According to the National Institute for Drug Abuse, there are more than 1 million opiate addicts in the United States and that number is rising. One of the reasons include the large number of Americans, from baby boomers to the elderly, who are getting hooked on pain medication for chronic pain.  Oxycodone, a potent opioid painkiller that health authorities say is increasingly abused, is playing a major role. Overall, use of the drug rose by 140% last year, according to a recent federal survey on drug use.

CEASe of Scott County featured guest speaker, Dr. Shane Avery, Family Physician from Scottsburg Family Healthcare. Dr. Avery gave a riveting presentation about opioid addiction, its impact on Scott County, and suggestions for combatting this problem.

Dr. Avery quoted results from a 2009 Indiana University School of Public and Environmental Affairs State Epidemiological Profile, which showed Scott County’s Oxycodone Retail Distribution between January 2, 2007 through June 30, 2008 was 40.3 per capita dosage units per person in the county. This is equal to almost one million doses of Oxycodone sold during this 18 month period in our county of 24,000.  The average rate for all of Indiana was 9.9 dosage units for the same period.  Scott county’s rate was the highest in the state.  Even more shocking, stated Dr. Avery, is that rate is double the next highest county, Floyd, at only 20 dosage units. Sadly, Scott stayed high and yet again showed the state’s highest Oxycodone Retail distribution in 2010 at 48.79 per capita dosage units per person in the county.

Dr. Avery reminded the CEASe members that this number represented the amount of oxycodone dispensed by pharmacies, and was not reflective of who is using.  Many prescriptions are being filled within the county by prescribing providers outside the county, including Kentucky.  Dr. Avery reminded the audience that even if half the prescriptions were being filled by individuals outside of Scott County, Scott county still has a major problem with Oxycodone and other prescription drugs, such as Opana and Xanax.  Why are individuals choosing to come here to get their prescriptions filled?  In addition, many of the young individuals mentioned in the obituaries of the local newspaper are dying as a result of prescription drug abuse.  It is a tragedy of major proportions.

Four Scott County physicians attended the Indiana State Medical Association’s District 3 meeting on Pain Management Issues in Primary Care in Clarksville.  This included Dr. Avery, Dr. Azad, Dr. Kasranini, and Dr. Croasdell.  They heard from Indiana Attorney General, Greg Zoeller and Floyd County Prosecutor Keith Henderson.  Also addressing the physicians were Pain Medicine Specialists James P. Murphy, M.D and Michael Cassaro, M.D., J.D., and Director of Indiana’s  INSPECT Program, Josh Klatte.

Since 2007, the Indiana Scheduled Prescription Electronic Collection and Tracking Program, better known as INSPECT, has sought to provide Indiana health care providers and authorized law enforcement with timely controlled substance treatment information for those patients to whom they are providing treatment.  The information contained in the INSPECT database is populated by all pharmacies dispensing controlled substances to Indiana residents (i.e., in-state, mail order, non-resident pharmacies).  Josh Klatte, director of the INSPECT program, stated that southeastern Indiana has a major problem with individuals coming from Kentucky to fill prescriptions for opioids in Indiana.

At the meeting, the pain specialists discussed opioid analgesics and how they can aid in relieving pain and improving quality of life for many patients.  They learned that the challenge is figuring out who should get them.  In a 2010 review, nearly 1 out of 3 adults in the United States reported chronic pain greater than 7 out of 10 lasting at least 6 months.

Physicians also learned of an initiative mentioned in the January 2011 Family Practice News on Dr. Ed Bujold, a family physician in North Carolina’s rural Caldwell County, who combated this issue by getting county physicians to agree to an aggressive program of monitoring opioid use in their practice.  As part of the program, patients sign a pain management contract agreeing to go to one doctor and one pharmacy.  Their program requires random pill counts and urine drug screens about twice a year for patients with chronic pain who do not have a diagnosis of cancer.  When patients violate their contract, they are cut off.  Caldwell County began using this program in 2007 and saw a 300% drop in prescription narcotic seizures by county law enforcement.

