Use or abuse?
East Tennessee residents consume potent painkillers at a rate sometimes twice as high as their middle and West Tennessee neighbors, according to the state's largest health insurer.
Local medical officials can't explain why, but they know a cluster of southern states including Tennessee, leads the nation is use of narcotic pain killers, according to a national drug use survey.
"I've not heard an adequate explanation, and I'm not sure there is one at this point," said Dr. Ron Blankenbaker, the associate dean of the University of Tennessee College of Medicine in Chattanooga.
Data from BlueCross BlueShield of Tennessee detailing prescription rates for two powerful painkillers — hydrocodone and OxyContin — points to what health experts say is a disturbing trend of increased usage.Hydrocodone, a synthetic drug from the opium family is often sold ad Vicoden or Lortab and relieves moderate to severe pain for up to six hours, is the state's most commonly prescribed drug, data shows. OxyContin, a stronger brandname opiate is prescribed less often but is used to treat pain for up to 12 hours. The drugs were originally created to treat patients with chronic pain, but officials said the medication is sometimes prescribed for toothaches and fractures.
For BlueCross customers alone, nearly 300,000 prescriptions for hydrocodone were filled last year. That's about one prescription for every nine of the company's customers.
Additionally, nearly 1.5 million prescriptions for Lortab, the brand name for hydrocodone, were filled last year for 1.3 million TennCare enrollees — more than one painkiller prescription for every man, woman and child on the state run program. TennCare officials said the drugs are needed because the program's enrollees are often sicker than the general population.
"TennCare is a last resort program from people that have a lot of medical conditions and are very sick," said Manny Martins, director of the TennCare Bureau. "(But) just like any other program, we have abuse."
A comprehensive effort to curtail abuse in TennCare and throughout the state is moving through the General Assembly.But national law enforcement officials who track prescriptions of narcotics see the numbers as a growing threat of illegal drug trafficking.
"It's a relatively new area of law enforcement," said William Benson, an assistant director of the Tennessee Bureau of Investigation. "It's something that's not going to go away so we have to be prepared to deal with it on a growing level."
While national law enforcement officials said abuse of painkillers in the Volunteer State isn't out of line with national data, medical records show that patients in Tennessee are receiving more drugs than any other state in the country.That means the abuse of hydrocodone and OxyContin, which have a street value of up to $80 a pill, could grow.
The emerging pattern of prescriptions is shaping a new debate that puts law enforcement at odds with doctors who say the medication is a vital to treating patients with chronic and sometimes debilitating pain.
"Pain is a serious problem that is appropriately receiving increased recognition and treatment from medical professionals," said Dr. Peter Rice, a pharmacology professor at East Tennessee State University. "Almost all health professionals will choose to go ahead and treat patients if there's not a clear indication they're manipulating the system."Still, as medicine finds new, more advanced medications to treat pain, the abuse of narcotic painkillers continues to grow."The physicians are caught in the middle," said Dr. Mitch Mutter, a Chattanooga cardiologist who also is a member of the state Board of Medical Examiners, the regulatory body for physicians. "If you don't relieve pain you're under criticism, and if you over-prescribe you're under criticism."
SEARCHING FOR ANSWERS
To obtain the medicines, some patients "doctor shop" by getting multiple prescriptions from multiple doctors, or purchase drugs illegally. Illict use of the medicines has become so common that federal statistics show non-medical use of prescription medicines is the second most commonly abused drug in the country, second only to marijuana.At local drug treatment centers, prescription drug abuse is found in about 30 percent of patients, said Paula Gault, director of community relations at CADAS in Chattanooga.The most commonly abused medications are pain killers and drugs like Xanax that are sedatives used to treat anxiety, she said.
But the best tool to track abusers who are doctor shopping and monitor doctors who are inappropriately writing prescriptions for pain medication is stuck in a bureaucratic log jam.
In July 2002, Tennessee's General Assembly approved $262,000 to create a controlled substance database that would track patients and doctors. Two years later, the provision is back before the General Assembly as part of Gov. Bredesen's TennCare reform plan, with hopes to getting federal money to support the effort, said Robert Gowan, a Tennessee assistant commissioner in the division of regulatory boards.
