When Michael Metzger forged himself prescriptions for the painkiller OxyContin, he was working more than 65 hours a week as a doctor, caring for patients who were often suffering from the chronic pain such drugs are meant to soothe.

"I was self-medicating, being overwhelmed both physically and emotionally with work. I think that's what happens with most people. They're not planning on becoming an addict," Metzger said.

Over a period of years, self-medicating with prescription painkillers had become Metzger's only method of coping with the long hours and stress of patient care. But the painkillers left him in anguish, unbearably alone and trapped in a dangerous dependence.

"The worst moment is when I think you realize that you are emotionally, physically and chemically addicted. There's the feeling of not being able to survive without the drug, and physically you really can't," Metzger said.

In 2008, Metzger found an escape from his addiction when he was caught and charged with the felony offense of prescription fraud for forging another doctor's signature on prescriptions.

He was lucky. That deeply embarrassing intervention is perhaps the only reason he's now clean and alive - unlike at least 321 Montanans last year whose deaths were associated with the abuse of prescription drugs.

"My knowledge of people with addiction is that they won't stop," Metzger said. "It's not something they will voluntarily stop. They will only stop if there's a crisis."

Last year's death toll from prescription drug overdoses is a 30 percent jump from 240 in 2007, with the figures covering fatalities related to 19 prescription drugs.

According to the U.S. Drug Enforcement Administration, opioid pain relievers, such as hydrocodone and oxycodone, cause more overdoses than cocaine and heroin combined. In its most recent report, the National Drug Intelligence Center found a surge of 114 percent of deaths due to prescription opioids between 2001 and 2005, the last years for which data is available. The center also tracked an increase of 71 percent in those entering treatment programs who reported prescription opioids as their drug of abuse between 2003 and 2007.

"You hear more and more about the impact prescription drug abuse, both illicit and licit, is having, but it's not necessarily on everybody's radar screen," said state Attorney General Steve Bullock.

Bullock, who made combating prescription drug abuse part of his election platform, recently announced the formation of a council composed of lawmakers, health professionals, law enforcement and others to confront the problem of prescription drug abuse. A summit to boost awareness and find solutions has been scheduled for Nov. 17 in Helena.

"It's one of those issues where I don't think the playbook has been entirely written," Bullock said.

In recent years, law enforcement officials, doctors and pharmacists have warned that the abuse of painkillers could become Montana's next drug epidemic. But unlike previous drug waves, painkillers such as OxyContin, Vicodin and Percocet are legal and necessary for pain management. That status has bred unprecedented challenges for police and health care professionals, whose duties are too specific to allow for a frontal attack on a problem marked by legal and medical gray areas.

"We're dealing with drugs by and large that are legal, and it's not going to always be as clear-cut as those investigations where the more traditional drugs were being used or trafficked," said Mike Batista, director of the Department of Justice's Division of Criminal Investigations.

The division recently reported that 42 percent of its drug cases this year are related to prescription drugs, an increase from 7 percent in 2003.

Lacking the needed tools

Metzger may not have been caught if a Billings pharmacist had not reported his prescriptions as suspicious to law enforcement. To outside eyes, he was a successful internist at St. Vincent Healthcare's Broadwater Clinic, living in a stately home on Billings' Bluegrass Drive with his wife and two daughters.

It wasn't all a façade. Colleagues describe Metzger, 49, as a good doctor, and when he was sentenced to three years on federal probation in April, the judge noted that numerous letters from notable people had been sent on his behalf. His family has also stood by him.

Authorities say it's typical for prescription drug abusers to be as seemingly atypical as Metzger.

"You're not talking about your stereotypical mental picture of a drug addict," said Billings Police Chief Rich St. John. "You're talking about professionals. They are in every walk of life."

That diversity and the legality of prescription opiates make cracking down on prescription abuse difficult for law enforcement officers. They can identify and arrest users who engage in pharmacy break-ins, home robberies and street dealing, but those who "doctor shop" to get multiple opiate prescriptions - a practicing that is growing more common in Montana - are harder to apprehend.

"If you go to Dr. A to fill a prescription he has no idea if you went to Dr. B and Dr. C to fill it too and he has no obligation to find out," said Billings Police Sgt. Brian Korell, who leads the department's City-County Special Investigations Unit.

No statute specifically prohibits the tactic, just as no law prohibits getting a quicker high by injecting, snorting or chewing pills that are meant to be swallowed.

