Editor's note: This story is the first of a three-part series looking at the challenges associated with using prescription pain medication for patients coping with chronic pain.
The public portrait of drug addicts evokes images of skinny, toothless meth users, strung out heroin junkies or crazed cokeheads.
However, more Americans abuse prescription pain medications than cocaine, heroin, hallucinogens and inhalants combined. Many of those addicts don’t fit into the standard stereotype.
In Montana, more than 300 people die each year in connection with prescription drug abuse.
In 2012, 11 percent of eighth-, 10th- and 12th-grade students around the state said they had used prescription drugs without a prescription.
With millions of Americans suffering from chronic pain — many of whom are treated with prescription pain medications — physicians and community members often face a dilemma: They must adequately treat patients who are legitimately suffering and simultaneously attempt to keep highly addictive prescription drugs off the streets and out of the hands of addicts.
When it comes to prescription pain medication, little is black and white. Doctors have to try to decipher the difference between a patient in real pain and someone who might be abusing the system. Law enforcement officials are not only chasing criminals with glass pipes and needles but also ones with prescription bottles and pills.
To begin to comprehend the complexities of the issues, it takes understanding of the source — pain.
The Yale Cancer Center defines opioids as “all substances that bind to the opioid receptors present in many tissues.” Opioid receptors are cell surfaces in the central nervous system that produce a feeling of being high and deaden pain when activated.
The general opioid classification includes all types of codeine, morphine, methadone, heroin and more. In essence, the codeine in prescription Tylenol and the illicit drug heroin are classified together medically.
Many types of pain may result in a prescription for opioid medication, including chronic back pain, post-surgical pain and pain derived from auto-immune diseases.
But physicians and patients alike struggle to pin down a solid answer to the question, “What is pain?”
“There is no objective definition of pain,” said Dr. Matthew D. McLaren, a pain specialist who formerly worked for St. Peter’s Hospital. “Pain management is a very young specialty.”
When prescription pain medications were introduced to doctors decades ago, there was a lack of sufficient information about their effectiveness for treating long-term pain and virtually no information about their highly addictive qualities and adverse side effects.
For years doctors only had two options for treating pain patients — high doses of non-steroidal anti-inflammatory drugs (NSAIDS) or opioids.
“There’s not really anything in between,” McLaren said. “The trend before the early ’90s was to sort of dose to effect.”
When McLaren and his associates established the pain management clinic at St. Pete’s, the goal was to eventually create a program to treat pain patients and also rehabilitate addicts. Physicians in Helena had a minimal arsenal for handling chronic pain patients at that time.
“Until we established the program four years ago here, there was no established pain management program,” he said. “They had a prescription pad or they could send someone 100 miles away.”
When management at St. Pete’s changed and dismissed the program’s original goal, McLaren set out to start his own clinic.
He is in the process of opening what he says will be a truly comprehensive program featuring interventional pain management therapy — injections, implantations, etc. — as well as physical therapists and addiction counselors.
“All of those people have to be ideally under the same roof,” he said.
A prescription for addiction
While many legitimate pain patients struggle to obtain the medicine they need to live normally, the street market for prescription pain pills is expanding.
Lewis and Clark County Coroner Mickey Nelson said he hasn’t necessarily seen a rise in overdose deaths in the county, but prescription drugs are becoming a more prominent factor in accidental deaths.
“Drugs are playing a larger role in definitely our traumatic-type deaths that it didn’t used to play,” Nelson said. “The combination, poly-prescription drug overdose … is more common today than it’s ever been, in my professional opinion.”
Combining prescription opioids with anti-depressants is becoming a popular trend as well, he said.
When the two types of drugs are combined with alcohol — something Nelson frequently sees — it can have deadly effects.
“You’ve got something taking you up, and you’ve got something bringing you down,” Nelson said. “It’s like a rubber band for your heart.”
Scott Larson, the toxicology supervisor at the Montana State Crime Lab said he has also seen an increase in such drug combinations throughout the state.
“The combination of these drugs with ethanol, alcohol, is a really major problem in the post-mortem cases that we got,” he said. “They’re going to depress their respiratory systems so much that it just stops working.”
Between 2009 and 2013, the Montana State Crime Lab has seen the number of DUIs in which prescription opioids were involved nearly double, from 491 cases in 2009 to 788 cases in 2013.
Steve Hagen, the assistant chief of the Helena Police Department, has seen that trend echoed in the city of Helena.
“We’re seeing a drastic increase,” Hagen said. “We’re seeing more and more of the pain medication where folks are either abusing the medication or they’re just on the prescribed amount.
