A pill problem: prescription drug abuse is the fastest growing form of substance abuse.

Hanson, Karmen

The figure is startling: A 96.6 percent increase in drug-related deaths in a five-year period.

What's most shocking is that the drugs involved are not cocaine or heroin or even methamphetamine. They are prescription drugs--medication prescribed every day by doctors, mostly for pain.

"The prescription drug problem is a crisis that is steadily worsening," says Dr. Len Paulozzi, a medical epidemiologist with the Centers for Disease Control and Prevention. "The vast majority of unintentional drug overdose deaths are not the result of toddlers getting into medicines or the elderly mixing up their pills. Our scientific evidence suggests that these deaths are related to the increasing use of prescription drugs, especially opioid painkillers, among people during the working years of life."

Opioid analgesia painkillers, one of the largest growing segments of prescription drugs, are medications such as OxyContin, Darvon and Vicodin. They include ingredients such as oxycodone, hydrocodone, fentanyl and propoxyphene. More than 201 million prescriptions were written in 2007 for products that have a potential for abuse opioid analgesics, methylphenidates and amphetamines--according to Verispan, a prescription information database.

It was a CDC study that found the 96.6 percent increase in prescription opioid analgesic-related deaths in 28 metropolitan areas from 1997 to 2002. During the same period, deaths from cocaine overdoses increased 12.9 percent, and deaths from heroin or morphine decreased 2.7 percent.

The problem is growing faster than previously estimated. Some 4.7 million people used various prescription drugs--pain relievers, sedatives and stimulants--nonmedically for the first time in 2008, according to the National Survey on Drug Use and Health.

As Paulozzi points out, "drug overdoses are now the second leading cause of unintentional injury death in the United States, exceeded only by motor vehicle fatalities.

People who initially take prescriptions for legitimate pain relief may go on to abuse these drugs for a recreational high. Others are abusing prescription drugs from the beginning as an alternative to illegal drugs.

State legislators are hoping to reverse this growing trend. In 2009, at least 11 state legislatures enacted Drug Abuse Awareness months, regulated pain clinics, and created prescription drug monitoring programs and unused prescription drug disposal programs to help prevent fraud and abuse and to rehabilitate current abusers.

GOING AFTER THE SUPPLY

The problem is widespread across the country, hitting every type of community. It began to increase after doctors started treating chronic pain with new, stronger medications in the 1990s. While thousands of people use these products legitimately every day, they may become addicted if the drugs are not used as prescribed.

More than half the nonmedical users of prescription pain relievers get them from a friend or relative for free, according to the national drug survey. The majority of those people had obtained the drugs from one doctor. Fewer than 10 percent bought the pain relievers from a friend or relative.

In Iowa, the Division of Narcotics Enforcement opened 243 percent more pharmaceutical abuse cases and seized 412 percent more prescription drugs in 2009 than in 2008. And the Statewide Poison Control Center reported a 1,225 percent increase since 2002 in calls about suspected hydrocodone and oxycodone overdoses.

To combat such increases, Iowa launched the first statewide prescription and over-the-counter drug abuse awareness campaign, called Take a Dose of Truth. A website features information for teens, parents, older adults and professionals on recognizing, educating and treating prescription drug abuse.

FLORIDA'S "PILL MILLS"

In some states, such as Florida, pain clinics are popping up everywhere, including in shopping centers. In fact, Florida has one of the highest concentrations of pain clinics in the country. Doctors in Broward County, for example, handed out more than 6.5 million oxycodone pills, and 45 south Florida doctors gave out nearly 9 million oxycodone pills in the second hall of 2008, according to an interim report of the Broward County Grand Jury.

Florida's numbers are potentially larger than nearby states because it does not have a prescription drug monitoring program. Pill seekers from across state lines may prey on neighboring states that do not track who is filling prescriptions for products prone to abuse and recreational use.

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John Burke, president of the National Association of Drug Diversion Investigators, says he saw the problem play out before when Kentucky had a prescription drug monitoring program, and Ohio did not.

"Scores of folks from the Bluegrass State carne into Ohio to obtain their medication at our pharmacies. Only after Ohio put their [program] in place did the influx of Kentucky illegal drug-seekers subside.

"Unfortunately this same situation exists today in Florida," he says. "The migration of Ohio drug diverters to Florida to obtain prescriptions for oxycodone is partly fueled by the fact that no [monitoring program] exists yet in Florida."

Florida legislators are considering bills to better regulate pain clinics and ensure legitimate medical need. For example, Senator Dan Gelber is sponsoring legislation that would require private pain management clinics to be registered with the department of health.

"Last year's effort to stem the tide of 'pill mills' didn't preclude felons from owning and operating pain-management clinics. This industry has attracted far too many bad apples, and this loophole needs to be closed," says Gelber. "This new provision is just common sense. The public expects, and the state should guarantee, that we not allow convicted felons to be in the business of providing powerful narcotics to people who need legitimate pain management."

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SENATOR

DAN GELBER

FLORIDA

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REPRESENTATIVE

JOSEPH ABRUZZO

FLORIDA

A House bill proposed by Representative Joseph Abruzzo would allow only licensed physicians to own and operate the pain clinics. "This is a national issue, as law enforcement agencies across the country are finding pill bottles with Broward or Palm Beach county addresses on them," Abruzzo says. "We need to make sure that the people who own and operate these clinics are licensed medical professionals."

