Addicts in the ER

AMBI – dog barking… “Down, Tucker,” etc.

I’m sitting with Bill in the dining room of the small apartment he shares with his mother.

In his sweatshirt and ragged shorts, Bill looks like any other college kid on vacation.

These days, he’s clean.

But only a few years ago, he was addicted to opioids – Ocycontin, Vicodin – even heroin.

As he tries to get his dog to settle down, he tells me about a time he faked illness to get drugs.

First, he visited his family doctor.

"I got given a bottle of 40 Vicodin and I used them all in a day."

Then he turned to his local hospital.

"So I went to the ER one night and just said my stomach’s killing me, and without them even thinking twice they gave me a shot of morphine."

And then --

"They gave me a bottle of Percocet to go home with and a prescription to fill the next day."

Doctors here say that there are hundreds of addicts like Bill, who go from doctor to doctor, hospital to hospital, seeking narcotics.
Dealers do the same, looking for drugs to sell.
They’re called doctor shoppers.
David Strang is an ER physician in Franklin.

"On average, there will be some days where you might not see one, you might be suspicious of one, other days you’ll have four people that you just know are trying to con you."

Last year, New Hampshire was ninth in the country for per capita prescriptions of oxycodone – that’s about 20 million pills.
No one knows how many of these pills are misused – but clearly there are many more prescriptions written than are used legitimately.
So why do physicians overprescribe?
One reason: doctors are busy.
David Strang says it’s time-consuming to call other doctors and pharmacies to verify a patient’s story.

"There are a lot of doctors who, even when they suspect a patient may have a problem with substance abuse, it’s a lot easier to write a prescription for six or ten pills of whatever it is in order to get the patient out of the ER and on to the next patient."

And addicts can get aggressive when doctors turn them down.

"I am frightened by many of my patients seeking opioids, many doctors are frightened by the patients that they see seeking opioids, and that’s all there is to it. And patients will threaten us to obtain opioids."

That’s Dr. Gil Fanciullo, director of pain management at Dartmouth Hitchcock Medical Center.

He says the really big dilemma is this: doctors need and want to treat patients’ legitimate pain.

"I’m so concerned about my lovely wonderful patients who benefit so much from the use of opioids. In no way do I want to have to restrict their access to these drugs."

Here’s part of the trouble: David Strang says there is no standard for what constitutes a normal dose of opioids.
And so patients who may need 10 pills often get 30, or they may get a higher strength than they need.
And some might not get enough.

"You’re not going to find this in a medical book or go to a medical school and say here are the prescription standards for headache or a broken wrist or a back strain. It’s going to be very variable from doctor to doctor, specialty to specialty and hospital to hospital."

And Strang says that even when physicians suspect other doctors of overprescribing, they tend to keep silent.

"Except in a case of obvious malpractice, you’re gonna find it hard for a practitioner anywhere to criticize his colleagues’ prescribing habits."

In an effort to cut down on inappropriate prescribing, 39 states now have prescription drug monitoring programs, which allow physicians to look up a patient’s prescription history.
Strang fought for a monitoring program in New Hampshire, which failed amidst concerns over patient privacy.
At the same time, providers have come up with their own policies for dealing with suspected doctor shoppers.
For instance, LRG Healthcare, which runs Franklin and Lakes Region General hospitals, won’t prescribe narcotics for dental pain, because so many addicts complain of toothaches.
But there is no statewide protocol that ER doctors and others can follow for assessing potential drug seekers.
The New Hampshire Board of Medicine and the New Hampshire Medical Society both post pain management guidelines on their Web sites.
Among other recommendations, they say that doctors must examine a patient before prescribing controlled substances.
But the Medical Society’s guidelines were written in 1998, about two years before narcotic overdose deaths began occurring in significant numbers.
And like most states, the New Hampshire guidelines don’t include dosage limits.
According to Gary Franklin, that’s a mistake.

"The problem with that is that I am 99 percent sure that that is why people are dying, that it is related to dose."

Franklin is the medical director for the state of Washington’s Department of Labor and Industry.

In the world of pain management, he’s viewed as a renegade.
He led his state to create pain management guidelines, published in 2007.

At the heart of those guidelines is a recommendation that physicians wishing to prescribe opioid doses that exceed 120 milligrams per day refer patients to pain specialists.

Franklin says it’s too soon to tell whether that limit is helping to reduce overdoses.

But in the meantime, pain specialists are furious.

And chronic pain patient advocates are suing the state of Washington.

They say such dosage limits invite litigation against doctors and have a chilling effect on pain treatment.

Dartmouth’s Gil Fanciullo led the American Pain Society’s effort to create its own new guidelines, which were published early this year.

"What are the unknown repercussions of making that kind of requirement? Does that mean that my 78-year old patient with multiple sclerosis and neuropathic pain in her leg had her dose of morphine reduced because her doctor was afraid she’d have to go see a pain specialist?"

There is some hope on the horizon: drug manufacturers are developing tamper-proof opioids – medications that can’t be crushed or that won’t make people high.

And New Hampshire doctors continue to hope that the legislature will one day pass a prescription monitoring program.

For NHPR News, I’m EG.