When Kimmberly Ruzynski goes in for an expected shoulder surgery next year, she doesn’t want painkillers.

That’s because the 41-year-old St. Paul woman spent three years addicted to prescription pain drugs following a leg operation in 2003.

This time, Ruzynski doesn’t want to tempt fate, even though doctors say recovering addicts don’t necessarily need to avoid such medications following surgery.

“It was horrible,” said Ruzynski, who credits a treatment program at St. Joseph’s Hospital in St. Paul with helping her stay clean since 2006. “You don’t know who you are. … You’re in a fog. You’re not in your right mind.”

Ruzynski’s comments help frame the baby-with-the-bathwater challenge facing physicians, pharmacists and hospitals as they confront the growing problem of prescription drug abuse.

A growing number of health care groups in the Twin Cities are investing in strategies to make sure doctors don’t serve as unwitting spigots of medications for addicts. But there’s also concern that increased regulation could prompt physicians to stop prescribing medications to patients with legitimate pain-control needs.

“It’s a two-edged sword,” said Dr. Alfred Anderson, a pain specialist in St. Louis Park.

“Every organization is trying to get on board to do something about this abuse situation. … It’s gotten too easy for people to get these medications,” Anderson said. “But what do you do for the patient in severe pain who can’t function without pain medication? This is the dilemma in treating the small percentage of patients who suffer from severe chronic pain.”

HOW TO DETER ‘DOCTOR SHOPPING’

Abuse of prescription opioids and narcotics is a topic of growing concern among health care professionals in Minnesota.

In November, the Minnesota Medical Association created a task force to address opiate addiction, abuse and diversion, and set a goal to raise awareness among physicians about the extent of the problem. The task force will consider ways to promote use of the Prescription Monitoring Program, a database created in 2010 that lets physicians see whether a patient has been “doctor shopping” in order to obtain prescriptions for controlled substances.

A state government report issued this fall, called the Minnesota State Substance Abuse Strategy, cited increased use of the Prescription Monitoring Program as one of three immediate policy priorities to address abuse of prescription opiates as well as heroin. The report called for training physicians in the basics of addiction, opiate prescribing and alternative approaches to pain management.

Hospital systems say they are providing more education to physicians about how to prevent abuse and diversion of prescription painkillers. Physicians in those hospital networks say they are using electronic health records in new ways to combat the problem.

“We’ve heard from our physicians that this is a stress on their practice — how to prescribe narcotics and opioids appropriately,” said Dr. Dave Thorson, a primary-care doctor in White Bear Lake who is board chair of the Minnesota Medical Association. “This subject is slowly rising to the top.”

HITTING UP THE ‘CANDY MAN’

The recent state report on substance abuse helps explain what’s commanding all the attention.

The leading cause of death from injuries in the United States is poisoning, and nearly 90 percent of those deaths are caused by medications, according to the report. Opioid analgesics were involved in more than 40 percent of drug poisoning deaths in 2008.

In Minnesota, officials expect that unintentional poisoning/drug deaths soon will exceed the number of motor vehicle traffic deaths, the report said.

“Over the past decade the increased nonmedical use of prescription drugs, in particular prescription narcotic pain relievers, has resulted in increased numbers of drug-induced deaths, hospital emergency room episodes and admissions to addiction treatment centers,” the report said.

“The rate of nonmedical use of pain relievers in Minnesota in the past year by people age 12 and above is 4.4 percent, compared with 5 percent nationally,” the report added. “This compares with a high of 6.2 percent in Tennessee and a low of 3.8 percent in Hawaii.”

The problem is a wake-up call for many physicians, said Dr. Mark Eggen, an anesthesiologist in private practice in Anoka County.

“Some doctors have trusted their patients too much,” said Eggen, who serves on the Minnesota Board of Medical Practice, which disciplines physicians.

The medical board doesn’t maintain statistics on how many doctors have been disciplined for failing to adequately monitor patients who have been prescribed controlled substances. But experts believe the number is growing, including two licensure actions this year.

“These addicts are incredibly manipulative and capable of figuring out where your buttons are and pushing them,” Eggen said. “You are their candy man.”

CROSS-CHECKING FOR ABUSE

One way doctors fight back is with the use of electronic health records. Minneapolis-based Fairview Health Services uses a health record that connects all clinics and medical centers within several services’ health systems, so a doctor can see whether a patient seeking pain pills in an emergency room has been getting controlled substances elsewhere, said Dr. Dave Milbrandt, an emergency physician at Fairview Lakes Medical Center in Wyoming.

The electronic health record also lets doctors see whether a patient has signed a controlled-medication agreement with his or her primary physician, Milbrandt said. Such agreements stipulate that patients won’t go to other doctors to get pain medication refills.

