Doctors will now face increased scrutiny, as part of the Attorney General’s multi-pronged effort to stop opioid overdoses. From the Boston Herald:
The stepped-up effort, [Healey] said, is “so we can shut down pill mills or go after doctors who are wrongfully putting prescriptions in people’s hands without regard to their health or well-being or the safety of the community.”
There is no doubt that opioid abuse is a serious public health crisis in the Commonwealth. What is less obvious to me, is that we can dry up the excess supply of prescription opioids by rooting-out bad doctors.
The Department of Public Health’s Prescription Monitoring Program already investigates the potential over-prescription of opioid painkillers by healthcare professionals. Healey believes that there are rogue doctors or “pill mills” that have been missed by this system. She hopes to find them, in part, by a high profile investigation of Medicaid databases.
What worries me is the potential for Healey’s investigation to dissuade some doctors from providing Medicaid patients suffering from pain with the best medical treatment possible. The medical community has only recently begun to give adequate treatment for pain. Cultural assumptions about pain, suffering and addiction, continue to work against an evidence-based approach to treating this silent epidemic. By focusing her investigatory efforts on a traditionally under-served population, there is great risk of unintentionally exacerbating one public health problem while we try to treat another.
David says
I think it depends on the scope of the problem. I don’t have much information about that; I assume Maura Healey does, and I’d like to hear more about it. A doctor would seem to be the easiest, lowest-risk way to get hold of certain powerful controlled substances that can then be resold at a substantial profit.
couves says
The street price of prescription opioids already far exceeds the price of heroin. Due to unavailability and high prices, many pill addicts end up using heroin, which in far too many cases will eventually kill them.
HR's Kevin says
I think that was his point. If you can get a doctor to prescribe you pills they will cost you nothing more than a co-pay. Most people who do this, whether they are abusing or not, will use the pills themselves so the street price is correspondingly high.
couves says
More than other drugs, opioid abuse seems to take the form of daily use. Due to the high tolerances that develop, even a prescription for oxycontin won’t last very long.
pogo says
First off, only recently has the brand name Oxycontin been rendered tamper resistant and tougher to abuse. But there are plenty of non-time released oxycodone (they are all opiates–heroin, morphine, etc.) drugs available for abuse.
Yes you are right that the price of street opioid pills are far more expensive than heroin. And that is why heroin addicts understand that a $50 bottle of Perc 30s are worth $1,000 in street value and that will buy them a lot of heroin.
Also, hrs-levin has a point, many “early stage” addicts are still trying to avoid Scarlet “H” and pretend that there problem is under control because they are popping pills and not using a needle. That eventually changes.
couves says
I don’t disagree with your first point. There is a long list of opioid medications.
pogo says
My first point is there is a long list of opioid medications that can be abused…which you seem to agree with.
And you seem to dismiss that people are selling their opioid pills…that is not a good thing, it is killing people and that is why there is a need for the prescription monitoring program.
HR's Kevin says
If a doctor has a patient with a history of addiction but has a legitimate need for pain medication, they may require the patient to get tox screens to ensure that they are in fact taking the medicine and not selling it and replacing it with heroin.
To the extent that regular people are given more pain pills than they need, I don’t know how you would monitor that. Perhaps that should be more of an outreach to the general public to encourage them to get rid of excess pills. (BTW, what is the right way to get rid of narcotic prescriptions? Is it ok to flush them down the toilet or something?)
pogo says
There are several options to safely get rid of unused opiates–instead of leaving them in the medicine cabinet for teens (and others) to steal.
There are a number of drop off boxes around the state where people can safely throw them away. Many police stations have them, so call your local one to find out (and if they don’t have them, they cost about $1,000 bucks…a small investment that can save a life). Here is a location finder of one vendor’s boxes, and they have lots of them in Mass.
Another recommendation is to mix the pills (without the bottle) with coffee grounds and garbage and throw them in the trash…which get burned or goes into a land fill. Yes, flushing them down the toilet is not the most environmentally friendly option, but far better than having a tempting target for abuse in your house.