"It's not illegal to consume your medication any way you want," Korell said. "At this point we've got nothing within the legal system to assist us with fighting this problem."

About a year ago, the Billings Police Department reassigned one member of its drug unit to the task of apprehending those who commit prescription drug crimes. Recently, the state also received a $1.2 million federal grant to create a six-person team dedicated to fighting prescription drug abuse. Efforts are also under way statewide to better train rank-and-file officers to watch for signs of misused opiate painkillers, as they now look for signs of illicit drugs such as marijuana and heroin when dealing with other crimes.

"Traditionally, we've taught about the drugs of choice, which have historically been drugs other than prescription drugs, so we're adding to our curriculum a segment on prescription drug abuse," Batista said.

But at least until 2012, Montana will lack one weapon that most law enforcement officials argue could be crucial in halting the abuse of opiate painkillers: a prescription drug monitoring program.

Finding a balance

Monitoring programs, which allow doctors and pharmacists to track prescriptions through a database, are being used or developed in at least 38 states. In many cases, law enforcement personnel also can access the databases after furnishing a search warrant or investigative subpoena.

Bills to establish such a program in Montana have failed in the past two legislative sessions, faltering due to what supporters describe as a lack of public awareness and concerns about patient privacy.

"The main objection across the board was feeling like this was an enforcement bill as opposed to a prescription management bill," said Rep. Teresa Henry, D-Missoula, who sponsored the bill in the 2009 Legislature.

Henry, a certified nurse practitioner, carried the bill so health professionals would have a tool to make better care decisions and prevent harmful interactions between prescriptions. She also wanted to ensure the database, which law enforcement could have accessed with a search warrant stemming from an existing case, would not have a "chilling effect" on help being available for people suffering from chronic pain.

"Public safety is a lot of our goal, but we have worked too hard to get appropriate pain management to now have prescribers who appropriately prescribe OxyContin feel like they're going to be investigated," Henry said.

Finding a balance between treating pain caused by a medical issue and identifying pain stemming from an addiction also creates hardships for doctors' offices and emergency rooms.

"Nobody comes in here and says I'm lying to you, and I want to abuse these medications," said Dr. Jim Bentler, the medical director for St. Vincent Healthcare. "They say I have a headache, and I have a history of migraines."

The fact that addicts may suffer from real health problems and may be experiencing painful withdrawal symptoms makes weeding out untruthful professions of pain even harder.

"The subjective sensation of pain is not able to be measured objectively," Bentler said. "There is just no such thing as a pain meter."

At the same time, emergency rooms across the country are handling more opiate-related overdoses, usually brought on by the use of opiates in combination with alcohol or other drugs.

Billings Clinic does not tally opiate overdoses. But St. Vincent's emergency room has seen 42 overdoses related to prescription opiates in the past year. In 2007, it treated 36 opiate-associated overdoses.

Treating those victims, along with the many other emergency room visitors, has to take priority for doctors over separating the addicts from those in real pain, Bentler said.

"My task and my mission are to treat people, so being an investigator, being the police and being a physician is a very difficult thing to do," Bentler said.

Finding a way out

Just being a physician was more than enough for Metzger, who says he was tormented by not being able to do more for his patients who suffered from chronic pain.

"I was overwhelmed by the feeling that I needed to do something and if all I could do was show more compassion, give more energy, then that's what I did," Metzger said. "It was sort of like owning a store and leaving the doors open until nobody wanted to come in anymore."

Metzger is a member of the attorney general's new commission. For him, it's an opportunity for healing and a way to be an advocate for those suffering from prescription drug abuse.

"This council needs to be about more than just taking care of people who are breaking laws and committing crimes," Metzger said. "This is a humanitarian issue."

Metzger, who grew up in Laurel, resigned from his position with Broadwater Clinic last August, and his physician's license is inactive. He does not know if he will ever practice medicine again. Right now he is attending Narcotics Anonymous several times a week, making up for lost time with his family and developing new hobbies, such as fly-fishing.

"I think I'm rediscovering the kid in me that likes to joke, that likes to laugh, that likes to goof around. I gave all that up before," Metzger said. "I just gave it up so slowly over a period of time that I didn't realize it and then who I was was gone."

Contact Kahrin Deines at kdeines@billingsgazette.com or 657-1392.

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