Collaborative Pain Management

Posted on Friday, December the 28th at 7:37pm

Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

There is a growing national trend of prescription drug abuse and drug diversion that is reaching epidemic proportions in some areas of our country.  There are several layers to this problem including: (1) patients scamming doctors and/or going “doctor shopping” for financial gain; (2) patients forging prescriptions or going “pharmacy shopping” for financial gain; (3) health care providers, pharmacy employees, and other greedy individuals diverting medications for financial gain; (4) people who have an addiction to prescription medication or other drugs (including alcohol) and use doctor or pharmacy shopping to manage their addiction; and (5) chronic pain patients who become addicted to their medication and end up either doctor or pharmacy shopping in an attempt to manage their pain.  The first three points obviously need to include strong law enforcement interventions, but points four and five should be addressed primarily as a healthcare or public health issue.

One controversial approach to prescription drug diversion and abuse currently used in at least fifteen states, and being considered in several others, is some type of prescription medication monitoring program.  One of the reasons these monitoring programs are so controversial, and often lobbied against, concerns the issue of privacy and doctor-patient confidentiality.  On the other side, there is a very positive health care related reason for endorsing these programs—they help people. 

A striking example of this is a recent consultation I participated in with a California pain clinic.  Patient X’s family members were concerned that he was exhibiting very bizarre behaviors, including falling asleep in the middle of dinner and being emotionally volatile for no apparent reason.  They were concerned he was over-medicated but the quantity and type of medications he was prescribed by the clinic would not account for his extreme behavior.  One of the doctors was suspicious and as part of his assessment of the situation asked for a pharmaceutical printout from the monitoring agency where he discovered that patient X was receiving similar medications from three other providers filled by three different pharmacies.  We initiated a medical intervention and the patient was eventually referred to medical detoxification, addiction treatment, and concurrent integrated pain management.  Both patient X and his family now believe that this intervention saved his life.

Unfortunately, patient X could easily have been arrested and incarcerated instead of having his legitimate health care condition effectively treated.  Unless specific provisions for intervention and treatment are included in a monitoring system too many people will be punished instead of helped.  Much of the fear and opposition to prescription monitoring centers around the fear that “big brother” will use law enforcement interventions with people who, through no fault of their own, become addicted to the medication they were given to treat a legitimate health care condition.  The other major fear is that others might gain access to these monitoring records and use that information to damage the individual.  One such case was documented in Nevada when a law enforcement officer who was using OxyContin was turned into his supervisor and was subsequently fired.  On the other hand several reports insist that in over 20 years there have not been any breaches of confidentiality in the fifteen states that currently have prescription monitoring programs.  There needs to be very stringent safeguards built into any prescription-monitoring program to avoid innocent people being harmed.

The solutions to the problem of prescription medication diversion are complex and need to be addressed not only by law enforcement, but also the health care industry.  With the quantity of Schedule II and Schedule III drugs continuing to increase significantly, the problem is only going to worsen.  Collaboration between law enforcement and the health care providers is crucial.  Only by working together can appropriate solutions be found to use an effective tool like the monitoring program without it leading to the frightening predictions of the factions that oppose such measures.  In addition, health care providers and law enforcement personnel need to be trained to look for the early warning signs of both drug diversion and addiction.  This can be accomplished by using strategic research-based training protocols that educate health care providers and law enforcement professionals about discovering which patients are illegally diverting medication for profit, as well as focusing on prevention, intervention, and appropriate treatment strategies for legitimate addiction issues.  It is very important to have a strong focus regarding how health care providers and law enforcement can best collaborate when there is obvious criminal drug diversion activity.

I realize this is only a partial solution, but it is one that is desperately needed.  Each state should also form multi-disciplinary task forces including all segments of law enforcement and health care providers working together.  Educating the public, especially our young children, how to avoid an addiction trap is critical.  In addition, we need to remember that although the vast majority of people with chronic pain may safely use pain medication, as many as 8.6 million people in 1999, to 11.7 million people in 2003, who used prescription drugs also suffered from coexisting abuse or addiction problems—these people need help, not incarceration.  I also believe that the other people who are illegally diverting prescription medication for personal profit and greed need to be tracked down and prosecuted to the full extent of the law.  However, I do not think it is appropriate to prosecute those who need intervention and help—addicts and chronic pain patients who obtain “extra” medication as a coping mechanism in order to deal with their pain.