SomervilleTom says
Flushing drugs like this down the toilet is a bad idea, especially if you live in an area like the Cape where private septic systems are common. It is not cool to poison neighbors and wild-life with opiates.
couves says
It’s run by the Department of Public Health.
pogo says
and there is a real need for it…
HR's Kevin says
The State for years has monitored over-prescription of narcotics so I don’t know what she really means by a “stepped-up effort”. Note that the process requires other doctors to review the suspected over-subscriber’s medical notes to see whether the prescriptions are justified. Also note that not all cases of over-prescription is actually due to intentional bad acting on the doctor’s part. I don’t think there is any reason to believe that this will significantly impact doctors’ ability to prescribe pain killers for legitimate reasons.
Prescription opiates are a huge part of this problem. Many people get hooked on prescription pills and then eventually have to move to heroin because it is much cheaper to obtain on the street, so it makes sense to try to do something about the prescription end of the problem. One approach would be to try to discourage surgeons from prescribing a large supply of opiates for patients recovering from minor surgery. I have had minor surgery twice and both times was given prescriptions for ~90 pills of percocet/oxycodone when I really didn’t need more than one or two pills on the day of the surgery. This is an extremely common situation and it is not surprising that many of those excess pills will be abused either by the original patient or a family member.
Jasiu says
I’ve also had this experience. The one time I did need relief for an extended period of time, I asked to get off the narcs (because I just hated how I felt) and was put on Tylenol 3s (codeine), which did the trick. It seems that a similar ramp-down plan could be put into effect for most patients – don’t prescribe more than a week’s worth of the narcotic and re-evaluate when those run out.
couves says
that she shares your concerns regarding those 90 pill prescriptions. As she said in one interview, people are “prescribed prescription drugs and in no time turn to heroin.”
It’s this kind of prosecutorial ambiguity that may cause doctors to change their practices, to avoid any unwanted scrutiny. They may be within the law, but who wants to be a test case?
It’s also worth remembering that prescribing practices are based on medical research. The addiction rate for opioid medications is close to zero, for people without a history of drug or alcohol abuse. The solution to drug and alcohol abuse is, of course, to provide medical treatment for drug an alcohol abuse.
HR's Kevin says
I find it hard to believe that the addition rates are close to zero as you claim. I have seen reports stating that something like 20% of adults have used prescription opiates at least once for a non-medical reason, so there is at least reason to believe that prescription pills are frequently abused even if short of an official addiction diagnosis.
I am also highly skeptical that the number of pills prescribed by surgeons is strictly the result of validated research. In fact, I actually overheard surgeons discussing this issue while I was in pre-op one time and the senior surgeon made it clear that he just gave everyone 90 pills (not sure of the exact number) as a matter of course so that he would not have to deal with patients coming back more.
couves says
for those with no history of addiction is 0.19%. This research is for those being treated for chronic pain, so it may be different in other contexts.
Regarding the prescribing practices or your surgeon — in my experience, refills of post-operative narcotics can be a major hassle, so I can appreciate why some doctors would just prescribe more pills at the outset. Preventing patients from experiencing severe pain (which in some cases, may even discourage follow-up medical care), is no small thing.
There are many considerations that go into healthcare decisions, which are not easy for us to evaluate here on a blog, or for the AG to evaluate either.
HR's Kevin says
Of course, 0.19% is not as close to zero as it may seem. That is still 19 people out of 10,000. This is not very surprising. After all even though there is a so-called explosion of opiate drug abuse in MA the absolute numbers are still a very small percentage of the population at large.
rcmauro says
… I believe by a nurse working in the pain management field.
Anecdotally, many personal stories told by relatives and friends of addicted people blame an initial prescription for an athletic injury for “hooking” them on narcotics. But I don’t know if there is much evidence for this.
couves says
I don’t have professional knowledge of these issues. It’s good to see that there was some representation of the pain management perspective at the hearing.
