The statistics are staggering, and the cost in lives and dollars is devastating.
In 2008, prescription drug abuse contributed to the deaths of more than 300 Montanans. That number outpaced deaths from motor vehicle crashes, homicides, methamphetamine, heroin and cocaine combined. And that number is growing.
To combat the “silent epidemic,” a task force of physicians and health care personnel from RiverStone Health, Billings Clinic, St. Vincent Healthcare and the Rimrock Foundation have joined forces.
“The problem of chronic pain and opioid abuse is really a community problem,” said Dr. Deb Agnew, chief of primary care for Billings Clinic and a member of the unified task force.
The group was formed in the spring of 2012 through the impetus of Dr. Sharon Mulvehille, who saw a need to address the problem citywide. Since then, the task force was successful in lobbying the 2013 Legislature to establish an interim committee that will study the crisis and come up with best practices for addressing it.
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“We want to address prescription drug abuse, but we don’t want to penalize people in chronic pain,” said Barbara Schneeman, in charge of communication and public affairs at RiverStone Health.
Over the past decade, prescription drug abuse has grown exponentially. According to the Centers for Disease Control and Prevention, more than five times as many women died from prescription painkiller overdoses in 2010 as in 1999. The number of men dying from prescription drug overdose nearly tripled during the same time period.
And the epidemic is everywhere among us.
“We all have been shocked by the face of addiction,” Agnew said. “It’s everywhere. It’s bankers, doctors, teachers, mothers.”
As task force members discuss the problem in Montana, they emphasize that many abusers don’t recognize they fall into that category.
“People don’t start out to get high,” said Dr. Jim Bentler, another task force member and medical director at St. Vincent Healthcare’s emergency room. “They just want to get feeling normal.”
Opioid analgesics, such as Vicodin (hydrocodone and acetaminophen), a drug frequently prescribed for oral surgeries and other pain, account for the majority of the abuse. Even a low dosage can set off a vicious cycle. The drugs not only ease pain, but they target receptors in the brain that result in a sense of euphoria. Because they’re addictive and because tolerance levels rise, the patient seeks ever-higher doses. It’s not uncommon, task force members say, for patients to start “doctor shopping” or going from emergency room to emergency room seeking another prescription.
Adding another angle to the crisis is the illegal trade in opioids, said Lenette Kosovich, CEO of Rimrock Foundation and task force member. With the street value at $1 per milligram, and some abusers craving 100 mg per day, she poses the obvious question.
“I can’t imagine how they can sustain their habit,” she said.
Dr. Megan Littlefield, medical director at RiverStone Health and also a member of the task force, speaks of the challenge that physicians face when trying to treat chronic pain. They must try to differentiate between patients who are faking pain, those with legitimate pain who have become addicted to their meds and those for whom narcotics are an appropriate part of their pain management plan.
“It’s not about denying medicine for chronic pain,” Bentler said. “It’s about weighing the pros and cons of a complex issue.”
Bentler traces the problem, at least in part, to an Institute of Health report from the early 2000s. The report gave physicians a poor grade for treating chronic pain. To make up for that weakness, he said, the health care community “swung too far the other way.”
About that same time, the television airwaves targeted consumers with more and more ads for pain meds.
“We were told they were safe,” Littlefield said. “Though the public’s perception is that they’re safe, actually they aren’t so safe. Meds that are marketed as not addictive often are.”
The problem can also be traced to lack of training. Physicians are taught how to diagnose and treat conditions such as diabetes and high blood pressure but are rarely provided adequate guidance in dealing with chronic pain.
“Chronic pain is 10 percent drugs and 90 percent lifestyle changes,” Littlefield said. “The difficult stuff we can’t write a prescription for.”
To address some of the issues that have already been identified, Mulvehill compiled a protocol referred to as the Chronic Pain Toolkit. Modeled in part after other states’ plans to deal with prescription drug abuse, the toolkit offers guidelines for treating chronic pain and tactics for preventing abuse.
“It’s important to have a consistent message at all access points,” Bentler said.
One step toward reducing the abuse came with the statewide prescription drug registry, which allows physicians to track narcotic prescriptions across the state. With the newly-created interim committee, the task force will offer input to create an approach customized for Montana. If it’s not statewide in scope, Agnew pointed out, the abusers will just go on to the next town.
“We recognize it’s a multifaceted problem,” she said. “If we all get together, I think our solution will be that much stronger. We’re not quite there yet, but we’re building the pieces.”