Deaths linked to prescription opioid use have doubled in 10 years in Colorado, and the steep increases in both legal use and dangerous abuse of painkillers are forcing the medical community to rethink the way it treats chronic pain.
Painkiller prescriptions written by the top 10 Medicaid prescribers for one popular drug, Roxicodone, shot up 46 percent last year, according to state records. Denver's Office of Drug Strategy found that prescriptions filled for oxycodone rose 58 percent from 2007 to 2011.
Nonmedical use of painkillers in Colorado is 19 percent higher than the national average, according to the Centers for Disease Control and Prevention. To illustrate the "epidemic" nature of opioid abuse, the CDC said enough of the painkillers were sold in 2010 to medicate every American adult with a typical 5-milligram dose of hydrocodone every four hours for a month.
"People think, 'It's a pharmaceutical, it's pure, it's good for me.' That lends itself to a casualness about the use of it," said Art Schut, deputy director of the Arapahoe House addiction-treatment center in Thornton. Patients learn too late that opioids are severely addictive, in part because of their ability to both block pain and induce euphoria.
The number of Arapahoe clients coming in for opioid dependency or addiction has doubled in four years, Schut said. Those kinds of numbers have raised questions about a pain-care philosophy that began more than a decade ago. Doctors say using opioid-based pills to treat lingering pain helped millions of people. But they increasingly acknowledge mounting abuse requires a safety overhaul of their practices.
State epidemiologists say opioid-related deaths in Colorado rose from 182 in 2000 to 421 in 2009, before retreating some. The 2011 count is at least 362 deaths, although the year's review of death certificates is not yet complete.
Opioids for patients in real need "are far and away the most effective treatments in many cases," said Thomas French, a senior instructor in the University of Colorado School of Medicine's Department of Pharmacology. "But they are very dangerous."
A good portion of the problem for doctors and their patients, French said, is "well-intentioned misuse. They don't realize all the dangers and extra care you need to take with opioids."
Kaiser moving aggressively
Kaiser Permanente in Colorado is among those moving aggressively to reform painkiller prescribing and dispensing.
The nonprofit HMO launched a review in January of every painkiller patient in its database. The review spit out lists of patients with complicating risk factors, such as other prescriptions for anxiety drugs or a family history of dependence. The system, covering 535,000 patients and 900 doctors, told each doctor to meet with those on the list within 60 days.
The Kaiser review, more possible in a tightly controlled HMO system with extensive electronic records on each patient, coincided with the highly publicized death of pop diva Whitney Houston. Houston, only 48, had a history of substance abuse, and investigators found unspecified prescriptions in her hotel room just before February's Grammy Awards.
Kaiser's new Castle Rock medical office is experimenting with other ways of ensuring that patients use painkillers legitimately without growing dependent, or giving or selling the drugs to others. Castle Rock won't dispense opioids on Mondays or Fridays, after doctors found troubled patients exploited the busiest prescription-filling days to seek extra pills. The Castle Rock doctors now keep a log of legitimate upcoming painkiller refills to avoid confusion when a patient's doctor is on vacation.
Signed agreements requiredAll Kaiser offices require signed agreements with opioid patients, including Kaiser's right to use random urine tests to check on patient compliance and overall health.
"Our main focus was to try to control painkiller use, instead of it controlling us," said Dr. David Craigie, medical chief at the Kaiser Castle Rock clinic.
Kaiser doctors have also tried to make their pain interviews more specific, hanging a chart in every exam room with a 1-to-10 scale of pain: 8, for example, means severe, "not able to leave my home ... I am in bed."
Plenty of doctors have tales about pain-medication abuse. Craigie recently took a call from a patient who was running out of a painkiller 10 days before it was due to be refilled. In an e-mail exchange, Craigie asked whether family members might be taking the drugs, a common abuse. The patient soon wrote back and said a relative was caught in the act of emptying the pill bottle.
One of Craigie's Castle Rock colleagues, Dr. Howard McGowan, mentioned a troubling patient whose demeanor caused him to check the name against a state database listing all controlled-substance prescriptions. The patient "had been to pharmacies all over the metro area every day for 45 days" getting multiple prescriptions, McGowan said.
Colorado is considered among the state leaders in providing access to the database to avoid such trouble, but checking it is voluntary with each new prescription request.
A growing collection of national voices is urging all pain doctors to take similar aggressive measures, without cutting off care to an estimated 100 million-plus people suffering "uncontrolled pain."
"Opioids can be life-changing, so how do we prevent diversion? That's the issue," said Dr. Paul Christo, a Johns Hopkins University physician and researcher who recommends wider use of urine screens.
"All of us who prescribe opioids need to take the steps to reduce abuse," Christo said. "No one person is completely free of potential abuse. So we should test anyone using opioids for more than three months."
Christo and many other pain specialists pair the drug tests with simpler measures. Christo asks some patients to bring in their remaining pills for a count, to make sure they haven't taken them too fast, given them away or sold them to illicit users.
