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Last updated: Sun. Dec. 28, 2008 - 02:36 pm EDT

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Rx FOR pain

As prescription relief soars statewide, so do deadly overdoses

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If you are addicted to pain medications or know someone who is, there are places to get help. Here are a few locally:

•St. Joseph Behavioral Health, 800 Broadway, 425-3606 or 1-800-694-9034

•Bowen Center, 2100 Goshen Road, 471-3500 or 1-800-342-5653

•Park Center, 909 E. State Blvd., 481-2700

•Parkview Behavioral Health, 1720 Beacon St., 373-7500

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Hoosiers are taking many, many more narcotic painkillers, and our appetite for some of the addictive, dangerous drugs is growing even faster than in the rest of the country.

The increase in prescriptions was so pronounced that in one year, we took enough of one narcotic - meant for people in so much pain they're immune to the effects of morphine - to equal a dose for one out of every three people in Indiana.

The use of fentanyl in Indiana, known by brand names Actiq and Duragesic, increased 744 percent from 1997 to 2006. Oxycodone, known by brand names OxyContin, Percocet and Percodan, was up 712 percent during the same period.

And our appetite for those opium-based painkillers was just a warm-up compared with our use of methadone: The amount of methadone prescribed in Indiana in 2006 was up 2,061 percent from 10 years before, nearly double the national increase.

But of all the Hoosiers gobbling up these powerful, addictive chemicals, those in northeast Indiana were among the hungriest: Fentanyl use was up 1,014 percent in the region surrounding Fort Wayne, and methadone use was up 8,643 percent, the second-largest increase in the state during the 10 years through 2006.

That chemical comfort comes at a price: In the last two years, county coroners have recorded at least 96 accidental overdose deaths in northeast Indiana and northwest Ohio in which prescription narcotics were involved.

"We're a heavily medicated society, and we have drugs for everything you can imagine," said Dr. Bruce A. Goldberger, the director of toxicology and a professor at the University of Florida's college of medicine. "The natural tendency of some people is to abuse these substances. They're very euphoric, and they're very potent."

The huge increases in prescribed narcotics were found in thousands of pages of U.S. Drug Enforcement Agency reports analyzed by The Journal Gazette in an agency database that tracks every controlled-substance prescription in the United States.

The newspaper's investigation also found that the rate of accidental poisonings in Indiana shot up 171 percent from 1999 to 2004. It was the biggest increase in the Midwest and a trend showing no sign of slowing.

Though accidental poisonings can be many things, such as an overdose of street drugs or alcohol poisoning, Centers for Disease Control and Prevention officials say the huge upward trend of deadly overdoses "can be attributed primarily to increasing numbers of deaths associated with prescription opioid analgesics."

Translation: The pills that seem like miracle drugs - that let us work despite bad backs, that bring comfort to millions and have names that have become household words - have frightening dark sides.

Pain untreated

For years, Kathy Havlock complained to doctors about the pain in her back. For years, her complaints fell on deaf ears.

Finally, an X-ray showed she had spinal stenosis, the narrowing of spaces in the backbone. That led to injections, powerful pain narcotics and an experimental treatment involving a spinal cord stimulator, all of which have helped ease, though not end, her pain.

That Havlock suffered her ordeal for years without treatment is hardly unique.

Eleven years ago, the American medical establishment sent a clear message to practitioners: stop ignoring pain.

In 1997, two expert panels introduced guidelines for managing chronic pain. They encouraged the expanded use of opioid pain medications - after careful patient evaluation and counseling - when other treatments are inadequate, recounts the Journal of American Medical Association in a report published this month.

Others followed suit, and the Joint Commission, which accredits hospitals and reviews medical care, adopted standards emphasizing pain assessment, control and education. The move corresponded with long-standing research showing that pain was regularly undiagnosed and untreated.

Since then, retail purchases of methadone, hydrocodone and oxycodone have skyrocketed, and patients - who, like Havlock, had been ignored - got relief. But the rates of emergency room visits and deaths attributed to opioid analgesic overdoses also rose sharply.

