We have a prescription pill problem

Fourteen years sober from drugs, Lin Michaels was written two prescriptions for narcotic painkillers by her doctor: one for hydrocodone, another for methadone.

She was in pain. It was the mid-2000s, and she’d been hit by a car traveling 50 miles an hour. She suffered extensive nerve damage and had metal stitched throughout her spine, chest and back.

Legally prescribed medications in Nevada, January 2010-August 2013 14,861,946 prescriptions filled 1,071,677,298 pills prescribed Pain: 727,074,944 pills Anti-anxiety: 220,757,635 pills Stimulants: 33,302,557 pills Sleeping pills: 48,291,922 pills Other: 25,527,989 pills Unknown: 16,722,251 pills Source: Final Report on the Reno Police Department’s Smart Policing Initiative to Reduce Prescription Drug Abuse

Michaels had reservations about filling the prescription but followed her doctor’s orders. He was the one with the white coat, the stethoscope, the medical degree.

“He’s a doctor,” Michaels said. “I’m trusting him.”

Michaels grew up in Queens, N.Y., the daughter of an alcoholic father and an enabling mother. She started partying on cocaine and acid at 19. At 32, she realized she didn’t want that life anymore. She divorced her first husband, whom she called her “drug buddy,” and moved to Georgia where she stayed clean — until the car crash.

That’s when the doctor put her on Lortab — a mixture of acetaminophen and hydrocodone — and methadone. She liked the Lortab better because it got her high. The methadone made it hard for her to function. Michaels doesn’t remember whether either actually managed her pain. When the Lortab stopped getting her high, she switched exclusively to methadone.

Like heroin, prescription narcotics, including Percocet, OxyContin and Vicodin, are opiates, derived from a natural byproduct of the poppy plant, which also can be manufactured in a lab. When ingested, opiates can relieve pain and produce a sense of euphoria. Like heroin, they also can be highly addictive.

Michaels tried to stop using the drugs on her own. She got rid of the methadone multiple times, but she always found a way to get a new bottle.

“It’s this horrible game you play with yourself,” Michaels said.

After eight years on methadone, Michaels­, who had moved to Nevada, woke up next to a police cruiser and ambulance. She had driven to the school she was attending and blacked out. She went to an acute detox facility for three days. Then her older brother showed up at her door, all the way from Alaska.

“I open the door, and there’s my brother, a big tall blonde,” Michaels said. “It’s like, ‘Oh crap.’”

It was then that Michaels broke down and surrendered. Her brother got her checked into a program at Solutions Recovery, and she stopped using Sept. 14, 2012.

But, as Michaels will tell you, recovery is an ongoing process, and her brushes with prescription pills weren’t over. Two years into sobriety, she fractured her hand and needed surgery. Michaels told the surgeon she was a drug addict in recovery.

“He forced the script of Vicodin on me,” Michaels said. “He said, ‘You’re going to need this.”

So she took the script home, where she would check in on it every so often, just to make sure it still was there.

•••

Nevadans have long struggled with prescription drugs. Studies place Nevada in the top tier of states for the highest number of painkiller prescriptions written, the worst prescription painkiller abuse problems and the most deaths due to drug overdoses — the majority due to prescription drugs. Data from the state pharmacy board place Nevada second in the nation for number of prescriptions written for oxycodone, sold commercially as OxyContin and Percocet, and hydrocodone, sold as Lortab and Vicodin.

Prescription painkiller use has been on the rise nationally over the past decade and a half, but there’s no consensus from experts on why the problem is worse in Nevada. Some say Las Vegas’ reputation as a party city and Nevada’s more liberal attitude toward drugs and alcohol may play a role. Others say states with a large rural population tend to have more severe pill problems.

To get help Las Vegas Recovery Center 800-790-0091 lasvegasrecovery.com Montevista Hospital 702-364-1111 montevistahospital.com Seven Hills Hospital 702-646-5000 sevenhillsbi.com Solutions Recovery Inc. 702-854-2404 solutions-recovery.com WestCare Nevada 702-385-2090 westcare.com Mission Treatment Las Vegas: 702-474-4104 Henderson: 702-558-8600 missiontreatment.com

While prescription painkiller dependence often is lumped together with other types of drug abuse, “this epidemic has been caused and is fueled by legitimate prescribing,” said Andrew Kolodny, a scientist at Brandeis University who studies prescription pill abuse.