HR's Kevin says
I think the problem is that there are increasing number of people whose path to heroin starts from some sort of prescription abuse, whether from overuse of one’s own prescription or through an initial “recreational” use.
pogo says
Of course 99.9% of Drs want to do the very best thing for the patient. But with the introduction of new opioids–and the criminal manner in which they were peddled to doctors–the medical community did not implement basic common sense when prescribing them.
The result, a deadly epidemic that is claiming 2 to 3 people a day in our state alone. You mentioned that that narcotics can be safely prescribed if people don’t have a history of drug or alcohol abuse. I’d like to amend that comment by adding…”in their family history” because there is a genetic link. So at the VERY LEAST doctors should be asking that question and they are not (hell Drs ask if people have guns in their home!).
Also, the topic prescribing huge quantity of narcotics as a problem and you understood that a Dr. was making it easier on themselves so people don’t keeping asking for more. That is a completely irresponsible reason. We’re not taking penicillin here, but a highly addictive drug. If the patient (who hasn’t been screened for a history of drug abuse) doesn’t abuse them, they sit in a medicine cabinet for the teenagers to steal…and something like 60% of first mite opiate users get their first pills from their family’s or a friends medicine cabinet.
You gave two very good examples of what “good doctors” are doing wrong. Never mind about the bad ones.
couves says
are not inconsistent with responsible medical practices. There are things that can be done (and there is much of Healey’s agenda that I agree with), but limiting responsible medical use of opioid medications should not be one of them.
pogo says
…where do I argue, “limiting responsible medical use of opioid medications”?
Unless you believe that asking patients if they have a family history of drug or alcohol abuse, or that they prescribe the appropriate amount of opiates (instead of enough so they won’t come back) is “limiting responsible medical use”.
HR's Kevin says
There is absolutely no question that many people are prescribed many more pills than they will ever need under the assumption that they might be one of the people who does need them. It seems that if we can find a way to limit the distribution of unneeded medication that wouldn’t necessarily limit the responsible use of the medication when it is needed.
For instance, instead of giving a patient a huge number of pills for the initial prescription, instead give them a prescription for a small number of pills and a second prescription they can fill if necessary.
couves says
and you would like them to follow “best practices.” Our AG, Governor and others have said similar things.
Medical decisions should be made by doctors, not politicians. If you and your family don’t want to use certain medications, you always have that option. At least let other people make decisions for themselves, with the best advice of their doctors.
methuenprogressive says
He’s about to announce his own “opioid taskforce”.
theloquaciousliberal says
Baker announced and Opioid Addiction Working Group in February:
http://www.mass.gov/governor/press-office/press-releases/steps-to-combat-opioid-addiction-crisis-announced.html
That 16-member group included AG Healey, EOHHS Secretary Sudders and 14 other heavy-hitters.
You still expect a different “Task Force” that “competes with Healey”?
methuenprogressive says
Peter Porcupine says
Note the past tense.
BTW – I had ‘medium’ surgery a year ago. After some time on morphine in the hospital, I was OK for pain. Told them I didn’t WANT opiates upon release, they wrote it anyway. Tore it up and threw it away, but even one batch could have been sold easily.
Christopher says
…and is the concern that doctors are prescribing beyond the limit? The reason I ask is that as long as the substance itself is legal it would seem we have to at least be very cautious about interfering between a doctor and patient, using exactly the same logic many of us use when opposing many restrictions on abortion.
HR's Kevin says
I don’t know if there are legal limits for dosages but there are legal limits for how many days of pills can be prescribed, limits to refills, and requirements for using actual physical prescriptions for narcotics. Those limits are effectively enforced by the pharmacies that actually dispense the medications, not the doctor.
Narcotics are legal when prescribed but are heavily regulated and closely controlled. Doctors must obtain a separate license from the DEA in order to prescribe controlled substances.
pogo says
…people are going to a number of doctors faking pain and getting multiple pain prescription from multiple doctors…how is that akin to restrictions on abortion?