State health plans are also under increased pressure — for medical and cost reasons — to check opioid abuse in public clients.
Colorado's Medicaid program has seen sharp increases in the painkiller prescriptions written by the top 10 prescribing doctors, according to records provided to U.S. Sen. Chuck Grassley of Iowa and shared with The Denver Post.
The number of Roxicodone prescriptions in that group rose 46 percent from 2010 to 2011, according to the state disclosure. State Medicaid officials said some of the increase may be attributable to the fast-rising overall patient rolls for Medicaid, but said they are also concerned about the trend.
"An indication of a problem""This kind of increase could be an indication of a problem," said Dr. Judy Zerzan, chief medical officer for Colorado's Department of Health Care Policy and Financing. Zerzan said a partial explanation may be the growth in specialized "pain clinics" that can lead to concentration of prescriptions.
"(Medicaid) is now looking into the comparisons over time and seeing if action is needed," Zerzan said.
State Medicaid focuses its prevention efforts on scouring records for patients who seek pills from multiple providers. The state can put a "lock" on patients with a history of doctor- or pharmacy-shopping for extra pills. Those patients are locked into only one allowed pharmacy, which can further screen problems by checking the statewide database for conflicting prescriptions.
Colorado does not require signed opioid agreements for Medicaid patients, saying it is impractical with a wide variety of doctors, and for patients who can't afford treatment delays.
"There is a set of clients that really do need these kinds of drugs, and we wouldn't want them to interrupt their therapy," Zerzan said.
There is no current push to make checking the state prescription database mandatory before writing or filling any controlled-drug order, officials said.
The U.S. Drug Enforcement Agency is not calling for that kind of mandate, said Denver special agent Mike Turner. The DEA is currently pushing for new pharmaceutical rules that would allow people to turn in unused prescription drugs at any time for destruction.
That would broaden an effort currently limited to twice-a-year drug "takebacks" by the DEA and local organizations. Health officials don't want the public to simply flush unused drugs down the sewer, since they can damage water supplies. The takebacks have been successful, but the DEA wants to lift the bar on pharmacies taking back drugs after they are dispensed.
Many patients use part of a prescription after surgery or other short-term pain, then leave the rest sitting in medicine cabinets or drawers. "Unfortunately, as adults we've become our kids' source of supply for drugs," Turner said.
That kind of unguarded access is a key problem, former addicts agree.
Bryce Moeder got hooked on Oxycontin after back pain from warehouse work sent him to prescription-friendly doctors.
"It's amazing how fast your tolerance goes up with these things," said Moeder, who after eventually descending into drug theft is now in outpatient treatment. "You could measure that daily. When I first started taking them, three 20-milligram pills would keep me messed up all day. Nine months later I could take six of the 80 milligrams a day without even the same effect."
Early in his addiction, Moeder said, he could go to three or four urgent clinics in one afternoon for different prescriptions. When those grew more connected and shared records, he went down the common list of addict access: faking injuries to get new prescriptions from pain clinics; searching friends' houses for leftover pills; breaking into houses and medicine cabinets; and even following customers out of clinics and stealing their prescriptions in the parking lot.
Doctors can help deter illegal use of legal prescriptions with their new measures, Moeder said, but they shouldn't simply cut off patients who fail a urine test. The addiction is so severe, treatment experts agree, dependent patients need to be tapered off opioids with replacements and counseling.
Pharmacies also can do more, Moeder said. "Schedule II," or restricted, drugs that include opioids should have their dosages and pill totals confirmed with the prescriber every time, he suggested. That would cut down on patients' altering prescriptions to get more pills.
Clinics can do the most good, Moeder said, by focusing on legitimate pain patients who might be on the brink of problems. Hard-core addicts will always find a way to get pills.
"It's an epidemic," he said, "and it doesn't seem like it could be controlled by one move."
Michael Booth: 303-954-1686, firstname.lastname@example.org or twitter.com/mboothDP
Know your opioids — and how to handle them
The opioid-derived painkiller prescriptions that have grown so much in recent years include an array of brand names and generics. They are highly prescribed, in part, because they are very effective at blocking pain; they are highly addictive because they also flood the "reward" pathways of the brain with good feelings, in the same way rewards are sent by drinking, eating and intimacy.
The most common forms are morphine, methadone, hydrocodone, fentanyl, oxymorphone and oxycodone. The more common names attached to brand names or generics include OxyContin, Vicodin, Percocet, Roxicodone, Roxanol and, more recently, the Opana version of oxymorphone.
HOW TO GET HELP
For help with questions about painkiller dependency, abuse and addiction, go to arapahoehouse.org. Addiction Research and Treatment Services, or ARTS, is also a good source. It is located at the University of Colorado Anschutz Medical Campus. Go to artstreatment.com. Also, the federal government has a substance-abuse referral at samhsa.gov and 800-662-HELP.