Non-medical use of prescription painkillers has declined nationally, while painkiller overdose deaths have soared, Kolodny and his colleagues found. The Centers for Disease Control and Prevention considers it an epidemic; 44 people in the United States die each day from overdoses of prescription painkillers.

“It’s the well-meaning doctors who are underestimating how addictive these drugs are and are overestimating how helpful they are for chronic pain,” Kolodny said.

•••

Doctors began focusing on quantifying and treating pain in the 1990s.

The American Pain Society — which like many pain management organizations has received financial support from pharmaceutical companies — presented pain as a fifth vital sign that medical professionals should assess, as they would a patient’s temperature, pulse, respiratory rate and blood pressure. There began a growing acceptance in the medical community for treating long-term chronic pain with prescription narcotics, which previously had been used only to treat short-term pain or chronic cancer pain.

The number of prescriptions written for painkillers skyrocketed as sales of the drugs increased by more than 300 percent from 1999 to 2011. Experts say that while the United States makes up only 4.6 percent of the world’s population, Americans consume 80 percent of opioids and 99 percent of the hydrocodone produced.

“There has been a proliferation of prescribing, and that’s not on the doctors,” said Kevin Quint, bureau chief of Nevada’s substance abuse prevention and treatment agency. “It just means that there has been more attention paid to people’s pain issues in recent years, and drugs are one of the remedies for it.”

In most cases, prescription painkillers are obtained through an appropriate channel. A doctor sees a patient, writes a script, then the pharmacy fills it. But there are a number of ways the process can go awry. Patients can visit multiple doctors to obtain multiple prescriptions. They can fake pain and fraudulently obtain prescriptions. They can swipe drugs from the medicine cabinet of a family or friend. They can take prescriptions not as prescribed.

Doctors and addiction specialists say the roots of painkiller abuse fall largely along a demographic divide. For young people, pill habits typically begin with drugs sneaked from a parent’s medicine cabinet or with pills offered by a friend. For older people, addiction typically stems from a built-up tolerance to legally prescribed pain medication.

•••

The reality is, obtaining prescription painkillers is fairly easy.

A trip to a primary care physician for back pain? Prescription. A trip to the dentist to get your wisdom teeth removed? Prescription.

Most of the time, doctors are just trying to do their job, helping patients with pain and abiding by the creed “do no harm.”

Sometimes, patients get hooked accidentally. Other times, they lie and steal to feed their addiction.

When prescriptions run out, many addicts try “doctor shopping” — going from doctor to doctor, collecting multiple prescriptions for the same drugs. Those with chronic pain repeat their symptoms to numerous providers. Those without legitimate pain mimic symptoms.

“I asked patients who were in treatment, ‘What did you tell your doctor to get what you wanted?’” said John Firestone, director of the Life Change Center, a treatment program in Sparks. “There were a lot of things, a lot of theatrics. Doctors don’t often have the wherewithall to outsmart a patient.”

When doctors cut patients off, the next fix often is found on the street. A 30 mg tab of black market OxyContin sells for about $20 in Las Vegas, said John Martin, of the U.S. Drug Enforcement Administration. Drug dealers obtain the pills in many ways: through fraudulent prescriptions, forged prescriptions, pharmacy robberies or pill brokers who buy pills off patients.

OxyContin, however, has become more expensive and more difficult to get on the street, likely because of stricter regulations and a reformulation that prevents it from being crushed, Martin said. A number of prescription drug users now are turning to black tar heroin, which sells for about $10 a balloon.

In the 1960s, heroin was associated with young men living in urban centers. Today, the typical user is a suburban white man or woman who progressed from prescription drugs to heroin.

“There has been such a stigma for many years with heroin — it’s such a dirty word — so some of the professionals and the elderly are like, ‘I would never use heroin,’” said Chris Gordon, admissions counselor at Solutions Recovery in Las Vegas. “But dependency is so insidious that if there’s no prescription, no opiates, and someone offers the heroin to them or they hear they can get it, they might do it.”