HR's Kevin says
You would need to make sure to see doctors from different medical groups so that they wouldn’t be able to see prescriptions in the medical record. You would also need to fill them in different pharmacy chains. I think this does happen but I don’t know how common it is. Such patients quickly get a reputation so this trick doesn’t work forever.
I do think it is not uncommon for drug-seeking patients to exaggerate their symptoms in order to get what they want. It is not just narcotics either. What percentage of people who are prescribed ED drugs actually have a medical need?
HR's Kevin says
Doctors can search the State narcotics database to see if their patient has prescriptions from other sources and in fact are encouraged to do so. That makes it harder for patients to get multiple prescriptions from different doctors.
pogo says
…and the database has been implemented as part of the effort to curb opiate abuse.
Christopher says
The abortion comparison is that those of us who are prochoice say that the decision to perform the procedure should be between a woman and her doctor. By the same logic, it would seem, the decision to prescribe medication should be between the patient and his/her doctor.
pogo says
Standard pain protocols calls for the Dr to treat pain a patient is in, even if there are no test to verify the cause/source of pain. That allows a dishonest person a lot to work with. Sure some/many Drs. ask tough questions and refuse to give the drugs to people who say they are in pain. Hardly the Dr. / Patient comparison you want to make.
Christopher says
If I as a non-doctor can recognize when a kid I substitute teach is faking to get out of doing something certainly a doctor has the training to figure it out. If I’m in doubt and I send the kid to the school nurse there are plenty of times she says, “You’re fine – go back to class.”
pogo says
You dismiss the reality of Doctor Shopping, which one recent study put at 1 in 5 orthopedic patients, and you forward a sophomoric agreement in dismissing it.
I applaud your ability to identify when a child is faking an illness. But that is hardly evidence that doctor shopping is easy to recognize.
Christopher says
I understand patients, like the aforementioned kids, might try to shop around to get someone to sympathize. I guess I assumed that each doctor consulted whether the first or the tenth by a given patient, would have some integrity and prescribe only as needed. You made it sound like a doctor is required to treat what the patient says is the problem without factoring in his/her professional judgement, and that is what I was pushing back on.
pogo says
First, you are a “Dr Shopping” denier. You mock it equating it with a child trying to fake an illness. Even when I present evidence about how wide spread it is, you still minimize it’s impact.
You also assume (and you know what happens when you ass u me things) Drs. would exercise their professional judgement before prescribing…but I don’t make my point clear enough, because I couldn’t find the correct evidence to back up my point (something you may want to try sometime).
Until recently, IT WAS PROFESSIONAL PROTOCOL to treat pain as a “5th vital sign”. Even though the only way to measure pain was a subjective rating by the patient to rate their pain on a scale of one to ten. Even if the other, objectively obtained, vital signs of blood pressure, body temperature, pulse/heart rate and breathing rate, or other tests gave no indication of pain, Drs were professionally obligated to address this 5th vital sign and–thanks to the crooked Purdue Pharma, makers of Ocxycontin–opioids were the recommended treatment.
So while common sense does support your argument that a Dr would do proper diligence and not just go by the word of their patient…for years that was exactly what the professional protocol required.
couves says
Medical choice is a constitutional right. There is a community interest in regulating certain medical practices, but the fundamental right should still be guarded.
Regarding the doctor’s obligation to the patient — doctors look for signs of addiction and diversion and frequently use drug tests to help with this. There is an obligation to protect patients from harming themselves, when it can be known that this is likely the case. That said, when a patient is lying, it will not always be possible for a doctor to know that. The doctor does have an obligation to treat real pain and this cannot be done by assuming the worst about every patient’s intentions.
When I hear people broadly declaring that medicine is not being practiced appropriately, that makes me worried about that fundamental right for the patient to follow his or her doctor’s advice.
Peter Porcupine says
.
couves says
the AG was looking at data from doctors, clinics and pharmacies. But it’s a good question.
rcmauro says
Full disclosure, I do not work for the Attorney General but I do analyze medical data in another capacity and substance abuse is one of the topics we work on.
