As Dr. Nora Volkow writes on the NIDA web-page, prescription drug abuse has become a major problem in the United States. Nearly 50 million people have reported lifetime use of prescription drugs for non-medical reasons, which makes prescription drug abuse one of the most common forms of drug abuse. Beyond that all indications are that prescription drug abuse is a growing trend.
It was into the ongoing effort to stem this rising tide of abuse that the New York Times Magazine stepped this past Sunday with an article entitled "When is a Pain Doctor a Drug Pusher?" Constructed around the story of Ronald McIver, a D.O. from Greenwood, S.C., the piece examines the often hazily defined regulations and statutes that govern the prescription of powerful pain medications. The piece paints a picture of McIver as a sloppy and perhaps irresponsible doctor who had a deep, and seemingly genuine, interest in helping his patients deal with lives riddled with pain. In doing this McIver provided massage along with other in-office palliative treatments, and he also prescribed an amount of opiod pain medications that raised eyebrows. After one of McIver's patients, an older man with a history of heart problems, died in his sleep with massive amounts of OxyContin in his system, McIver was brought in and tried on a variety of charges. He is now serving a 30-year sentence in a federal prison.
McIver's story is meant to situate readers in the larger discussion about the dissemination of pain medications. On opposing sides of this whole debate are the two elements discussed above: patients who are in pain and need help, and a country that has an ever-growing problem with prescription drug abuse. In the article we hear from law enforcement officials who claim they don't want to tell physicians how to do their job, but then make life hell for doctors who they feel are over-prescribing, a practice for which there is no clear statute.
As the article explains:
Prosecutors are in essence pressing jurors to decide whether an extra 40 milligrams every four hours or a failure to X-ray is enough to send a doctor to prison for the rest of his life. One doctor, Frank Fisher, was arrested on charges that included the death of a patient taking opioids — who died as a passenger in a car accident. A Florida doctor, James Graves, is serving 63 years for charges including manslaughter after four patients overdosed on OxyContin he prescribed — all either crushed and injected their OxyContin or mixed it with alcohol or other drugs. “A lot of doctors are looking for safe harbor,” Caverly said. “They want to know as long as they do A, B, C, D or E, they’re O.K.”
Legislators and those involved in law enforcement have resisted making those kinds of distinctions though, insisting that they want doctors to do their jobs and help clients. But that insistence is tested every time a legitimate doctor is brought in to answer for practices that create even the slightest whiff of impropriety or incidents wherein an irresponsible client abuses his or her prescription.
All of this is problematized by dishonest clients who exaggerate pain or fictionalize pain to deceive prescribing physicians. When the health care system allows doctors only a couple of minutes to assess the situation before making a decision, subterfuge can often go unnoticed:
There are red flags that indicate possible abuse or diversion: patients who drive long distances to see the doctor, or ask for specific drugs by name, or claim to need more and more of them. But people with real pain also occasionally do these things. The doctor’s dilemma is how to stop the diverters without condemning other patients to suffer unnecessarily, since a drug diverter and a legitimate patient can look very much alike. The dishonest prescriber and the honest one can also look alike. Society has a parallel dilemma: how to stop drug-dealing doctors without discouraging real ones and worsening America’s undertreatment of pain.
We addressed this topic over a year ago with a video presentation by William Hapworth, M.D. As he discussed then, much of the onus for prescription drug abuse must fall to the medical community. The authorities have no interest in unnecessarily prosecuting doctors, and physicians have no interest in allowing those unqualified to make medical decisions to tell them how to do their jobs. That means that doctors need to work with state and federal agencies to come to terms on a plan that is amenable to both parties. Writing last March, Dr. Hapworth proposed peer-review as part of a successful solution:
A better method would be for hospitals and physicians to be able to report anonymously a patient who is iatrogenically addicted and the physician or physicians involved in this outcome to a friendly agency. The reporting agency then could contact the physician and progressively educate without punitive action. Repeat offenders would need to have progressively more aggressive interventions. The behavior of physicians would change in a hurry if peer review called their treatments into question.
While the story of Ronald McIver may live in the gray areas that surround this issue, there is no reason for future cases to do the same. We need to work toward a system that helps educate and instruct doctors on constructive application of pain medications, so that they do not fear writing scripts for those clients that truly need them. At the same time, we need to identify the small minority of doctors who may be practicing unscrupulously and determine how to organize proceedings against them. Certainly jail is appropriate in some cases, but it benefits no one to send a careless or over-worked physician to prison for making a mistake. Of course, a pattern of mistakes and blown chances is a different story, but by establishing a network of peer review, the hope is that those situations would be few and far between.
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