“When that bottle says you shouldn’t operate machinery, it means if you don’t feel yourself, you shouldn’t drive,” he said.
Many opioids cause lethargy and dizziness, which could hinder someone’s ability to drive just as much, if not more, than alcohol.
“That’s where your average person who would never think of drinking and driving would get in trouble,” he said.
Hagen’s department is also working to try and curb drug diversion — the sale of prescription medication on the streets — in Helena.
“A lot of people who are getting (opioids) prescribed to them are not using them, they’re selling them,” he said, noting Hydrocodone pills sell for $1 per milligram on the streets.
Hydrocodone pills are typically between five and 10 milligrams each, meaning dealers could make as much as $10 for an individual pill.
He has also seen an increase in prescriptions stolen from residences.
“A lot of the prescriptions are folks that, oh, they have surgery, they leave them in their cabinet and forget about them,” Hagen said. “And a friend or relative will steal them.”
Lewis and Clark County Sheriff Leo Dutton is seeing similar trends at the county level.
“The cases that our drug task force are working on, they used to infrequently work on a prescription drug case,” Dutton said. “Now it’s common.
“When you have an addiction, you’re unscrupulous,” he said.
When someone lands in jail because of an opioid addiction — whether they are criminally buying, selling or stealing the drugs — it’s easy to place blame on “overprescribing” doctors.
Gray areas in both federal and state laws governing the prescribing of opioids create a conundrum for doctors forced to make black-and-white decisions while sitting face-to-face with a patient in pain.
“We don’t have a protocol for treating pain,” said Cynthia Gustafson, executive director of the Montana Board of Nursing. “The practice rules are more general about giving safe patient care.”
Marcie Bough, the executive director of the Montana Board of Pharmacy said her board also lacks concrete guidelines for regulating prescribers.
“Montana, as with the rest of the country, continues to look at ways to address prescription drug abuse,” Bough said. “Ensuring that legitimate physician-patient relationship down to the pharmacist, but also the valid prescription order and also patient safety —that’s a role that the pharmacist is required to play.”
Despite the absence of a specific set of prescribing guidelines, both the Board of Pharmacy and the Board of Medical Examiners have the responsibility of ensuring licensed prescribers are operating in the best interests of their patients.
Bob Twillman, deputy executive director for the American Academy of Pain Management in California said that concept is great in theory but rare in practice.
“Most opioids are prescribed by primary care doctors, not pain specialists,” Twillman said.
“They’re paid for seeing a new patient every 15 minutes,” Twillman said of primary care doctors. “For turning the room over as quickly as possible.
“And the fastest way to do that is to write a prescription, hand it to the patient and be on your way,” he said.
Lisa Robin, chief advocacy officer for the Federation of State Medical Boards — based out of Texas and Washington, D.C. — echoed Twillman’s concern.
“With many treatments there are significant risks,” she said. “There’s certainly a need for additional research.”
The federation recently released its “Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain,” she said.
“By promulgating its model policies, the FSMB has sought to provide a framework for the legitimate medical use of opioid analgesics for the treatment of pain while emphasizing the need to safeguard against their misuse and diversion,” the policy said.
“Physicians should not fear disciplinary action from the board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met,” the policy said.
But rampant abuse of prescriptions has some physicians regulating their prescribing practices for fear of discipline from the Montana State Board of Medical Examiners.
In Helena, Dr. Mark Ibsen, owner of Urgent Care Plus, knows that fear all too well.
The Board of Medical Examiners is currently investigating Ibsen after a former employee filed a complaint accusing him of overprescribing pain medications to his patients.
The complaint cites eight chronic pain patients all prescribed a high-dose regimen of opioids to treat their individual conditions, Ibsen said.
But, at the time the complaint was filed, he said six of those eight patients had been weaned completely off of their opioids and the remaining two are on lower dosages than when they first arrived at his clinic.
Ibsen is a firm believer in treating the psychological and emotional issues that may lead to or worsen chronic pain. His main goal with every chronic pain patient is to reduce or remove the use of opioids as a primary treatment.
“Ultimately, narcotics don’t work for chronic pain,” he said. “We have to treat chronic pain as a separate illness, as a diagnosis in and of itself.”
Because people across the country are abusing the physician-patient relationship by diverting, some doctors feel they have to turn away people who may be legitimate pain patients simply because they require high doses of opioids to function.
“And then there are people saying that these people are criminals and that the doctors who prescribe for them are criminals,” Ibsen said. “When we start to characterize our patients … or people start to characterize doctors who prescribe narcotics to narcotics patients, we’ve lost the game.
“We’re no longer healers,” he said. “We’re just providers.”