A year ago, John realized that his daughter, Jane, was addicted to powerful prescription drugs used to alleviate pain, depression and anxiety.
John, who is in his late 50s, leads a “back to the land” lifestyle and runs his own organic products business. Jane is in her 30s and has two young children.
Jane had trouble with alcohol through her adult life, John said. A year ago, he said, he learned that she was also hooked on powerful pharmaceutical drugs.
Jane and her children were living with John at the time, and she helped him out with his business, which is labor-intensive.
One day, he said, he received a call from a local hospital regarding an appointment she had made for an injury to her arm. She hadn’t mentioned any injury to him. So, with a little investigation, he said, he became aware that Jane had been “doctor-shopping” for powerful anti-pain narcotics such as Vicodin and anti-anxiety drugs such as Lorazepam, and also obtaining prescription medications on the street. The drugs are used recreationally for the euphoria they induce.
John recalled a conversation he had with one of his daughter’s treatment providers.
“I told the head nurse that when the doctors prescribe these pills, they ought to superglue the pill bottle on their head with the side effects, so as we’re walking by we know who’s on what. Because they’re driving by you every day on the highway. And it’s legal.”
Jane insisted that she needed the drugs solely as medication, John said.
But, John said, he found himself witnessing his daughter’s slide into drug addiction and neglect of her children.
Two months ago, the family reached a crisis point. Jane and her children were living at her father’s house. Jane had disappeared and John went to look for her at the homes of friends where she hung out in the neighborhood. At one home, John happened to answer the phone – and heard the voice of his daughter. Jane apparently thought it was her friend on the line.
“She calls his house and she said, ‘I need drugs,’” John said. “She didn’t know it was me on the phone. I said, ‘You know who this is?’ She said, ‘Who?’ And I said, ‘It’s your father.’”
John returned to his house to find that his daughter had made two slice marks on her wrists. She wasn’t bleeding and didn’t need hospitalization. Still, John said, “It was an attempt. It was crying out for help.”
Jane subsequently signed over temporary custody of her children to her father and agreed to seek help at the Open Door Recovery Center in Ellsworth. Although she left town for a while – during which time John began the process of obtaining permanent custody of his grandchildren – she has now returned and is receiving treatment.
John said he was willing to share his family’s story as a way to raise awareness about the phenomenon of “doctor-shopping” and the need to stop the practice. Part of the responsibility for stopping the practice, he said, lies with the medical community.
His daughter, he said, is like many people who get hooked on powerful, euphoria-producing medications that are prescribed by providers who don’t look into a patient’s prescription history.
“It’s a path of death and destruction everywhere they go, the drugs and the alcohol,” John said. “The side effects are frightening. They get enraged and there’s violence and suicide. And they’re everywhere. They can get them like candy.”
In 2003, the Maine Legislature recognized the gravity of the problem of doctor-shopping when they passed a law to institute the Prescription Monitoring Program.
Administered by the Department of Health and Human Services’ Office of Substance Abuse, the PMP is a tool created to prevent and detect prescription drug misuse and diversion.
The question, however, is whether prescribers use the service. It turns out than far fewer than half of most categories of Maine’s clinicians use it. According to a “scoreboard” maintained by Maine’s OSA, the numbers are as follow: dentists, 16 percent; medical doctors, 29 percent; nurse prescribers, 41 percent; osteopathic doctors, 47 percent; physician assistants, 52 percent; and podiatrists 11 percent. Only 33 percent of all prescribers in Maine use the PMP.
“It’s an intervention tool for the people who use it,” said OSA director Guy Cousins. “Every prescriber is given information about it. But not all of them use it.”
“We could certainly be utilizing the monitoring program much more,” said Rep. Anne Perry (D-Calais).
Perry is the chairman of the Legislature’s Health and Human Services Committee and the sponsor of the legislation that resulted in Maine’s PMP. She is also a family nurse practitioner in Washington County.
“We were hoping there would be more buy-in by physicians and [other health care] providers,” said Perry. “It’s a good tool.”
The PMP is designed to maintain a database of all transactions for controlled substances dispensed in the state. Pharmacies – both in and out of the state – submit data weekly. The database is available online to prescribers and dispensers Clinicians have immediate access to a patient’s history with Schedule II, III, and IV controlled substances. Schedule II-IV comprise those drugs which have a potential for abuse but also have medical uses. Schedule II poses the highest potential for abuse; this class includes Oxycontin and Ritalin. Schedule III drugs are slightly safer and less prone to abuse; this class includes Vicodin. Schedule IV drugs, such as the benzodiazepines, are considered less potentially harmful and addicting than those in the Schedule III.
Schedule I drugs, such as heroin, have extremely high potential for abuse and no medical application in the United States. The drug schedules were established by the Controlled Substances Act, passed by Congress in 1970.
According to the National Institute on Drug Abuse, the most commonly abused class of controlled drugs are opioids, which treat pain; central nervous system depressants, for anxiety and sleep disorders; and stimulants, most often prescribed for attention-deficit hyperactivity disorder.
Opioids include morphine, codeine, oxycodone (e.g., OxyContin, Percodan, Percocet), and related drugs. Opioid drugs can induce euphoria by affecting the pleasure regions of the brain. The feeling is often intensified by administering opioids in ways other than those recommended, such as snorting or injection.
Depressants, sometimes referred to as sedatives and tranquilizers, are useful in the treatment of anxiety and sleep disorders. They include barbiturates such as Mebaral and Nembutal; and benzodiazepines such as Valium, Librium and Xanax. By increasing the activity of a particular neurotransmitter in the brain, depressants produce a drowsy or calming effect.