Abusers might try to visit doctors at different hospital systems to avoid detection, but Fairview and several large local systems — including Allina, HealthPartners and North Memorial — use an electronic health record from the same vendor. A doctor at any one of these hospitals can look at a patient’s medication history at the other medical centers.

“The patient has to sign a release,” Milbrandt said. “If they don’t sign a release, that’s a clear red flag.”

Controlled-substance agreements between doctors and patients have been common for years, but the Minneapolis-based Allina Health System is spending more time making sure the agreements are enforced, said Dr. Rod Christensen, chief medical officer of Allina’s network of 59 clinics in Minnesota and Wisconsin.

In addition to putting limits on where patients can refill pain prescriptions, the agreements stipulate that patients will be subject to urine drug testing, Christensen said. Agreements are used with patients who chronically use medications such as Oxycontin, Vicodin, morphine or fentanyl, but not for patients with short-term prescriptions for acute needs.

45 VICODIN PILLS? MAKE THAT 15

As for education, Allina this month is distributing to physicians in its clinic network more than 600 copies of a reference manual on responsible opioid prescribing.

“As big a problem as this has become in society, many of us have a different sense of the risk-benefit ratio of these medications,” Christensen said. “We have to factor in not only the risks and benefits for the patient sitting with us, we have to take into account — at least a little bit — the risk that we could be contributing to a societal problem.”

Striking that balance is delicate, said Dr. Pat Courneya, medical director at Bloomington-based HealthPartners, which is both a health insurance company and an operator of hospitals and clinics.

Narcotics have an important place in treating pain for cancer patients and people with serious burns or acute injuries, Courneya said. But with increased use of narcotics, there can be a “vicious cycle,” he said, of patients needing more and more medications.

HealthPartners has been experimenting with ways to reduce the quantity of pain pills prescribed to patients by making changes to its electronic health record. When some doctors go to write a prescription within the health record, the default quantity that pops up is now 15 or 20 pills, rather than 45.

“Forty-five Vicodin pills was the reflex,” Courneya said. “The vast majority of patients don’t use that many pills, but they don’t throw them away, either. … So, there’s this built-up supply in medicine cabinets across the community.”

Medicine cabinets often are pilfered during break-ins. But they also can be a source of “quiet theft,” Courneya said, as teenage baby sitters, family friends or even children pinch a few pills and use or sell them.

ENSURING SUPPLY, LIMITING ABUSE

HealthPartners and other systems encourage physicians to use the Prescription Monitoring Program, but use of the database has not been mandated. There’s no accident in that decision, said Cody Wiberg, executive director of the Minnesota Board of Pharmacy, which maintains the database.

Requiring doctors and pharmacists to check the database every time would waste tremendous time, Wiberg said, because the vast majority of prescriptions issued for controlled substances are legitimate. The pharmacy board might support a limited requirement for pharmacists to check the database if certain red flags were present, he said.

In addition, a broad requirement almost certainly would have a chilling effect on legitimate prescribing, Wiberg said. That’s what happened in Minnesota during the 1980s and 1990s when several state government agencies started sharing information about prescribers of controlled substances, said Robert Leach, executive director of the Minnesota Board of Medical Practice.

“The medical community felt kind of hunted by the board,” Leach said. “We saw that individual physicians were not prescribing controlled substances when they needed to.”

Only about 30 percent of Minnesota pharmacists and doctors who are allowed to prescribe narcotics are enrolled in the Prescription Monitoring Program.

The pharmacy board is making changes to the program to make it easier for doctors to use. There’s also interest in integrating the database with electronic health records at hospital systems, although technical and legal barriers must be cleared.

Doctors in the east metro should be even better able to detect abusers once Wisconsin launches its Prescription Monitoring Program database in January, said Dr. David Frenz, medical director of the HealthEast mental health and addiction center.

Prescription opioid overdose deaths have skyrocketed, Frenz said, as have admissions to treatment programs for people addicted to the medications. He said he feels a personal connection to the issue through treating patients like Ruzynski, the former painkiller addict in St. Paul who credits Frenz with “saving my life.”

Although Ruzynski hopes to avoid painkillers in her coming surgery, she believes doctors are right to be concerned about maintaining access to the drugs.

“If it’s prescribed right,” she said, “pain medication can be absolutely needed.”

Every doctor in Minnesota should use the Prescription Monitoring Program database, Frenz argues, admitting there were cases when he was “burned” prior to its creation. Still, Frenz doesn’t want to make use of the database a legal requirement.

“How do you police it?” he asked. “What are the penalties? Will there be audits? What sort of infrastructure would a physician need to comply?”

“If you create a regulatory structure that’s so onerous and punitive that doctors say, ‘It’s not worth the trouble or the risk to prescribe these drugs,’ then it’s the patient who suffers,” Frenz said.

Christopher Snowbeck can be reached at 651-228-5479.

Follow him at twitter.com/chrissnowbeck.