Another House bill from Representative John Legg would limit pain prescriptions to a 72-hour supply. This effectively would eliminate abusive pain clinics, Legg says, that make money from volume dispensing, not physician visits or prescribing. Patients requiring more than a 72-hour dose would have to go to a licensed pharmacy to fill their prescriptions, instead of getting the drugs directly from their doctor's office or a questionable pill mill.

Texas lawmakers recently passed legislation to regulate pill mills because of concerns similar to those in Florida.

"The legitimate practice of pain management clinics has a valuable role in the state," says Representative Mike Hamilton, one supporter of the new law. "However, some pain management clinics work as an illegal drug diversion, causing great harm to many families and communities. We have seen an increase in the demand of controlled substances throughout the state, and part of the problem is the proliferation of these pill mills."

ROLE FOR DOCTORS AND PHARMACISTS

Physicians and pharmacists play pivotal roles in curbing abuse. They are expected to identify and care for patients who are dependent on or addicted to prescription medicines and to help prevent prescription drug abuse. It is often difficult, however, to determine if a patient is one of the 70 million Americans who experience pain every day or among the 10 percent who struggle with addiction.

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REPRESENTATIVE

MIKE HAMILTON

TEXAS

Physicians, including most in primary care and emergency medicine, are often trained to recognize drug-seeking behavior and how to thwart drug abuse. They may also rely on validated questionnaires or interview instruments to recognize uncontrolled pain, and have recently begun using clinician-patient agreements defining the expectations and responsibilities of patients receiving addictive substances. Doctors also can refer to prescription drug monitoring programs for more information about a patient's history with controlled substances.

These approaches, however, can increase time-consuming paperwork. And even the well-trained and methodical physician can fall victim to dishonest patients.

Pharmacists are responsible for ensuring that patients get the most benefit from their medications. They can also be part of the first line of defense in recognizing prescription drug abuse. By monitoring prescriptions for falsification or alterations and being aware of potential "doctor shopping"--patients who obtain multiple prescriptions from different doctors--pharmacists play a valuable role in prevention. They are trained to detect suspicious behaviors, including fraudulent prescriptions.

About half the states require security features such as watermarks on prescription pads to help prevent fraud. Pharmacy and insurance company computer systems may also issue a warning if patients are taking too many controlled substances or refilling their prescriptions too quickly.

State and local pharmacy associations have historically relied on "phone trees" to contact each other when a physician reports a stolen prescription pad or a customer attempts to pass a fraudulent prescription. Greater use of electronic health records, electronic prescribing and the exchange of information may help prevent drug abuse and diversion.

"The best way for a pharmacist to balance the risks of drug abuse and undertreatment is to have a relationship with the patient and the physician," says Dr. John O'Brien of the College of Notre Dame of Maryland School of Pharmacy. "A pharmacist-physician conversation can identify more information helpful in preventing a chronic pain sufferer from being branded an addict, and also identify a patient in need of assistance with addiction or dependency."

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Excluding alcohol, prescription drugs are the second most commonly abused substance--marijuana is the first--according to a 2007 study by the Substance Abuse and Mental Health Services Administration.

In response, most states are using Prescription Drug Monitoring Programs to help regulatory and law enforcement agencies and public health officials collect and analyze controlled substance prescription data. Statewide databases contain information from pharmacists and other prescribers on drugs dispensed in the state. Most states keep track of drugs with the most potential for abuse, such as pain killers, tranquilizers, stimulants and some steroids, referred to as Schedule II, III and IV drugs.

As of late 2009, 40 states had laws establishing the monitoring programs, and 33 states had operating ones.

The programs vary in how they identify and investigate potential abuse. Some are reactive, health-oriented monitoring programs and generate reports only in response to specific inquiries. Other states identify and investigate cases as well as generate unsolicited reports when suspicious behavior is detected. A 2006 study conducted by Simeone Associates Inc. for the Bureau of Justice Assistance found enforcement-oriented programs to be more effective at reducing drug supply and potential abuse than reactive ones.

Some concern over patient confidentiality have been raised by physicians, pharmacists and patients. In response, states with drug monitoring programs often have legal safeguards in place that limit access and use of confidential health care data, as well as statutory penalties for misuse.

In Kentucky, for example, state law prohibits any authorized user from sharing that information unless under court order. Misuse of data can result in a felony conviction.

Other state programs have been delayed by the costs of creating and operating them. Start-up costs average $350,000 and state annual operating costs range from $100,000 to nearly $1 million, according to the U.S. Department of Justice.

Since 2002, congressional appropriations to the Bureau of Justice Assistance have supported competitive grants under the Harold Rogers Prescription Drug Monitoring Program. To be eligible, states must have or plan to have a law requiring drug prescribers to submit information to a central database. So far, more than 100 grants have been made to plan, start or improve monitoring programs. In FY 2009, $7 million was available, and the same amount was proposed for FY 2010.

"Doctor shopping"--the practice of seeking multiple prescriptions from multiple doctors--increases in neighboring states when one state starts a monitoring program. State and federal officials think monitoring programs are most effective when states have programs that can share information with each other.

Kentucky and Ohio are engaging in a pilot program to share data, and more states are expected to come on board this year.

"The nonmedical use of controlled substances continues to be a serious public safety and health concern," says James H. Burch II, acting director of the Bureau of Justice Assistance. The bureau's goal is to help all states implement prescription drug monitoring programs, he says.

"These programs, if used effectively, can help detect diversion and prevent abuse of pharmaceutical controlled substances within states and across state lines."

--Vicky R. McPheron, NCSL

* CHECK OUT more about efforts to combat prescription drug abuse at www.ncsl.org/magazine

Karmen Hanson covers prescription drug issues for NCSL.