Proactive treatment

"The increase in pain prescriptions is not a negative thing, per se," said Dr. William Hedrick, president and founder of the Fort Wayne-based Centers for Pain Relief, which has six area offices. Havlock is one of his patients. "Ninety-five percent of the time, it's a positive thing."

That's the rough percentage of people who, Hedrick and others say, take powerful pain narcotics responsibly.

Hedrick and other pain specialists see the sharp rise in pain medications reflecting an attempt to correct the problem of undiagnosed and untreated pain.

The aging population - baby boomers dealing with bad backs, bum knees and the onset of more dire conditions such as cancer - also contribute to the increase, they say.

Just as doctors have been instructed to screen patients for pain, patients are increasingly getting the message that they don't have to live with it.

Patients are now more proactive and expect their pain to be treated, said Dr. Stephen J. Hatch, a partner at Pain Management Associates in Fort Wayne. He and Hedrick said that improved pain drugs, including long-acting ones, also likely contributed to the increase in prescriptions.

Hatch said pain specialists are wary of "diversion," where drugs prescribed for one person end up in the hands of another. Pain doctors say they take steps to limit the problem, checking out patient claims, looking to see whether they have obtained pain drugs elsewhere, and having patients sign a medication contract outlining physician expectations.

But some collateral damage is inevitable.

"I can't deny 95 percent of people pain medicine," Hatch said, "because 5 percent may be doing something with it they shouldn't."

Painful transition

Many doctors credit - at least in part - the Joint Commission's standards for pain management with driving increased prescriptions of pain narcotics. The commission has powerful sway over medical providers, especially hospitals, and its established standards have ripple effects throughout the medical field.

Even so, an official with the commission was quick to shrug off any causal link between its standards and higher pain narcotic-prescription rates. The official said the commission doesn't certify many ambulatory, or outpatient, offices where many of the retail prescriptions for pain narcotics originate.

The commission agreed that pain was underdiagnosed and undertreated. But Dr. Robert Wise, vice president of the commission's division of standards and survey methods, argues it didn't dictate that doctors prescribe more pain narcotics.

Rather, he said, it dictated that practitioners assess pain and manage it according to their own best judgment, or refer patients to other practitioners if they saw the need.

Not that all doctors balked at the commission's standards, the product of a two-year collaboration between the Joint Commission and the University of Wisconsin that have been in effect since January 2001. An updated version takes effect Jan. 1.

Hedrick lauds the commission's efforts to see to it that hospitals have an accurate way to measure and treat pain.

"I think there's been no more humane pursuit than that," Hedrick said.

How one interprets the surge in prescription rates depends more on whether treatment was appropriate and less on the raw data, doctors interviewed for this story said.

Still, "2,000 percent sounds pretty high to me," said Wise, reacting to the rise in methadone use between 1997 and 2006.

Methadone is cheaper than other potent painkillers, and many people with chronic pain eventually lose their jobs and insurance and have to pay for drugs out-of-pocket.

Although it has its advantages, methadone can be an unforgiving drug, Hedrick says, requiring a lot of supervision and specialization to administer correctly.

"The only way you're going to know when you get too much in your system: You just don't wake up one day," Hedrick said. He says he uses it sparingly.

Painkillers as killers

For 40 years, the leading causes of injury deaths in the United States had been car crashes and firearms. But in 2004, poisoning took the No. 2 spot, beating out deaths by firearms. In 2005, it did it again.

The "vast majority" of fatal poisonings, according to the National Center for Health Statistics, was accidental drug overdoses, with 56 percent of them involving narcotics.

"This is an epidemic," said Dr. Scott Wagner, director of the Northeast Indiana Forensic Center. "The numbers keep going up and up."

Wagner performs autopsies for 16 counties in northeast Indiana, and more and more of the autopsies he does are on people who have accidentally overdosed on narcotic painkillers.

The biggest killer, coroners said, has been methadone, often sold under the brand name Dolophine, but close on its heels is fentanyl, best known as a patch with the brand name Duragesic.

The National Center for Health Statistics reports that deaths from methadone went up almost 500 percent from 1999 to 2005, when 4,462 people died from it in the United States. That's double the number killed by heroin in 2005 and quickly approaching the number killed by cocaine.

