The rampant abuse of prescription painkillers in the United States is turning pain care into a big headache for some physicians and patients.
As the government tries to limit the supply to prevent pills from flooding the black market, it's become more difficult to prescribe and obtain certain medications.
It's still possible for patients to get powerful painkillers, but it generally requires extra hassles that could be a hardship for some people, including the elderly. Also, physicians in New York must now consult a state database before prescribing certain painkillers.
Here's what you need to know.
1. Contracts and drug tests
The painkillers in question are the narcotic drugs (known as opioids) that the federal government defines as having a high or moderate potential for abuse and addiction. They include such medications as OxyContin, Percocet, Vicodin and Demerol and often are prescribed by physicians and dentists.
In many practices, patients must sign a contract with their doctors before they can be prescribed narcotics. "This contract has certain stipulations; specifically, it states that the patient may only obtain opioids from this specific doctor, must use one pharmacy and may be subject to periodic urine drug screening," said Dr. Raj Krishnan, an anesthesiologist and pain specialist with St. Catherine of Siena Medical Center in Smithtown. If patients run out of meds before their scheduled refill, they may not receive another script.
Patients with contracts also must go through urine drug tests before getting their medications, Krishnan said. "If the patient is found to be in breach of the contract, the doctor may discharge the patient from the practice or stop prescribing opioids to this patient entirely."
Why all the rules? "This is mainly because of patients using the meds for reasons other than pain control -- to feed an addiction or divert the meds sell them]," Krishnan said. "Also, there have been several events recently involving armed robbery and murder at pharmacies to obtain the medications," including on Long Island.
Dr. Scott Krakower, an assistant professor of psychiatry at Hofstra North Shore-LIJ School of Medicine, agreed that there's plenty of need for regulations. "The opioid epidemic has been extremely alarming, and the number of deaths have been climbing in the area," he said. "Without tighter control, the epidemic will only get worse."
2. Appointment for refill a hardship for many
Drugs like Vicodin often are prescribed for acute pain after surgery. In almost all cases, the pain will go away within a few days to a week, said Dr. Brian Durkin, director of the Center for Pain Management and an associate professor of anesthesiology with Stony Brook Medicine, but if the pain lasts longer, the patient may need a refill. That's where challenges come in.
Under New York law, patients often must seek a doctor's permission to get opioids refilled. However, there's an exception for people with several conditions, including panic disorder and narcolepsy, and for "relief of pain in patients suffering from conditions or diseases known to be chronic or incurable."
Having to seek refills through a doctor's appointment can be more than a minor hassle. "That can create some hardships on some people, especially elderly people who don't drive and don't have transportation," Durkin said. "There's a financial burden as well -- an extra doctor's visit you've got to pay for."
But it's not just the elderly who may have trouble getting the drugs they need because of the rules, Krakower said. Patients with developmental disorders "often have difficulty with simple tasks, and it will make it harder for these patients to receive the appropriate pain medications in a timely fashion," he said.
3. Some doctors avoid opioids entirely
"There are a handful of primary care doctors on Long Island that have stopped writing [opoid prescriptions] altogether," Durkin said.
He's not a fan of this approach. "Whenever someone is all or none, it's usually not the right answer in medicine," he said. "Medicine has a lot of gray areas."
Still, he noted, addiction is a major concern. "We're a society of addicts, and if you expose an addict to something that triggers a response in the brain that gets pleasure from an addictive substance, that patient is at high risk of developing an addiction," he explained. "The key is to properly assess the patient. If they're very high risk for addiction and it's a pain problem that can be treated with other means, they should avoid opioids."
4. Other options
Opioid painkillers often are an appropriate treatment for acute pain, such as the type people might suffer after a traumatic injury or after surgery, Durkin said. They're commonly used to treat certain cancer patients. However, he said, there's little evidence to support use of the drugs in people with chronic pain who don't fit into those groups.
The best alternative is to fix the problem that's causing the pain, he said. And if physical therapy or surgery doesn't work, medications like anti-inflammatory painkillers and pain drugs such as Lyrica and Cymbalta may play a role.
"There are many ways to treat the problem," Durkin said. "The key is to identify it and treat it appropriately. But in this age of five-minute office visits, sometimes the easiest thing to do is write a prescription for an opioid."
Krishnan added that pain patients also may find relief through acupuncture and yoga. Other drugs may help as well, he said, including anticonvulsants, antidepressants and muscle relaxants.
5. Psychological therapy may help people in pain
Mental health therapy can help patients in addition to -- or instead of -- opioid painkillers. One possible explanation for this has to do with how the body feels pain.
Mentally disabled patients and those with dementia often don't need higher and higher doses of painkillers like other patients, Krishnan said. "They do suffer from pain, but they usually respond to lower doses of less potent meds."
This may be a sign that "the way we respond to pain has an emotional aspect to it," he said. "This is sometimes what contributes to increasing pain."