In the year 2007, the State of Ohio found itself in possession of some very threatening statistics. It had an epidemic on its hands, and no one had seen it coming. The death rate in that State from accidental drug overdose, almost all of it due to opiates, had ballooned by 300% since 1999. Now, 37% of all accidental deaths were due to opiate overdose, and for the first time in the history of that state, death from accidental opiate overdose surpassed the death rate from suicide or auto accidents. Moreover, more than 26% of high school students admitted to the use of illegal drugs on one or more occasions. It appeared clear that Ohio had created a generation of opiate addicts, who were killing themselves off at a very high rate, and was preparing their next generation to continue that trend at an even greater degree.
The response of the State of Ohio was substantive in at least two major endeavors. For one, they created a task force to study drug and alcohol abuse, which interviewed addicts in the street, to find out what drugs they were using, what they named them, what they were paying for them in various quantities, how available those drugs were in various cities and counties of the state, how they used these drugs, and what their patterns of sequential use were. Secondly, they created a central data based web site, which required that all controlled substances filled by pharmacies had to be registered in this data base. This web site, called OARRS, and the information gathered by the task force, became extremely valuable to both law enforcement and the medical profession. The Muskingum County Sheriff’s office, for example, states that more than 80% of all the work they do, including break-ins, murders, domestic violence, suicides, auto accidents, raids, stake outs, detective work, etc., relates directly to opiate use. For us as medical professionals, we were suddenly deluged by a large flow of demanding, difficult patients who were requesting pain medicine. Faced with this challenge, our community health center had to decide whether to send all of these patients elsewhere, or to develop our own pain management program. We opted for the latter, and in that effort, found this information available from the State of Ohio to be immensely valuable.
The foremost criterion we selected for patients to be allowed long term opiate prescriptions was that they had to have significant disease in the area of pain, documented in the chart. That disease had to be at least moderate in degree. If there was not that documentation, which correlated directly to the area of the patient’s complaint of pain, no narcotic was given. Provocative dresses in women, crying theatrics, hobbling men who jumped when touched, previous narcotic prescriptions, previous surgery, all did not qualify for entry into our pain management program. Cocaine use in the past, polysubstance abuse in the past, alcohol intoxication leading to hospital care or injury within the last 5 years, failure to follow the rules in two previous pain management programs, all immediately disqualified patients from entry into our program. We did allow patients who were alcoholic, but who had remained sober for 5 years, to be given narcotic medicine, if there was documented reason for their pain. We did allow patients with neuropathy to be treated with narcotic pain medicines if there was electromyographic documentation of neuropathy, caused by diabetes or previous chemotherapy. We did not accept patients for entry into the pain program for some conditions commonly treated with narcotics. Those included fibromyalgia, largely a psychiatric disorder, migraine headaches, a very subjective disorder, and occasional use for arthritis pain. We ruled that if that pain medicine was not needed every day, a narcotic was not indicated for control of that pain.
Owing mostly to my personal naivety, we did initially allow patients who smoked marijuana on a regular basis, to enter the pain program, if they otherwise followed our rules. I considered marijuana to be such a ubiquitous part of the culture in Southeastern Ohio, that I thought it pointless to worry about it. After reading the accounts of the actual street users, as compiled by the Ohio Department of Alcohol and Drug Abuse, however, it became abundantly clear that all of them followed the same pattern of abuse. Whether they were talking about “vics, percs, oxys, coke, black tar, meth, adds or stratts,” they all related the way they used that drug to get high – and then they all used marijuana to come down enough to sleep. It appeared clear that if we did not attempt to control the back part as well as the front part of that equation, we would never be able to exert any control over this epidemic. We posted notices in our examining rooms telling patients that, after a certain date, all those who are found to be positive for marijuana on their drug screens will no longer be allowed any access to controlled substances at our clinic.
Once patients are admitted into our pain management program, they are asked to sign a contract, which was carefully researched and reviewed, and adopted by all the medical staff. Those patients are told by me, face to face, what is in that contract. They are given an instruction sheet, which contains that same information. They are asked to read that contract carefully before they sign it. They are told to take a copy of that contract home with them, to read it point by point, to understand every point, because if it is violated, they will never again get any controlled substances from our clinic. We make it clear that none of them can come back later and claim for valid reason they did not know what they were signing. Their contract, in brief, tells them that they cannot sell this drug, give it away, take it any way other than as prescribed, must show for appointments, must keep all other appointments made for their other health care, will have regular and unannounced drug screens, must use only one pharmacy for their narcotic prescription, and know that this information will be shared with the hospital system, if requested. Their contract is signed and dated, countersigned and dated.