Deaths by accidental poisonings from all narcotics and hallucinogens were up 55 percent from 1999 to 2005, mainly because of prescription painkillers, the CDC said.

"There was a point in time that when there was a drug overdose, it was a street drug. Now it's a prescription drug," Huntington County Coroner Leon Hurlburt said. "Kids can get these prescription drugs from mom and dad out of the medicine cabinet, and they can sell them on the street. And they don't know what they're messing with."

What they're messing with are opiates or synthetic opiates that in some cases are much more powerful than people understand. Fentanyl is 80 times more potent than morphine and hundreds of times stronger than heroin. It is so powerful, it is prescribed in micrograms instead of milligrams.

In 2002, the Russian military used fentanyl gas against terrorists holding hostages in a Moscow theater, incapacitating them and killing 127 of the hostages.

For two years starting in April 2005, there was an epidemic of deaths among heroin users, who were overdosing on non-prescription fentanyl made in an illicit lab that was up to 50 times more powerful than heroin. By March 2007, more than 1,000 people were dead.

If a fentanyl patch breaks open - abusers seeking an intense high will sometimes chew them - a massive dose of the drug is delivered all at once, often fatally.

The "black box" warning in the prescription packaging for Duragesic in 2003 was less than one page in 28 pages of information. The warning approved in February by the FDA is almost three pages long, and the entire packet is now 48 pages.

The first warning says the patch is to be used only by patients who are already heavy users of morphine. But the FDA a year ago, in its second fentanyl warning since 2005, said doctors are prescribing it for acute pain after surgery or even for headaches.

Methadone is best known as a treatment for heroin addiction, but it is most often used as a painkiller for people already immune to morphine. The increases in prescriptions for methadone - its use is up 8,208 percent in Fort Wayne from 1997 to 2006 - do not include addiction treatment.

Methadone also comes with a potentially deadly surprise. While it relieves pain for four to eight hours, its side effects - mainly depressed breathing - last from eight to 59 hours.

"Just because the buzz has worn off, that doesn't mean the drug is out of your system," said Kosciusko County Coroner John Sadler, who has handled 10 accidental overdose deaths in the last two years - eight from methadone and two from fentanyl.

"You take more, and you're stacking doses unintentionally, and then you're in trouble."

Overdose deaths tied to prescription drugs aren't limited to Indiana, either.

"This seems to be a significant, growing, worrisome problem" in Ohio, said Paul Brose, Defiance County coroner. Concerns were raised at an annual meeting of Ohio county coroners this spring, he said.

These are great medicines for relieving pain, but they're "not without serious side effects if you overdo it."

Handling with care

Dr. B.P. House has heard his share of fishy stories from drug seekers.

House is the medical director of emergency services at Lutheran Hospital and president of Emergency Medicine of Indiana, a group of about 55 full-time ER physicians based on the hospital's campus.

Patients say they're from out of town and forgot their pills or grandma threw them away.

In such cases, he's quick to check the INSPECT database, Indiana's prescription drug monitoring program, where he can see whether they have been prescribed drugs elsewhere. He also regularly uses Lutheran Health Network's electronic system, which shows recent ER visits and other patient information.

Based on what he finds, there are occasions he will tell patients they don't need narcotics. He'll offer non-addicting, non-narcotic substitutes and provide a referral to a primary-care doctor if they don't have one.

Reactions run the gamut. Sometimes people accept his denial of pain narcotics, sometimes they get upset and walk out, and sometimes they plead and continue to try to game the system.

Fortunately, he says, most patients he sees, maybe 95 percent, are seeking drugs for legitimate medical reasons.

But even for those patients, House limits the pain narcotics he gives out so as not to invite abuse or addiction.

Most acute injuries require painkillers only in the short term, so he usually prescribes enough to last just a few days. If a patient needs more, he encourages them to see a doctor for a follow-up appointment.

Pain doctors say that managing pain goes well beyond medications and that it's important not to rely too heavily on narcotics.

