Government’s Prescription to Treat Drug Abuse

I recently attended a seminar in which I learned about a program in my state which was enacted into law; a poorly thought out law that created an unsolvable problem for physicians while addressing a different one. This program is designed to address the growing problem of abuse of prescription drugs in our country.Several years ago, it became apparent that physicians, afraid of  being accused of over prescribing pain medications, were under treating chronic pain in our country. This resulted in an effort to educate physicians to correct this problem. As is often the case, the “Law of Unintended Consequences” came to play, and we have become a nation of over users of prescription drugs. Often, people look upon prescribed medications as “safer” than illegal drugs, and, as a result, people have abused prescription narcotics resulting in too many accidental deaths from this abuse. In fact, in several states today, the primary cause of accidental death is the abuse of prescribed narcotic and sedative drugs. It is believed to be the primary cause of accidental death among the 18-25 year olds today. 4.8% of Americans over the age of 12 report having used a pain reliever or sedative non-medically at least once during the past year and 13.7% have done this at least once in their lifetime. Seven of the ten states with the highest incidence of this problem are in the West. Misuse of prescription drugs is second only to marijuana as the Nation’s most prevalent drug abuse problem. (http://www.samhsa.gov/data/2k12/NSDUH115/sr115-nonmedical-use-pain-relievers.htm). Approximately 140,000 patients entered substance abuse treatment for non-heroin drug abuse in 2009. Teen-agers now say that it is easier to obtain prescription drugs than it is to purchase beer! Death from the abuse of prescription drugs is not linked to the rate of sales of these drugs as might be expected, and often is linked to the concomitant abuse of several different drugs at the same time.  Of interest, those who are being treated for chronic pain rarely become addicted to the medication when it is used as prescribed. The combination of these drugs used to treat chronic pain, with the potential for addictive behavior leads to the abuse and its problems.

Clearly both chronic pain and prescription drug abuse have become public health issues. This has led to state and federal governments instituting programs to try to address these issues. One of these is a prescription monitoring program that looks at physician prescribing practices, and patient purchasing practices to identify abusers. This has become a tall order for physicians who are trying to do the right thing, treating chronic pain without increasing the potential for abuse and addiction. In New Mexico for instance, Title 16, Chapter 10 Part 14 of the state code specifies in detail what a prescriber MUST do and document to prescribe narcotic pain relievers to a patient. It is four pages long, single spaced and detailed. It specifies the examination of the patient, the details of past medical, psychological, and addictive history that need be obtained, documentation of the treatment plan and consultations prescribed, and more, and more. All these ideas are good! Whether they will be effective remains to be seen.  In addition, there are two barriers to ideal implementation of these ideas, the major one of which is TIME.

During the seminar, we were exposed to a video of the ideal interview and examination. It became clear that this intervention and documentation required by law, would take close to an hour to complete. This legal requirement falls upon the busy practice of the

general practitioner.  It is also clear that the compensation that can be expected from insurance carriers for this intervention is inadequate to pay for the time that is needed. In the present healthcare environment, internists and general practitioners are rewarded for the number of patients they can see in the shortest time, while keeping the patients happy with the encounters. This encourages practitioners to find ways to shortcut the imposed system, in the same way that factory piece workers found ways to turn out more product in less time than expected, to increase their compensation. Similarly, the patient will get what he or she perceives as good personal care, and the physician will find a way to do more in less time, perhaps compromising the details of the program, as long as the documentation is complete as required by law.

The other major flaw in the law comes from the fact that those more likely to become abusers are people who have a history of other addictive behaviors yet need medical relief of chronic pain. When a physician determines that there is this potential, good care includes the involvement of professional addiction counseling which is not usually available in many areas of the country. If it isn’t available and the physician withholds therapy, the patient is undertreated under the law.  If treatment is provided and the patient becomes an abuser, the physician can be held responsible. Under the law as

written, the physician is wrong either way. This is another case of government meddling in an attempt to address a problem and creating a bigger one. When will our legislators learn that meddling in medical practice by creating more work with less compensation and with limited time will not solve any problems but simply create new ones?