Those who are on narcotics must be seen every 3 months. Those who are on anxiety agents must be seen every 6 months. Those who are on weak opioid agonists, such as Tramadol. Soma and Meprobamate, must be seen every 6 months. No narcotic is ever filled early, whatever the reason, none is ever changed by phone call, none are filled out of state, and all are filled to the date, not before. Those who consistently fill late have the frequency of their prescription reduced, and a note placed in the chart as to the reason for that decrease. Those who persist with strange calls are asked to come in within the next few days for a pill count and additional drug screen. If they do not appear within that time span, their contract is voided. A note is placed in the chart that this patient was on a controlled substance contract, broke that contract, and the reasons for that violation cited.
For each visit, an OARRS report is generated, and carried into the room. It is immediately referred to, to determine what drug they are on, what their refill record is, when they last filled that drug, and whether they are getting any other controlled substance from anyone else. If that report is okay, then they are given one simple statement and asked one simple question. “None of this stuff is good for you. Can you do with less, or do you need the same amount of pain medicine you are now getting.” If they reply that they need the same amount, that is the end of that discussion. We move on to other needs, and refill their prescription, which is given to them only after they have submitted a urine drug screen. If any of them state that they need stronger pain medicine, they are given one additional statement and asked one simple question. “You have to understand that the more of this stuff you take, the shorter your life will be. There are a lot of reasons for that, but that is the bottom line. If you tell me you are aware that the more of this pain medicine you take, the shorter your life will be, and are willing to pay that price, then I have no problem increasing your pain medicine, within reason. Is that what you want me to do? If the answer is affirmative, then they are given stronger narcotic medicine, and that conversation documented. Some are startled to learn that this is not a free ride. Others jump at the chance to get more narcotic.
The reasons for broken contracts are varied. Cocaine use remains high in our community. Use of unprescribed methamphetamines is often seen. Perhaps the most common reason is that patients are not taking the medicine prescribed to them. It is also very common to find that they are taking some other narcotic substances not prescribed to them. It appears abundantly clear that these drugs are freely traded amongst the users. Sometimes it requires detective work, further chart reviews, dates of scripts and dates of fills, additional OARRS reports to see if controlled substances are being given by other medical providers. Once a contract violation is noted, it is triple checked by the nurses who work with me. If all agree, the patient is sent a certified letter which informs them they will no longer receive controlled substances from us. We do offer them further medical care in all other areas, and drug abuse counseling. They are offered an additional appointment to discuss this letter, if they wish. Many do so, and the facts are laid out for them. That decision is seldom reversed.
We used to allow patients who had failed our pain management program to have multiple other referrals for pain management, but no longer do so. If they have failed any other pain management program as well as ours, no referral is made. If they have failed only our program, and consent to counseling, one, and only one, referral is made. It is made only if they complete that counseling. It is a lifetime decision for that patient. At no time, during that rest of their lives, will they get controlled substances from us through any of our service lines, with the exception of psychiatry. They can get those drugs from us only if they are given through our psychiatrists, and keep all their appointments with those psychiatrists,
There are other details about this program, which do not need to be listed at length. Suffice it to say, we have our yellers, slammers and disrupters, who are denied narcotics, and who we have difficulty managing. We are still working on that problem. We do have some variability in the detection of drugs on our screens, and have to be very cautious about fill dates and counting the days, making sure of the date of the contract, contacting other providers who are supplying other controlled substances to that same patient, and correlating refill dates with “as needed” prescriptions. We are still a program in evolution. These are all minor problems, however, in comparison to our one remaining major problem.
There are providers within our own health care centers, and multiple providers in multiple other offices in our community, who are still giving patients long term narcotic medicines without drug contracts, without regular OARRS reports, without regular drug screens, without unannounced pill counts and drug screens, and with refills on their narcotic prescriptions. All of that has to stop, before we can make any headway in reclaiming these wasted lives, and reducing these high narcotic high death rates in our society.