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Sunday, Nov 22, 2009
State laws passed over the next few decades added more specific hurdles for doctors: stronger penalties for over-prescribing, and in some cases, mandatory use of triplicate forms that gave state regulators a copy of every prescription written for opioids and other highly addictive but medically useful drugs -- a category defined by the government in 1970 as Schedule II narcotics.
Most doctors reacted to the laws -- and a growing public fear of drug abuse -- by avoiding patients with pain that required strong medication. There were, and are, exceptions: Doctors who treat cancer patients have typically plodded through the extra paperwork and state scrutiny in order to prescribe opioids. But the vast majority of physicians in states with triplicate regulations responded to additional scrutiny by dropping opioids from the list of drugs they would prescribe. A survey that Dahl conducted in the mid-90s found that only 60 percent of California's 96,000 doctors -- oncologists included -- were authorized to write triplicate prescriptions, and that only 40 percent of these doctors actually did. Other surveys in other states found similar results.
The advent of managed care has compounded the problem, says Dr. Daniel Carr, founding medical director of the pain management program at Tufts New England Medical Center. Diagnosing chronic pain often requires extra time -- X-rays and the usual tests may turn up nothing, even when patients are visibly suffering -- and managed care demands extra efficiency. Doctors who participate in that system, with its attendant focus on quickly moving patients in and out of doctors' offices, "are extremely pressured for time," Carr says. "Anything that looks like it will take more time is a tremendous disincentive."
Greater obstacles to aggressive pain management resulted in more undertreated sufferers of chronic pain. A handful of doctors, aware of the problem, sought to focus on treatment of pain by forming specialized study groups in the early '70s. But it wasn't until 1985, when an article in the New England Journal of Medicine identified a widespread lack of adequate care, that victims of undertreated chronic pain became more visible to doctors and the public.
The journal article, by Dr. Kathy Foley, offered new medication and treatment guidelines that became the model for doctors treating pain. Medical schools and regulatory boards also responded, gradually, with dedicated training programs and ethical guidelines for the treatment of pain. Tufts University was the first, in 1991, to establish a master's program for doctors in pain studies. By 2000, 24 state medical boards had adopted pain guidelines that specifically advised doctors on the dangers of undertreatment. Meanwhile, large healthcare providers created pain clinics, increasing the number of locations where strong drugs could -- and would -- be prescribed.
And then, out of the blue, came the OxyContin scare. Abuse of the drug began to reverse advances in pain management by early 2001, in concert with a broad crackdown on painkillers. The problem with OxyContin was not its main ingredient (oxycodone hydrochloride), which is found in Percocet and other painkillers, and has been around long enough to be widely prescribed and relatively uncontroversial. The problem was with OxyContin's potency, promotion and chemical formula. OxyContin carried an extremely high dose of oxycodone -- up to 160 milligrams or 16 times the highest dosage available in Vicodin. It was extremely popular (sales exceeded $1 billion in 2000), which made it very accessible. And its time-release qualities were easily defeated by simply crushing the pill.
Towns that didn't have easy access to heroin or other hard drugs became the first "Oxy" hotspots. Rural Maine, western Pennsylvania and the Appalachian areas of Kentucky, Virginia and West Virginia in early 2001 were the areas first hit. But word -- and addiction -- spread fast, and deaths attributed to the drug began to be reported. Calls for legislation and increased law enforcement came quickly, and painkillers of every variety came under new scrutiny.
The first controls of the drug sought to cut off abuse by Medicaid patients. There was no body of data indicating that the poor abused the drug more than wealthier Americans, but by the summer of 2001, six states had introduced legislation making it harder for Medicaid patients to get their pills. Other states followed, with regulations aimed at aid recipients with OxyContin prescriptions or at Medicaid patients in need of pain medication. Vermont, at the behest of its Gov. Howard Dean, who is a physician, ended coverage of OxyContin for all its Medicaid patients. If poor patients needed the pills, said the state's lawmakers, they had to move.
"I'm on Medicaid and I'm scared that the state's going to stop paying [for OxyContin,]" says Sarah Murray, a 51-year-old Louisiana woman on Medicaid who suffers from multiple cysts in her kidneys and liver. "I know in some states they've stopped paying. And if they stop paying here, I'm dead."
In the past 18 months, 17 states set up electronic prescription databases to track doctors who prescribe, and patients who receive, Schedule II drugs. Six more states are considering similar systems. Meanwhile, legislators in West Virginia are considering a ban of all the drugs that contain oxycodone. One Pennsylvania legislator has introduced a bill that would move OxyContin from Schedule II to Schedule I, a category that includes mescaline, heroin and other drugs considered to have no medical purpose.
"The entire idea of [the Virginia tracking law and others like it] is to go after people who are willingly and intentionally breaking the law," says Tim Murtaugh, spokesman for the Virginia attorney general's office. "It's clearly growing as a problem, and we believe that it's the commonwealth's responsibility to address it."
But doctors have blanched at the sweeping changes and proposed bans, and their panic has only increased in the wake of cases like that of Dudley Hall, a Bridgeport, Conn., doctor charged July 17, 2001, with 36 counts of over-prescribing. Sure, they argue, Dr. Hall, who prescribed more OxyContin that any other doctor in his state, (earning the title Dr. Feelgood), deserves to be prosecuted. But Hall was busted by officers posing as patients, and doctors fear that undercover operations will become the norm. The new laws, say doctors, even if they didn't lead directly to Hall's arrest, make police especially brash, far too confident in their ability to decide which prescriptions are valid or invalid.
