
addiction as a brain disease that is best combated through prevention.

"This is a chronic neurological brain disorder, and there is no 
cure," he said. "There is treatment."

Silverman, the Rushford Center psychiatrist, agreed.

"Prevention is more important than treatment," he said.

Since addiction usually begins with behaviors that start in the 
teenage years, he advocates "earlier and earlier interventions" 
through school nurses, pediatricians and others who can identify 
substance abuse at its first stages, along with more mental health 
counseling for youth.

Rushford Center is involved in a pilot program underway at 15 
pediatric practices in the state that is teaching pediatricians to 
screen patients at risk for addiction, and channel them toward early treatment.

"Addiction is a solution that becomes a problem. Kids take these 
substances to feel better," Silverman said. "Then it leads to 
problems and risky behaviors. We've got to address mental health issues."
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MAP posted-by: Jay Bergstrom