Lining up at the Pill Mill – next stop, the ER
In a recent discussion among American College of Emergency Physician governing Council members, the question of the role of emergency physicians in addressing the crisis of rapidly increasing abuse of prescribed narcotics and other addictive drugs, and the overdose deaths that often ensue; the consequences of criminalization of drug abuse; and the obverse issue surrounding the failure of some emergency physicians and nurses to provide appropriate and timely pain management to patients in the ER, reflects a classic ‘between a rock and a hard place’ dilemma. This crisis is not without some possible solutions, and this dialogue is worthy of broader dissemination. The following is a two-contributor guest post reflecting on the issues raised by recent news media attention to the narcotic addiction and pain management conundrum. The first is an edited commentary from Thomas Carter, DO, FACEP, Emergency Medicine Residency Program Director at Ohio University Heritage College of Osteopathic Medicine and Southern Ohio Medical Center in Portsmouth, Ohio. It focuses on a major source of prescribed drugs of abuse, and what ER physicians and their communities can do about it. The second is a response from Stephen Grant, MD, FACEP, an emergency physician and ACEP Councilor from Aiken, SC.
From Dr. Carter: Please allow me a little poetic license and think Shakespeare, not Homer. I have enjoyed the (ACEP Council) thread and wanted to give a local perspective.
Referring to the first use of the poppy plant and early opium application in medicine in 150 AD, Galen is often described as the first physician describing addiction: “the plant must be used sparingly; it was better to endure pain than be bound to the plant”.
I would postulate that we have made little progress on addiction since then, other than enhancing and refining the substances abused and identifying the physiologic target sites. Becker, a Nobel prize winning economist, and Murphy, his fellow professor at the Booth School of Business in Chicago, more succinctly explain the financial argument (in favor of decriminalization) in a January 5th 2013 WSJ article “Have We Lost the War On Drugs?” Even before their economic argument was so effectively spelled out, many of you (ACEP Councilors) probably agreed with Dr. Larry Bedard from the Great State of California. He argued that criminalization of drug use was not reducing our patients’ use and abuse of drugs so much as it was increasing the numbers of people incarcerated, the wealth of the dealers, and the variety of drugs used.
So let me tell you about Scioto County in Ohio. This a state was noted to have a significant increase in drug overdose mortality rate in the Trust for America’s Health Report on Prescription Drug Abuse. Dr. Wayne Wheeler, a local EM physician, was our coroner in the 1990s; and he noticed a local rise in suspicious and drug related deaths. He encouraged all suspicious deaths be tested and began labeling many of these as drug related. The state of Ohio, through the Ohio Highway Patrol, quickly added mandatory screening for all traffic fatalities, and these deaths were then classified as drug related when positive. This accounts for the rise in the numbers of drug related deaths from 2000 to 2008. Ohio went from 125 to 534 deaths, a 280% increase. Scioto County Direct Drug and Drug Related Deaths tripled. One person had 312 prescription pain pills from five doctors, all located within 170 miles of his home, in the seven weeks prior to his overdose death.
The DEA also noticed that 7 million Americans are abusing prescription drugs, up 80% in 10 years. In the early 2000s, the University of Michigan 8th Grade Drug Study said that prescription drugs have overtaken marijuana as the first drug of abuse; and most of these children reported obtaining the drugs from their own home’s medicine cabinets. Scioto County made it on to the DEA top-10 watch list for prescription drug abuse.
Identifying a “Pill Mill” was like defining pornography: for most in the region you knew it when you saw it. There were lines of patients around the block waiting to get in for minimal medical care no physical therapy, testing, osteopathic manipulation or even a physical exam just a questionnaire filled out in the lobby and a prescription written and filled on sight at a dispensary or a specific off sight pharmacy sometimes owned by the same person or family. The characteristics were easy enough to spot: legal medical practices on paper would only take $200 in cash for an office visit; but in some cases they would happily bill insurance for “dispense as written” narcotic prescriptions at significant additional profits from the on sight dispensary. Scioto County had 8 such “pill mills” in operation, some owned by physicians born and raised in the area, others by convicted felons who ran the front office and hired in doctors from out of town or out of state at unbelievable profits. One physician from Wheelersburg, Ohio, a town with less than 5,000 people and no police department, made it into the top ten nationally for oxycodone prescriptions written.