The database would track medications for all Tennesseans, not just TennCare enrollees."The quality of what we can develop rests on whether it's included in TennCare," he said. "We can develop what we'll call a bare-bones database, but if we're allowed to put this in TennCare we'd have the system and personnel in place that you need to make this system effective."
A bill pending in Congress would create a national database, but it is stalled in a House committee.Now, the only databases that exist are private and operated by individual insurance companies or pharmacies. That means until state and federal lawmakers decide what to do, the responsibility of tracking patients who misuse the medication and doctors who improperly prescribe it falls on individuals who report abuse.
"It's unfortunate," said Dr. Blankenbaker. "We certainly don't want physicians to back off from the better treatment of pain we're seeing these days, but on the other hand we need to be careful."
FIGHTING ADDICTION
Former addicts know how powerful the drugs can become.OxyContin can be ground to remove its time-release element, unleashing its 12 hour power in a quick dose.
A Chattanooga woman who asked that her name not be printed spent 10 years addicted to morphine, a powerful painkiller that is chemically related to OxyContin and hydrocodone. Now she's celebrating a decade of being drug free.
"I liked that euphoric feeling where everything was just happy and wonderful," she said. "Toward the end, it really gets the point where it's no fun. You have to use to feel normal, just to get through the day."
It's that kind of experience that Ken Huddleston wants to avoid. The Crossville, Tenn., resident has been taking OxyContin for XXX, and is now is working with Chattanooga pain specialist Dr. Thomas Miller to make sure he doesn't become addicted.
A GROWING PROBLEM
Sales figures for hydrocodone and OxyContin show their use is increasing. One manufacturer of hydrocodone posted a 27 percent growth in sales of the drug last year, according to IMS Health, a group that tracks industry growth. OxyContin sales exceed $1 billion a year, and it is the most frequently prescribed brand-name narcotic pain medication, according to a report by the U.S. General Accounting Office.
But the drugs, which can offer great relief to patients with cancer and chronic pain, can come with dangerous side effects other than addiction. Overdosing on the medication can cause patients to stop breathing.
Between 1997 and 2000, 14 states including Tennessee saw increased rates of patients visiting emergency rooms because of problems from narcotic painkillers, according to a report released in April by the Substance Abuse and Mental Health Services Administration. Between 1992 and 2000, the admission rates for treatment from potent pain medications more than doubled, climbing from nearly 30,000 visits to about 60,000 hospital visits.
As growth of the opiate medications continues, the state's medical community also is reviewing a growing number of health care providers who are improperly prescribing the drugs. "We're seeing quite a few more than we used to see," said Dr. Larry Arnold, the medical director of Tennessee's Board of Medical Examiners. "A lot of the cases we review patients simply come in and ask for pain medicine and doctors don't do the work up and just jump straight to OxyContin. That's a real problem."
Dr. Arnold said one Tennessee patient was being prescribed 1,000 pain pills a month — the equivalent of taking one tablet every 44 minutes. Other cases the board reviewed showed patients getting nearly twice the amount of painkillers than someone with terminal cancer.
The state regulatory boards investigates allegations of health provider misconduct that can be reported by patients, family members, insurers and others in health care. After investigations that can take as long as three years, the board hands down sanctions that can be as severe as revoking a doctors' license or a as minimal as a letter of reprimand.
State officials said they don't track how many doctors are disciplined specifically for improper prescriptions, but annual data from a nationwide health advocacy group shows the board took 41 "serious sanctions" on physicians last year, compared to xxx in 1995.
A national campaign by the Association of American Physicians and Surgeons has called the board and law enforcement investigations "21st century witch hunts."The group, representing private physicians across the country, says doctors are prescribing in good faith, and if the investigations continue, doctors won't be willing to prescribe pain medication for patients who legitimately need pain relief.Officials said the only way to keep abuse from growing is to educate health care providers and patients.
Around the state, pain management experts lecture other doctors on how to properly diagnose and treat pain. Last year, half of the country's OxyContin prescriptions came from primary care doctors.
Dr. Miller, who is president of the Tennessee Society of Interventional Pain Physicians, said he carefully monitors patients, only sees people referred by other doctors, and randomly drug tests his patients.
"Doctors are really being educated as to proper ways to write pain medicines, which, really, we were not taught in medical school," he said.