Pain can also be treated by therapy - physical, occupational, chiropractic; injections such as epidurals used to numb and reduce inflammation; surgeries; psychological intervention; and other alternative approaches.

Hatch says about 70 percent of Pain Management Associates' treatments don't involve medicine; the practice focuses on interventional care, injections and surgery.

Hedrick at Centers for Pain Relief says he uses "co-analgesics," a wide range of medications including sleep sedatives and muscle relaxers that treat conditions amplifying pain and reduce the need for opiates. He echoed that opiates are just one option.

In an editorial accompanying a December report in the Journal of the American Medical Association - on a spike in unintentional overdose deaths associated with pain relievers - a cautious, multipronged approach to treating pain was emphasized.

"When deciding whether to prescribe an opioid, physicians should ask patients about their prior and current histories of alcohol and other drug use," the editorial said.

"Patients with histories of substance use, mental health problems or both should receive special attention and co-management from pain management specialists when possible. Treatment of mental health disorders should be considered part of successful pain management."

But not everyone is urging restraint.

Pharmaceutical maker Purdue Pharma LP last year agreed to pay $19.5 million to settle complaints that it was urging doctors to prescribe its OxyContin every eight hours instead of the 12-hour regimen approved by the FDA.

Purdue Pharma had sales of $1.83 billion of its prescription painkiller from January to October of this year, according to figures from IMS Health, a health care information company.

Purdue Pharma admitted no wrongdoing in the settlement, but state attorneys general in the case said the overprescribing encouraged patients to abuse the drug or sell it to others to abuse.

Even without prodding, doctors, because of the limited time most spend with patients, might be more likely to try to fix what ails with pills.

The Joint Commission's Wise says the organization is especially concerned about overcrowding in emergency rooms. Under these types of stresses, where interaction with patients is minimal, he said it's just easier for doctors to write prescriptions.

Kosciusko County's Sadler said patients shopping for drugs will go to doctor's offices late in the day when they are especially busy, be vague about their medical history and describe pain that can't be diagnosed.

"Physicians don't want to leave patients in pain," Sadler said. "At the same time, how do you sort all that out?"

‘Next big thing'

Despite the massive increases in the amount of narcotic painkillers prescribed to Hoosiers over the last 10 years, Indiana does not stand out nationwide in its consumption.

Instead, the increases appear only to have been the state catching up with the rest of the country's pill-popping habits.

Methadone prescriptions, for example, are up 1,176 percent nationwide and up 2,061 percent in Indiana. But even after that increase, Hoosiers ranked only No. 22 among states for the amount of grams prescribed per 100,000 in population.

That means an ever-growing segment of the nation is using powerful, addictive painkillers, leading to addictions among legitimate users who were prescribed the medication, and to wider availability for those who abuse the drugs but don't have a prescription.

And those who are addicted will do anything to get the drug. A Garrett man who admitted to robbing 70 pharmacies in less than three years to feed his OxyContin addiction told The Journal Gazette in 2003 that the first time he took the drug, "it took the place of everything."

Mary and Ron England of Leesburg lost their son Zachary, 27, to a fentanyl overdose Nov. 22. Zachary had been struggling with painkiller addictions for years, and when a relative died of an overdose two years ago, Mary told her son, "don't you ever do what he did" to his family.

"But he couldn't help it," she said.

In their effects, side effects and addictiveness , narcotics are powerful in every way. Actiq, a brand of fentanyl that is delivered on a stick like a lollipop, is so strong it is intended only for "episodes of breakthrough cancer pain." It comes on a stick so doctors can remove it from a patient's mouth if an overdose begins.

Mike, a county law enforcement officer who has worked drug cases for 22 years and asked that his full name not be used because he often works undercover, said prescription drugs are now the subject of a quarter of their cases. They're widely available and cheaper than street drugs, because insurance companies cover most of their cost.

And fentanyl, he said, is poised to become the leader of an ugly pack. It is now so popular that undercover officers are having trouble buying it.

"They're using it so much, we can't get it," Mike said. "This is becoming the next big thing."

dstockman@jg.netmschroeder@jg.net


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