Dr. Avery offered the following suggestions for Scott County in combating prescription opioid abuse:

1. Awareness is high among the medical community that prescription drug abuse is a big problem.  But no provider believes they are a problem.  Professional medical associations nationwide are guilty of double-talk.  On one hand they preach prescribing to relieve patient pain and suffering.  On the other hand they preach restraint and caution to prevent abuse.  When 1 out of 3 adults in the United States report having significant chronic pain, this is a set up for disaster.  Assessing a patient’s pain level is very difficult.  Doctors are worried about being sued if they prescribe too much or if they prescribe too little.  As a result, opioid abuse nationally is up 400% from 10 years ago.  This is going to take a tremendous awakening among physicians nationally for what they have allowed to happen in the name of medical science.
2. The legal authorities are only willing to pursue physicians who show extreme gross negligence, such as Dr. Kamal Tiwari of New Albany, who was arrested and underwent a trial for health care fraud and unlawful drug distribution.  Removal of his practice will help the numbers reported for Scott County, but it’s unclear to what degree.  Greg Zoeller, the Indiana Attorney General, stated that the medical licensing authorities are not helpful with the prosecution of a bad doctor.  Only very rarely will they pull a doctor’s prescribing privileges, and then only after a successful prosecution.
3. As a community, we can encourage our physicians to adopt an aggressive plan for monitoring usage of controlled substances by their patients, such as what has happened in North Carolina. Efforts are being made by staff physicians at Scott Memorial Hospital to adopt these practices for Scott County.
4. Medicaid has a restricted program that could be used to enforce that patients on that insurance see one doctor and go to one pharmacy.  It is not being used currently for all patients who are on chronic opioid pain medications.  This would help to reduce the number of pills circulating on the streets.  Efforts are being made by local physicians to lobby the state of Indiana to consider such a plan.
5. Public awareness of the dangers of prescription drug abuse can be done in the local media. The Louisville Courier Journal just completed a series in the last month on prescription drug abuse in Kentucky.  This could be modeled on a smaller level in our county.  We can empower family members to prevent abuse and help their loved ones get help.
6. The 2009 Indiana Epidemiological Profile study reflects the number of pills dispensed in Scott County pharmacies.  The INSPECT database could answer questions such as where the prescriptions are originating from and where they are being filled.  Despite the unusually high numbers of pills being dispensed in Scott County, Josh Klatte, director of INSPECT states that the database cannot be used legally to help answer these questions.  At this point, only individual physicians or law enforcement can legally access information on individual patients.  Dr. Avery reported that this is a tragedy because such information could be utilized by communities in crisis, such as Scott County.
7. Dr. Avery cautioned that we must be careful when we discuss prosecution.  Locking up offenders appears to be an easy answer, but the system is backlogged and it takes jail space that we don’t have.  We must change public perception of prescription drug abuse in our homes, with our neighbors, and raise expectations of the medical establishment.  Eliminating prescription drug abuse will not solve the problem, as was seen in North Carolina.  Once prescription drug abuse was curtailed in Caldwell County, methamphetamines and cocaine became the drugs of choice the following year.  Dr. Avery stated that historically, people will abuse whatever is the easiest substance they can obtain.  This is a very complex problem that does not have an easy solution.

Dr. Avery stressed at the root of the problem are people seeking an escape to physical and spiritual problems that cannot be solved by their physicians.  But we have grown as a society to expect physicians to provide a pill for any problems we have.  He calls this “chemical coping” and stresses that it is reinforced by professional medical organizations.  For example, recent studies have called into question the effectiveness of antidepressants, despite claims by the manufacturers.  Dr. Avery challenged that the medical community and the pharmaceutical industry are failing to accept the obvious, that the answer to life’s pains and sorrows are not always found at the bottom of a pill bottle.

Dr. Avery closed with, “I personally believe the solution to the problem lies within local churches, who can reach out compassionately to addicts, family members who have lost loved ones to overdoses, and providing positive role models for teenagers.  We have forgotten that physical and spiritual pain are normal life experiences.  I will end with a challenge to each one of you to consider your obligation to others in our community: who do you know personally that is struggling and what will you do to help them?  It’s not their problem, it’s ours.”