Chad Ryan | The Journal Gazette Dr. Tracy Brooks, a professor in the Manchester University School of Pharmacy, served on the Attorney General's task force that wrote the prescribing guidelines for physicians. She also served on the Allen County group that presented and ultimately got approval for a syringe exchange program.
Chad Ryan | The Journal Gazette Manchester University School of Pharmacy students Kacie Knapp and Sipan Keshishyan discuss pharmacists’ roles in the fight against opioid addiction while still providing pain medication.
Sunday, November 13, 2016 7:51 pm
Fight to get prescriptions for pain filled
Ron Shawgo | The Journal Gazette
Emaciated and disheveled, the man waited for the pharmacist to fill his prescription for powerful painkilling drugs.
Suspicious, the pharmacist balked. The store was in Ohio and this prescription was from Indiana. Possible doctor shopping?
Undeterred, the disheveled man got Tracy Brooks on the phone to explain that, yes, the man was a patient in need of the drugs.
"You look at him and if you label and assume, you might label him as a drug addict," said Brooks, a palliative care pharmacist and professor of pharmacy practice at Manchester University in Fort Wayne. "He’s not. He’s a stage 4 cancer patient, and that pharmacist would not fill his prescription."
The medical community is on edge about opioids.
Indiana physicians who prescribe controlled substances and pharmacists who dispense them can be held liable if a prescription is not for a "legitimate medical purpose," according to administrative rules issued two years ago in reaction to a growing epidemic. With an additional burden to thoroughly assess patients, many doctors stopped prescribing opioids, leaving patients waiting months for an appointment with the handful of pain clinics left to treat them.
Meanwhile, substance abuse disorder goes untreated by general physicians who are either untrained to screen for it, believe treatment is ineffective or who lack empathy, according to one researcher. Medical schools are responding by adding curriculum, including substance abuse screening.
"We know that primary care physicians can do a perfectly fine job treating addiction given education, given the right resources, which is contacting counselors and mental health professionals," said Barbara Andraka-Christou, a post-doctoral fellow at Indiana University-Purdue University Indianapolis’ Fairbanks School of Public Health. She made her comments at an Indianapolis drug abuse conference in October.
The popularity of opioids have waxed and waned over the years.
In the 1960s and ’70s, opioids became less popular because of the availability of cocaine, marijuana and other drugs, said Dr. Bradley Allen, senior associate dean for medical student education at the Indiana University School of Medicine. In the mid-’90s, with aging baby boomers developing legitimate medical issues, concerns were raised that chronic pain was being undertreated.
"There was increased awareness and, frankly, I think pressures, brought on health care providers to make sure they were being responsive to individuals who were in chronic pain," Allen said.
Doctors became reliant on prescribing pain medications instead of alternatives, which "are not always appreciated by the majority of primary care providers across the United States," Allen said.
With 109 painkiller prescriptions per 100 people, Indiana was among the top prescribing states in 2012, according to IMS Health, an information firm.
More recently, the New York Times reported in May that for the first time since 1996, the number of opioid prescriptions in the U.S. fell between 2013 and 2015, even as fatal opioid overdoses continued to rise.
Andraka-Christou points to studies that show low U.S. physician involvement in addiction treatment. While national medical organizations, including the American Medical Association, encourage more physicians to address addiction with alternatives, including medication-assisted treatment, or MAT, many doctors choose not to, she said in a phone interview.
MAT – the use of alternative drugs to normalize brain chemistry, counseling and family support – is promoted by the U.S. Department of Health and Human Services as an effective detox method.
And though the nation’s medical schools have increased lecture time dedicated to substance abuse disorders to an average of 12 hours, Andraka-Christou believes not enough require courses on the topic. Substance abuse, she said, is not being addressed like many other treatable diseases.
"It’s not being viewed as, or trained for, as vigorously as other chronic medical conditions that have treatments that work effectively," she said.
Allen said in the last few years the IU medical school has added more than 12 hours of training that address issues surrounding pain medications, including screening patients for abuse. He doesn’t dispute that many older doctors have not been as diligent in responding to the epidemic.
Younger caregivers are in a much better position to detect underlying issues that lead patients to addiction and programs that can help, he said.
"So, I think, we are beginning to be in a better place than we were five or 10 years ago," he added.
Manchester pharmacy students are required to spend about 12 hours focused solely on medications that treat illnesses, Brooks said. In their fourth and final year, students are required to take rotations that expose them to retail pharmacy, hospital pharmacy, and outpatient clinics that bring them in contact with patient pain issues, she added.
For pain sufferers who become substance abusers, Brooks said, "We just need a better mechanism to get these patients into treatment programs."
Brooks uses her Ohio patient as an example of the misconceptions that have grown around the drugs. Too often legitimate patients are denied their medication for chronic pain; too often Brooks finds herself on the phone explaining the need.
With doctors becoming more unwilling to prescribe opioids, Brooks notes high-profile investigations that have put pain sufferers further in a bind.
Dr. James F. Hanus of South Whitley had his office and residence searched in early October after a two-year investigation by federal and state authorities. Hanus voluntarily surrendered his U.S. Drug Enforcement Administration registration, leaving him unable to prescribe controlled substances, according to the Whitley County prosecutor’s office. No details were released other than the investigation continues.
Two local pain doctors, William Hedrick and Michael Cozzi, came under scrutiny for their prescribing practices. Criminal charges were filed against Hedrick. Cozzi’s license is under an emergency suspension until October 2017.
Suddenly, there were more than 3,500 patients who were chronically dependent on opioids but had no prescriber, Brooks said.
Also on the hot seat, pharmacists have become reluctant to sell the drugs if they have the slightest doubt. With no medical records to draw from, all they have, Brooks said, is a prescription and a statewide computer database of patient prescription histories, called INSPECT, but no training in how to interpret the data.
INSPECT summarizes the controlled substances a patient has been prescribed, the doctor who prescribed them and the pharmacy where they were obtained. It’s to prevent patients from using several doctors to provide prescriptions for a drug habit.
"So, what you’re finding now is an atmosphere of patients with legitimate opioid prescriptions that are having a very difficult time getting them filled," Brooks said. "That’s very concerning."
Fourth-year Manchester pharmacy student Kacie Knapp has worked in retail stores for five years. She said a general prescription for legitimate purposes needs more than a diagnosis code. A cancer patient likely has a high drug dose, she said. "But to someone whose thinking, ‘Oh, well, is this a chronic pain? Is it cancer pain?’ Pharmacists are a little wary of that and are hesitant of dispensing higher amounts."
Brooks also says patients seeking pain medications are stigmatized by pharmacies.
Pharmacy student Sipan Keshishyan said some patients prescribed opioids are reluctant to take them because of the stigma. He mentions a patient who declined a low dose of morphine.
"Just because he heard somewhere that he might get addicted to morphine, all of a sudden he’s not OK with taking it," Keshishyan said.