Doctors caught in painkiller dilemma

Dr. Daniel Laieta pictured in his office, where

Dr. Daniel Laieta pictured in his office, where all medical records and prescriptions are electronic. (Feb. 20, 2012) (Credit: Newsday/Audrey C. Tiernan)

The prescription painkiller abuse epidemic has left doctors across Long Island with a dilemma over how to sort out patients in genuine need from addicts and criminals.

The Institute of Medicine, the health arm of the National Academy of Sciences, said last June that more than 116 million Americans suffer each year from chronic pain, much of it undertreated.

Treating that pain, the chair of the IOM report committee, Dr. Philip Pizzo of Stanford University, recently told a Senate committee, is "a moral imperative."

However, doctors are being urged by law enforcement and New York State to identify potential drug abusers -- and could be held legally accountable if they don't.

After David Laffer killed four people while robbing a pharmacy in Medford for prescription drugs on Father's Day, Suffolk County District Attorney Thomas Spota convened a special grand jury to investigate so-called "doctor shopping" for prescription painkillers and the possible criminal conduct of physicians.

Dr. Seddon Savage, president of the American Pain Society, said doctors are caught in the middle. "I think most clinicians are trying to do their best in balancing these very difficult realities," she said.

For Dr. Daniel Laieta, the dilemma occurs about once a week.

A patient will come to the internist's Holbrook office, he said, asking for prescription opioids to treat his pain.

But something the patient says or does raises a red flag, and the doctor becomes suspicious that the individual wants the drugs to feed his habit or to sell.

"When you know in your gut" the person is not telling the truth, "it's not very hard to say 'no' " and confront the patient, he said.

Laieta, president of the Suffolk chapter of the American College of Physicians, admitted he has lost sleep wondering if he had made the right decision. "I sometimes worry," he said. "Am I sending somebody out in pain? How do you balance that? We're here to help people."

New York State Attorney General Eric Schneiderman has called for requiring practitioners to review a patient's prescription drug history on a real-time Internet system before prescribing opioids.

These legal ramifications are having an impact on how doctors prescribe.

The Institute of Medicine report found: "Twenty-nine percent of primary care physicians and 16 percent of pain specialists report they prescribe opioids less often than they think appropriate because of concerns about regulatory repercussions," the report said.

 

Prescriptions not declining

Despite these pressures, prescriptions for opioids on Long Island don't appear to have fallen.

In 2009, an average of 23,907 prescriptions per month for oxycodone were written in Nassau County, according to the New York State Department of Health.

That number had risen to an average of 30,228 per month in 2011. Prescriptions in Nassau for hydrocodone averaged 24,160 per month in 2009; that number dropped to 21,362 per month in 2011.

In Suffolk, oxycodone prescriptions for 2009 averaged 25,074 per month; in 2011 that monthly average rose to 34,077, according to the health department. Hydrocodone prescriptions in 2009 averaged 37,653 per month; in 2011, that monthly average was 32,940.

The epidemic has left some local doctors anxious about their safety. Others are frustrated by what they see as the demonizing of drugs that, if used appropriately, give their patients the ability to function.

Dr. Sal Skeivys, a solo family practitioner in Woodside, said he doesn't usually prescribe opioids for chronic pain other than cancer. "I don't typically prescribe to someone who wants 180 pills a month," he said. "That's just a drug seeker."

That decision has caused him at times to worry about his safety. He cited a recent experience when a patient demanded his money back after the doctor refused to supply him with a prescription for opioids. The patient's "two 300-pound friends" standing in the waiting room made him feel "under pressure," he said.

But Dr. Daniel Brietstein, associate director of division of integrative pain medicine at Pro Health Care in Lake Success, said his patients complain they are now being heavily scrutinized when they try to fill legitimate prescriptions. His office closely monitors his patients' drug use and they have access to a slew of other treatments, he said.

Giving opioids for chronic pain "is not an ideal form of treatment, but it gives relief from symptoms," he said. "Everyone can point a finger all they want -- until you have the pain. Legitimate providers take care of legitimate patients."

He blames much of the current epidemic on parents not guarding kids from stealing drugs from the family medicine cabinet.

In fact, more than 70 percent of people who abused prescription pain relievers got them from friends or relatives, according to an April 2011 report issued by President Barack Obama that detailed a 48 percent increase nationwide in prescriptions written for highly addictive drugs such as oxycodone and hydrocodone from 2000 to 2009.

 

Some minimize concern

Other doctors don't believe the problem is that common in their practices. Dr. William Healy, an orthopedic surgeon in Huntington, said he doesn't prescribe medication for chronic use and works hard to balance giving patients enough drugs after a procedure to relieve pain and not enough to encourage abuse.

Yet, he conceded, on the day he was interviewed by Newsday, he had to confront a patient he believed was seeking painkillers beyond the time the doctor thought he should need them.

Dr. Andrew Kolodny, chair of the department of psychiatry at Maimonides Medical Center in Brooklyn and president of Physicians for Responsible Opioid Prescribing, said doctors need to acknowledge their role in the epidemic and be more cautious in prescribing addictive painkillers, especially long term.

In an article published in the Annals of Internal Medicine last September, Kolodny and his co-authors cited the lack of evidence for the benefits of prescribing opioids long term. They also detailed their side effects -- other than addiction -- that range from fractures to chronic constipation to an suppressed immune system.

"Expert evidence that these are helpful long term doesn't exist," he said. "I am coming to the conclusion that we may be hurting more than helping."

Laieta -- like others -- said the problem could be mitigated if doctors, other than certified pain specialists, didn't prescribe large volumes of painkillers and required patients to revisit the office if they called in for a refill. "It goes to how much you're prescribing," he said.

But he doesn't want painkillers banned or so heavily regulated he can't, in effect, prescribe them: "I think there's a time and place for everything."

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