Is the crusade against pill mills turning into a witch hunt?

I care for a 65-year-old woman suffering from sarcoidosis affecting her lungs, her skin, her bones, her nerves, her blood chemistries, her kidneys, her colon and her mind. She has gone from an active spouse, mother, grandmother, tearing up the dance floors with her husband, to a home recluse calling friends to drive her to medical and care appointments while ambulating with assistance of another strong individual supported by a 4 wheel walker with a seat. She describes her foot pain as feet burning on fire…

When the Mayo Clinic suggested a biopsy on the normal colon and the pathology revealed a new entity responsible for all her symptoms she was reclassified from a neurotic, annoying wife of a professional to “an interesting and rare case” by many in the medical community. Throughout her trials and tribulations, she has sought the care of board certified gastroenterologists, nephrologists, urologists, rheumatologists, psychiatrists, psychologists, ophthalmologists, dermatologists, general internists and a neurologist specializing in pain management…

Our unfortunate chronic patient had her pain controlled by a board certified neurologist who through trial and error found a formulary that the patient tolerated. During the months of experimentation, the patient suffered through nausea, vomiting, constipation, diarrhea and dehydration. Trips to the ER for anti-nausea medications or IV hydration were frequent and common. When her neurologist found a mix that worked he stuck with it. That patient’s pain doctor moved out of Florida 3 years ago because he was afraid that the implementation of the Florida pain law would limit his patients’ access to needed medications and make his prescribing subject to inappropriate review and scrutiny. He is currently working at a university medical center in North Carolina providing patient care and teaching medical students and doctors in training.

As the patient’s primary care physician, I became the narcotic prescriber for the patient in her neurologist’s absence. The patient executed a pain contract with our office that she has followed religiously while she continued her care with her multiple specialty doctors. We tried several other neurologists and pain physicians but the high volume impersonal nature of medicine today left her unhappy and dissatisfied with the care and attention provided.

When the patient turned 65 years old and went on Medicare, she purchased a Medicare Part D prescription drug plan that directed her to a large chain pharmacy. They told her they would not prescribe her narcotics because they did not want the liability and did not like the combination of medications ordered by her board-certified pain specialist. That company had been fined for illegally selling pills without prescriptions to drug dealers out of their Samford, Florida distribution site.

The alternative pharmacy — a popular supermarket chain — was audited by state regulators. The auditors were upset with the pharmacy releasing a controlled substance in the quantity given especially along with her antianxiety and anti-migraine headache medicines on this patient’s medication list. They had no patient records or history to explain why she was receiving these scripts, but nonetheless so intimidated the pharmacy that they called the patient and told her they would no longer be able to sell her the prescribed pain medicines. The patient called my office in tears wondering where to obtain her medications and frightened about the prospects of abruptly stopping these medications. The pharmacy simply said the liability and fear of losing their license necessitated the change in policy.

I am a board-certified physician in internal medicine, with extra study in geriatrics who has practiced in this community for 36 years. I list on my medical license application every two years that I will prescribe pain medications for legitimate chronic conditions. I take my required continuing education courses especially in the areas of prescription pain medication to meet the state requirements. My patients who receive chronic pain medications must execute a pain medicine contract that outlines their responsibilities as well as mine. I do not take lightly the prescribing of a controlled substance, but recognize that sometimes there are medical conditions that leave you with no other options.

I have been told that after the state regulators look at the pharmacy’s role in prescribing short-term narcotics for long-term use, they will be contacting the Florida Board of Medicine to review my prescribing of these medications for this patient…

The problem with the White House’s heroin program

Most American addicts are not in treatment, however, not even a free 12-step program. Of those who are in treatment, the vast majority will quit or start using again within a year, studies show. And the result is an endless loop of denial, decline, recovery, and relapse.

So what do we do? “It’s not rocket science,” McLellan told NBC News last year as part of a special series on Heroin in America. It’s simple, he says. We need to offer people five years of care, beginning with rehab, progressing through stages of monitoring, and ending up in an out-patient setting. That’s it: acute care, monitoring, and consequences. We already provide it to drug addicted airline pilots, McLellan points out, and we get success rates above 80%…

How many years of care are cancer patients given? From diagnosis to options for treatment to some sort of recovery? How about heart patients, diabetics, or others with chronic conditions? How many years of care do they get? Is addiction considered an acute condition or a chronic one?

But addiction, according to the best science, is a brain disease that can never be cured by the cops. It’s a chronic disease, a lot like diabetes. While absorbing the White House’s new Heroin Response Strategy as a treatment option, consider what it would sound like if the same program were applied to people with a blood-sugar problem.

It would mean busting people with bad diets, shaking them down for details on where they get their food, and launching a multi-state response to the big food cartels that are pushing this stuff down our throats. Then it would mean discharging the user to a church basement somewhere for a 28-day rehab program. Two months later, most likely, they’d be sick again.

Florida Legislation Aimed At Opioid Abuse Tied To Dip In Prescriptions

To address so-called “pill mills,” or rogue pain management clinics where prescription opioids were being inappropriately prescribed or dispensed, Florida passed legislation in 2010 requiring the centers to register with the state and be owned by doctors. The state also established a Prescription Drug Monitoring Program (PDMP), which became operational in September 2011.

A year after both changes took effect, these policies were linked to a 1.4 percent decrease in opioid prescriptions, the researchers report in JAMA Internal Medicine…

To understand the impact of Florida’s “pill mill” law on opioid use in the state, researchers reviewed 480 million prescriptions from July 2010 to September 2012 in the state as well as in neighboring Georgia, which didn’t have a similar law. Overall, about 8 percent of the prescriptions were for opioids. The database included records for 2.6 million patients, almost 432,000 prescribers and roughly 2,800 pharmacies.

Over the study period, total opioid volume decreased 4 percent in Florida and 2.3 percent in Georgia, based on the weight of the prescribed drugs…

Nor did the study track whether the decrease in opioid prescriptions was linked to fewer overdoses or deaths.

Even so, the findings suggest that Florida’s policies are having the intended effect, said Dr. Laxmaiah Manchikanti, a researcher at the University of Louisville and medical director of the Pain Management Center of Paducah in Kentucky.

“Both are meant to control abuse and excessive use and illegitimate use of medications,” Manchikanti, who wasn’t involved in the study, said by email. “Florida’s pill mill law has achieved these goals.”

Andrew Rosenblum, executive director of the National Development and Research Institutes, a non-profit health group based in New York, told Reuters Health by email that in addition to pill mill and prescription monitoring laws, other strategies for cutting opioid overuse include educating patients about risks and encouraging doctors to limit the number of medications prescribed, particularly for short-term pain relief after surgery or dental work…

I feel bad for dentists and surgeons. The drug war is reducing their customer base. Who wants to have a root canal or knee surgery if doctors refuse to treat the resulting pain?