While the new awareness of the importance of treating pain provided relief to millions of patients, it helped spark a new manifestation of an old phenomenon, the unwitting addict. In the late nineteenth and early twentieth centuries, America experienced the first of what would become several waves of widespread narcotics addiction. The culprit back then were opiate compounds like laudanum which were prescribed by doctors — and sold over the counter — to treat everything from menstrual cramps to alcoholism. Newspapers and literature of the day were full of examples, perhaps most notably the drug-addicted matriarch in Eugene O’Neill’s “Long Day’s Journey Into Night,” of middle-class law-abiding citizens ensnared in addictions that began with medical treatment.
According to Weingarten, patients should be aware of the potential for addiction, even the context of medically necessary pain treatment using opioids. Weingarten said that “habituation” to narcotic pain medication can set in. After stopping the drug, some though not all patients may suffer withdrawal symptoms.
Weingarten estimated that about five percent of the patients at his Suffolk County practice will require some sort of in-office detoxification when their course of treatment is finished. Fortunately, a relatively new drug suboxone can ease patients off the opioid without withdrawal symptoms. The drug works by replacing the narcotic on the brain’s receptors without producing a high. The dosage is decreased gradually over the course of a few months allowing patients to taper off without the discomfort and disruption of full opiate withdrawal.
“It’s really a wonderful drug because you’re not looking at the clock all day waiting for the next pill,” said Weingarten. “People feel normal; they can go about their daily lives.”
Doc shopping
Awareness and prompt treatment can head off potential problems with prescription medications. But for a subset of patients, addictive behavior can set in gradually. According to Al Nace, director of outpatient substance abuse services for HealthAlliance of the Hudson Valley, pain-pill addiction often starts with patients simply taking an extra few doses each day to treat a legitimate condition. Addictive behavior begins to creep in when the pills run out. The next step, Nace said, is often a call to the doctor falsely claiming that the pills were lost or asking a friend for a few old pills lying around the medicine cabinet.
Down the line, patients may begin “doctor shopping,” going to multiple physicians seeking pain medication or buying pills off of the thriving black market. All along, Nace said, addicts may not recognize the seriousness of the situation because the drugs are legal.
“People are just people, they may think they have a value system that keeps them away from all of that really negative street stuff,” said Nace. “But it’s easy to get romanced into addiction with prescription drugs.”
Doctor shopping has become widely recognized as a major route for illicit traffic in prescription drugs. Addicts and black-market dealers in prescription drugs (often one and the same) will relentlessly pursue prescriptions from multiple doctors.
According to Weingarten, family-practice doctors and walk-in emergency-care clinics are the most frequent targets of doctor shoppers. since they may not employ drug screening and other techniques used by specialists accustomed to treating chronic pain. The attorney general’s report found that non-specialists are also more likely to over-prescribe, for example by writing a prescription for two weeks’ worth of painkillers for a condition that is unlikely to last more than a few days.
“The family practice is basically like the sitting duck for patients to be able to get opioids,” said Weingarten. “They’ll come in and say, I fell off a ladder and hurt my leg, and without an x-ray that shows a break there’s no way to tell if they’re telling the truth.”
New York State has recently taken steps to curb doctor shopping. A new plan promoted by the state attorney general’s office would require doctors to consult with an on-line data base before writing prescriptions for controlled substances. The Internet System for Tracking Over-Prescribing (I-STOP) provides real-time monitoring of narcotic prescriptions, allowing — and soon requiring — doctors to check to ensure that a patient seeking narcotic painkillers or other controlled substances has not been receiving the same medication from other practitioners. The state Department of Health, meanwhile has issued new guidelines intended to discourage non-specialists from treating patients for chronic pain conditions.
Lying around the medicine cabinet
But experts say that doctors’ prescription pads are not the only, nor even the most common, method by which addicts obtain illicit pain pills. Far more common than doctor shopping is “medicine cabinet shopping” — begging, buying or stealing pills from friends and family members.
According to a 2010 survey by the Office of National Drug Control Policy, just 18 percent of users of prescription drugs for non-medical purposes obtained the drugs from a doctor and just 4.3 percent reported buying them on the black market. A whopping 70 percent of the misused drugs were obtained from a friend or relative. In most of those cases, moreover, the survey found that the drugs were given away freely rather than purchased or stolen.
“There’s a lot of what would be called drug dealing if it was happening out on the street,” said Nace. “People get it from a well-meaning relative or friend who says, Oh, they’re in pain and I’ve got some of those in the medicine cabinet.”
The brisk traffic in old pain pills lying around the medicine cabinet is a symptom, experts say, of overprescribing. Patients who receive the commonly prescribed painkillers for outpatient surgery or a bad sprain may be left with dozens of pills left over after the pain subsides. The surplus pills then become a tempting target for addicts.
Reducing the number of excess pills in medicine cabinets is one of the goals of Schneiderman’s strategy to combat prescription medication abuse. His plan calls for establishing drop boxes at police stations and hospitals for patients to safely discard their unneeded pills.
Meanwhile, prescription-drug addiction will continue to take a toll. DePaolo said that abuse of pharmaceutical drugs is on the rise among high-school-aged youth and senior citizens, and encompasses a broad swath of society, including many who would never think of themselves as at risk for addiction.
“People think, Hey, a doctor gave it to me, I’m not doing anything illegal,” said DePaolo. “It makes it a little harder to recognize when there’s a problem.”