Appalachia became notorious for prescription drug abuse over the last quarter century, until legislative efforts began to catch up with quasi-legal drug trafficking pill mills. The prescription pain pill problem exploded so much that the local press caught on to the vernacular of abuse, such as Oxycotin© being referred to as “Hillbilly Heroin. The seventy-five dollar plane ride from Huntington, West Virginia to Miami, Florida was nicknamed the “Oxycotin© Express” due to the number of people exploiting the flight to travel to the pill mills in the two areas. Trafficking and “pill mills” expanded from there. Prescription drug abuse was so rampant that our hospital, most notably the maternity unit, took extra steps to try to protect the most vulnerable populations. The maternity service, led mostly by the nurses, brought the department to implement mandatory urine and cord blood testing, and initiated the Finnegan Neonatal Abstinence Scoring Tool for all infants born in Scioto County.
Our next elected coroner was Dr. Terry Johnson, who felt almost helpless in the “Pill Mill” fight. Law enforcement had no ability to go after these practices and inappropriate prescribing. Dr. Johnson ran for the state legislature, was elected, and in two month passed House Bill 93, which gave law enforcement teeth to shut down the “Pill Mills”. The Ohio News Network reported that Dr Johnson’s House Bill 93 went from concept into law in record speed. We have since shut down all of the eight pill mills in Scioto County, and Dr. Johnson has gone on to help the health department implement Vivitrol© naltrexone monthly injections, and distribute rescue naloxone to users. EMS first responders now have the ability to utilize naloxone for reversal of suspected overdose as well.
It takes physician leadership at all levels to get in front of these problems. We have since begun educational activities with the OU-HCOM CORE hospital system for EM residents. We organized a Drug Diversion conference with Dr. Terry Johnson; Dana Droz, Pharm-D, the Ohio Board of Pharmacy administrator; and Detective Dennis Lukins to explain the interaction of physicians, legislators, the Board of Pharmacy and law enforcement and define tactics to reduce ED prescribing, and increase utilization of the state’s narcotic prescription monitoring system. Ohio shifted the fight out of our state, but the end users are still here, heroin has made a comeback, and methamphetamine and cocaine are starting to come in to an area that has preferred downers for decades. The fight for prescription drug abuse had changed fronts, as Florida followed with similar legislation in 2012; and now Georgia has the highest density of “Pill Mills”, most of which are transplants from Florida. Thomas Carter, DO, FACEP
From Dr. Stephen Grant: Thomas. Thanks for an amazing summary written from the facts and from the heart.
One thing that I would like to add is the major push by regulatory and administrative agencies from TJC (formerly known as JACHO) to the VA to address the “epidemic” of under-treated pain in the United States. The flawed science behind this myth has come to light recently (see JAMA 2012:308{18}:1865 and a video link http://bit.ly/XhlKle), but the damage inflicted by pain policies from central planning remains.
As with any centrally planned mandate, there is always a safe harbor and in the case of pain management it became high dose, chronic narcotics in millions of patients. If you think I exaggerate the role of regulatory agencies in creating a climate that led to where we are today, recall that in 2004 The Federation of State Medical Boards urged that their component state medical boards punish physicians for not treating pain adequately. Since state medical boards usually spring into action when there is a patient complaint, it becomes easy to see how a physician is pressured to write prescriptions that he might not otherwise write.
The American Pain Foundation, which pushed for pain as the “5th” vital sign, annually received up to 90% of it’s funding from drug companies that sold high dose narcotic formulations. After the start of a bipartisan U.S Senate investigation into these relationships, the foundation shut its doors. The American Pain Foundation is no more, but the millions of Americans now physically dependent on high dose opioids, a disproportionate number under the age of 40, are still with us. Stephen Grant, MD, FACEP