Stimulants include medications such as Dexedrine, Adderall, Ritalin and Concerta. Historically used to treat respiratory problems, obesity, neurological disorders, and other ailments, stimulants increase alertness, attention and energy. They do this by enhancing the effects of brain neurotransmitters such as norepinephrine and dopamine. This increase is associated with a sense of euphoria.
According to the “National Prescription Drug Threat Assessment 2009,” issued by the U.S. Department of Justice’s National Drug Intelligence Center in February 2010, doctor-shopping is one form of the “diversion” of controlled drugs. Diversion also involves the sharing or purchasing of drugs between family and friends or theft from family and friends. And drugs are sometimes diverted, said the report, by “unscrupulous physicians who sell prescriptions to drug dealers or abusers, unscrupulous pharmacists who falsify records and subsequently sell the drugs, employees who steal from inventory, executives who falsify orders to cover illicit sales, individuals who commit burglaries or robberies of pharmacies, and individuals who purchase CPDs from rogue Internet pharmacies.”
Pain relievers are the most widely diverted and abused prescription drug. Most diverted pain relievers are controlled prescription opioids.
“Often these drugs are unused and unneeded pills prescribed to treat pain for a temporary condition such as recovery from a surgery,” the report says. “Implementing a national incentive program for patients to return unused pills to collection facilities for proper disposal would reduce the diversion and misuse of CPDs.”
In the meantime, the report says, more opioids than ever are made or arriving in the United States, due to increased demand for new or more aggressive pain treatment.
Given the prevalence of controlled substance, the report says, the problem is to find a way to stop the doctor-shopping phenomenon and other forms of diversion.
Prescription monitoring programs have turned out to be key, the report says. Doctor-shopping has decreased in states that have implemented PMPs. Currently, 40 states either have operating PDMPs or have passed legislation to implement them.
“However, many individuals continue to acquire the drugs by simply traveling to doctors in nearby states where there are no such programs,” the report says.
To stem the problem further, the report calls for increased information-sharing between physicians, pharmacists and law enforcement officers. To this end, the report says, PMP representatives are working to establish a nationwide information-sharing platform.
Maine’s PMP has been up and running since 2005, said OSA director Cousins. The web-based system allows any prescribing physician and pharmacy to sign up free of charge and access it from anywhere. Data is downloaded weekly.
“To be a member, all you have to do is sign up,” said Cousins. “If I’m a prescribing physician, and a patient tells me he has chronic pain, I can go into the program and get access to information about this person and find out if they got any other medication from any other prescriber,” he said. “The gist of the mechanism is, if somebody is coming to me for additional pain medication, I need to be talking with the other care providers” to address potential addiction issues and coordinate care.
The prescriber’s ability to discern between a real need for medication and “doctor-shopping” comes down to knowledge, training and skill, said Cousins. The PMP is an additional and useful tool, he said.
The OSA disseminates information about the PMP to the medical community, said Cousins.
Information gathered from the PMP shows that, like the nation, prescription drug use in Maine is trending upward. Between June and December 2009, 1,210,411 prescriptions were reported to the PMP, an increase since 2005, according to the OSA’s May 2010 report, “Substance Abuse Trends in Maine.” Prescriptions for narcotics consistently account for the bulk of the reports – 50 percent – followed by tranquilizers and then stimulants.
The latest survey by the OSA shows that people age 18 to 35 have the highest rate of admissions to treatment for prescription drug addictions. There were 3,423 treatment admissions for prescription drugs in 2009. The number of admissions for prescription drug misuse/abuse has risen for people age 18 to 35 since 2006. In 2009, 11.3 percent of high school students – one in nine – and 6.6 percent of students in grades 7 and 8 used a prescription drug without a doctor’s prescription.
Perry said she was motivated to sponsor the original bill in her capacity as a nurse practitioner, when she and colleagues found that the incidence of hepatitis B was growing; the liver virus is associated, in part, with the use of contaminated needles. In order to get information about the type of drugs being used, Perry said, she and colleagues spent an enormous amount of time calling pharmacies – time that would have been better spent, she said, on treating her patients.
Perry said that she routinely uses the PMP. The program, she said, is essential not only for people who may have substance abuse issues, but those who may, for example, have trouble remembering their prescription history.
But the OSA’s scoreboard of those providers who use the PMP shows that it is underutilized, she said,
There has been some discussion in her committee, Perry said, of finding a way to make sure that all health care providers sign up for the PMP. However, she said, it would be difficult to enforce the use of the PMP, even among those providers who are signed up.
As the use of health information technology systems increases, and as they become easier to use, it is likely that use of the PMP will also increase, Perry said.
“There’s a lot of work being done on health data systems,” said Perry.
Currently, Perry said, providers might not have signed up on the PMP because of lack of awareness or lack of time.
“I’m sure that time is a factor in that,” she said.
Both Cousins and Perry suggested that anyone interested in strengthening the law or making other changes should talk with their legislator or with the Maine Medical Association.
For one father and grandfather, the biggest concern right now is to make sure his grandchildren grow up in a stable, healthy home. Before his daughter’s recent turnaround, a visitor to his home enjoyed the enthusiastic greeting of one of John’s bright-eyed grandchildren. The 5-year-old hopped up in his grandfather’s arms for a quick cuddle and then was off, vrooming around on a plastic trike in the spacious yard and.
His situation as a grandparent, John said, is not unusual.
“Five of my friends, we’re all grandparents, and we’re all raising our grandchildren because our kids are on drugs – pharmaceuticals, methadone, OxyContin,” he said. “It’s an epidemic.”
(Published in The Bar Harbor Times, Nov. 3, 2010.)