The opioid task forces are one and the same; Healey is a member of a task force assembled by Baker. They have been holding public meetings in various locations around the state.
Governor Baker Announces Initial Steps To Combat Opioid Addiction Crisis
In the Herald article, Healey doesn’t mention anything specifically directed at Medicaid patients. There may be some confusion on the part of the original poster regarding what is in the DPH database. It contains information on all controlled substance prescriptions dispensed within the Commonwealth and some data from other states as well. Data is fed in from dispensers (e.g. CVS), not from payers. Here is a good description.
Prescription Monitoring Program (PMP)
With expanded use of the PMP database, analysts would have the advantage of being able to track all opioids prescribed by a single prescriber or obtained by a single patient. Insurance plan databases (including Medicaid and Medicare) have a fatal flaw in this regard: because the drugs involved are mostly generic and inexpensive, even if a plan puts limits on opioid prescriptions a patient can easily get around them by paying cash. Also, these drugs generally have a street value that exceeds the retail price.
couves says
Perhaps the reporter got it wrong, but that’s my source.
Are you suggesting that this is what the AG is doing? Looking at individual patients is a violation of patient privacy and perhaps a HIPPA issue (which is a problem with our medical marijuana law, but I digress…).
rcmauro says
It would make sense that the AGs focus would be on prescribers not patients–since I don’t work with this database myself I don’t know the details, but I assume there could be various levels of masking identity so that patient privacy is not violated.
Note that the AGs office has always had significant involvement with provider data as they have been involved in various legal cases regarding questionable billing, marketing, and so forth.
ryepower12 says
people are dropping like flies.
This epidemic is getting worse and it was already so bad.
Any attempts at stopping it is not a waste of state resources. There are few more important or immediate issues going on in Massachusetts right now.
pogo says
…do no harm. And today, with at least 2 to 3 people dying a day in MA because of opiates, they are currently part of the problem and not the solution.
Yes, 99.9 % doctors just want to help patients. Yet they get duped by a corrupt drug industry and even one bad doctor can wreck havoc and prey on the vulnerable.
Given this level of corruption, it is only prudent for law enforcement to use this data to crack down on the very small but very bad elements in the medical community.
But in general, “bad practices” instead of “best practices” are being implemented by the medical community. With opiates they have a double edge sword. One side alleviates pain and I’m thankful for the comfort these drugs gave my father in his last days. But the other side is a highly addictive blade that, at best, leads to a lifelong chronic battle with addiction…but often leads to death, jail and broken lives.
Duh, in the 90’s we had a new wave of opiate drugs. Yet we focused in the good and ignored the bad…and now the bad is killing people at a huge rate.
Good doctors are unwittingly becoming part of the problem…with addicts going to different drs getting multiple prescriptions for opiates. These regulations give them a understanding that some of their patients are lying to them and this is a tool to stop that. And that is a problem why? And if there is indeed some bad actors…and there are…then we need to stop them
There is NO REASON legitimate why people who suffer from end of life or long term chronic pain will not be able to get opiates. Only if a doctor wants to claim the “scrutiny” may dampen their desire to prescribe…but that is BS. That’s like arguing we can’t have background checks at gun shows will somehow threaten the 2nd amendment. It is a red herring. People are dying, these a re modest rules that can stop a lot of pain for the families to those dying and addicted.
SomervilleTom says
I like this so long as the focus remains on providers and not patients, and so long as patient privacy is preserved.
Opiate abuse is not the only domain for which “MD” should no longer be an impenetrable barrier to further investigation. Massachusetts has a LOT of doctors, and we also have very long history of abuse of disability laws by certain segments of our police and fire employees. Those abuses require the cooperation of corrupt doctors, and I know of no serious effort to pursue those corrupt doctors by Ms. Healey’s predecessors.
Perhaps this might also open the door a bit wider into investigation of the chummy relationships between MDs and pharmaceutical companies.
I’m glad to see Maura Healey demonstrating that a new sheriff is in town.