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Doctors’ dilemma How to keep opioid drugs from fostering addiction

Opiod-based pain killer overdoses have become the No. 1 cause of accidental death in New Jersey.-(DEPOSIT PHOTOS)

Christina R. never imagined becoming a drug addict.

“It started with one prescription,” said the 38-year-old former nurse, sipping coffee on a cold winter’s night outside a Narcotics Anonymous meeting in Iselin.

She’s been clean for four months, but the toll of eight years of addiction to prescription painkillers and heroin is clear in her prematurely wizened face.

Christina’s life spiraled out of control in the winter of 2009, when she was prescribed a vial of 40 Percocet pills for a dislocated elbow suffered after slipping on a patch of ice while shoveling snow. She was living with a boyfriend, had just graduated nursing school and was working at a local hospital.

After becoming physically dependent on Percocet due to prolonged use, she turned to heroin two years later because pills on the black market became too expensive and difficult to obtain. She lost her job and her boyfriend as a result of addiction, and today she is unemployed and living with her parents in Woodbridge, trying to piece her life back together.

“I didn’t think I’d get hooked after one script,” she said. “But I found that the pills became my coping mechanism, and I just couldn’t stop. Afterwards, I started going to doctors who I knew I could pretty easily fool into giving me a prescription. I tried to steal pills from the dispensary [at the hospital she worked for at the time]. My dealer told me to think about [heroin] when I couldn’t afford the pills anymore. All I cared about was getting the next pill.”

“Most doctors don’t prescribe opiods with the thought that, ‘Gee, I want to cause the ruination of this person’s life.’ “

James Curtin, president of Daytop

Sadly, Christina’s story is all too familiar, especially in New Jersey, which in the past decade has seen a 700 percent rise in admissions to drug rehab programs specifically for opioid and heroin addiction. Overdoses on opioid-based pain killers has become the No. 1 cause of accidental death in the state.

Her story also raises an important question that health care providers in the state have been grappling with for several years: How can doctors strike a balance between prescribing addictive pain killers such as Percocet or Vicodin for legitimate medical purposes, while at the same time taking steps to ensure the patient does not become addicted to those painkillers?

“Most doctors don’t prescribe opioids with the thought that, ‘Gee, I want to cause the ruination of this person’s life,” said James Curtin, president of Daytop, a nonprofit group and one of the largest networks of drug rehabilitation centers in the state, in an interview with NJBIZ.

“I realize that sometimes patients who are dealing with pain may need one or two pills to get to sleep at night, but at the same time I think doctors should be required to ask a patient about their medical history and see if they have a history of addiction before they prescribe painkillers to them,” Curtin said. “If a doctor does not inquire about that and the patient becomes addicted, that doctor’s license to practice should be taken away.”

Christina said the doctor who prescribed her opioids never inquired as to whether she might be prone to addiction.

Curtin said many of Daytop’s rehab patients initially became addicted to opioids after receiving a legitimate prescription from a doctor. The opioid problem has become so bad in New Jersey that Daytop is in the early stages of opening a new medical detox facility near its exiting treatment center in Morris County.

According to the U.S. Center for Disease Control, which measures opioid prescriptions in morphine milligram equivalents (MMEs), the average county in the state saw 745.1 MMEs prescribed in 2017, down from 769.9 in 2010.

Despite regulations passed under former Gov. Chris Christie, such as limiting the dosage of painkillers that can be prescribed at one time and requiring doctors to check if patients recently obtained prescriptions from other doctors to avoid “doctor shopping,” Burlington, Cape May and Gloucester counties still saw a rise in prescriptions of MMEs from 2010 to 2017. There were sharp declines, however, in Bergen, Hudson, Morris and Ocean counties over the same time frame.

Christie last year signed a bill into law imposing a five-day limit on initial prescriptions for opioids. But opinions among New Jersey doctors continue to vary on what the medical community can do to prevent addiction to opioid-based painkillers. 

Laura Balsamini, national director of pharmacy services at Summit Medical Group, the state’s largest physician-owned network of primary care physicians and specialists, said doctors must manage patients’ expectations when it comes to pain-management programs and prescribe realistic doses.

“Physicians can strike this balance by managing patient expectations through the establishment of treatment goals prior to prescribing an opioid, including risks and realistic goals for pain and function and discuss how an opioid will be discontinued if the benefits do not outweigh risks,” Balsamini said in an email.

“In addition, physicians should prescribe the lowest effective dose of immediate-release opioids for acute pain and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids,” she added. “Physicians can also prevent opioid treatment morphing into an addiction by reviewing the New Jersey Prescription Monitoring Program database to assess any history of opioid use and require urine drug testing before starting opioids for chronic pain.”

Peter Carrazzone, president of the New Jersey Academy of Family Physicians and a practicing family physician at Vanguard Medical Group, said opioid-based painkillers should be the “last resort” when treating patients for pain.

He added state agencies such as the New Jersey Department of Consumer Affairs and the state’s Department of Health provide tools for doctors on what to ask patients before prescribing potentially dangerous painkillers.

“Physicians need to do a better job of working with their colleagues in the addiction field to know the best ways to handle a patient that has become addicted to a prescribed substance.”

Dr. Ramon Solhkhah, Jersey Shore University Medical Center

“They have risk-assessment tools that ask doctors to go through family histories, histories of personal and psychological abuse and come up with a risk score measuring the likelihood of a patient becoming addicted to opioids,” Carrazzone said. “It’s encouraged that physicians use those tools.”

He suggested people consult with their family doctors on pain management. “Family doctors have a unique insight because we know the entire family and whether there is a history of addiction. We’ll know if your sibling or parents suffer from addiction and that will raise a red flag for us.”

Carrazzone said Vanguard has an internal committee that examines the prescribing patterns of all its doctors, and suggested all practices do something similar.

Dr. Ramon Solhkhah, chairman of the Jersey Shore University Medical Center’s Department of Psychology and head of Hackensack Meridian Health’s new Christopher Center, a program that will be run out of the health system’s new HOPE Tower to educate the public and medical community on addiction, stressed that primary care physicians need to consult with addiction specialists.

Physical addiction to highly potent painkillers may be inevitable after they are prescribed due to the “nature of the drug,” Solhkhah said. Where doctors often err, he added, is when they realize a patient is addicted and simply cut them off without referring them to an addiction treatment center.

“The patient is physically dependent on the drug, so it’s not humane to cut them off without tapering them in a reasonable manner,” he said. “I’ve seen patients in the ER who are there for withdrawal. They are irritable and sometimes suicidal. Physicians need to do a better job of working with their colleagues in the addiction field to know the best ways to handle a patient that has become addicted to a prescribed substance.”

Vince Calio
Vince Calio covers health care and manufacturing for NJBIZ.

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