For Ginger Paulsen, the transition from painkillers to heroin is a familiar story. Her daughter, Sabrina Paulsen, died of a drug overdose in 2009 at 24 years old. She was found with alcohol, Xanax, two prescription narcotics and heroin in her system.

Paulsen said her daughter had no chronic pain or injuries. Yet police found prescriptions in her possession, all with her name on them. Each had been covered under the family’s insurance plan.

The insurance company had sent a flag out to Paulsen’s doctors because of the large number of pain medications prescribed, but it was too late. The alert went out the day Sabrina died.

•••

State officials are trying to ensure that narcotic painkillers are prescribed only to those who need them.

A bill spearheaded by Gov. Brian Sandoval and First Lady Kathleen Sandoval passed the Nevada Legislature last session requiring doctors to check a state database that tracks narcotics prescriptions.

The legalities The U.S. Drug Enforcement Administration has cracked down on prescription drug abuse in recent years. Part of the agency’s role is to monitor doctors who prescribe a significant amount of painkillers. When individual patient abuse is discovered, the agency typically works with prevention and treatment agencies, Assistant Special Agent in Charge John Martin said. Agents come down harder on people who sell prescription painkillers on the black market. “A patient might sell all their pills, or they might have a habit and sell half their pills,” Martin said. “Pill brokers are definitely a problem. People can make a lot of money selling their pills.” On Sept. 22, six people, including a Las Vegas man, were indicted by a federal grand jury on charges they sold lawfully-obtained prescription pills on the black market. Prosecutors accuse Las Vegas resident Dennis McPherson of working with a crew of about 40 to legally obtain oxycodone, then sell it on the streets out of state. The U.S. Attorney’s Office in Nevada also has prosecuted five doctors and one pharmacist since 2012 for unlawfully distributing prescription drugs, and more cases are under investigation, a spokeswoman said. The doctors are accused of selling drugs or knowingly writing or selling fraudulent prescriptions.

The drug monitoring program has existed since 1997, but it is used only sporadically. Just 5,037 of the 9,150 prescribers authorized to distribute controlled substance in Nevada are registered, and only about 2,100 actively use the database. It is accessible by both doctors and pharmacists.

“This bill says, ‘Hey, here’s this tool. There’s no reason not to use it,’” said Larry Pinson, executive secretary of the Nevada Board of Pharmacy, which oversees the database. “It mandates that if a physician is going to initiate therapy with an opiate, then they have to access (the database) prior to that.”

New York and Tennessee have required doctors to check drug monitoring databases since 2012. A year after the program took effect, the number of patients doctor shopping had dropped 75 percent in New York and 36 percent in Tennessee, Brandeis researchers found.

Because faking pain or visiting multiple doctors is relatively easy, state officials say Nevada’s database will provide another level of screening for patients that may slip under a doctor’s radar.

“The patient-doctor relationship is critically important,” said Dr. Tracey Green, Nevada’s chief medical officer. “It’s difficult to tell if there’s doctor shopping or abuse, and having the ability to look up (prescriptions)will help that.”

Although many providers already have begun using the database, it will be required starting Oct. 1.

“We use the database all the time,” said Dr. Devon Moore, an emergency room doctor at UMC. “If there’s a suspicion, even if there’s not a big suspicion, we’ll reference it because you can never tell.”

Evaluating pain can be even more difficult in an emergency room, where doctors have limited time with each patient. Although he relies on the database, Moore called the bill a hindrance and worried that other bills could come down the pipeline and limit doctors’ ability to prescribe pain medicines.

“Everyone’s not doing this for the wrong reasons,” Moore said. “Some people really need it.”

State officials say they will monitor the rollout of the bill and receive quarterly reports to see what kind of an impact it makes on prescription drug practices in Nevada.

•••

In the meantime, local providers are trying to cure Nevada from its prescription painkiller problem.

Doctors are trying to help patients manage their pain. Treatment centers are trying to help addicts kick their dependency. And state officials are trying to educate the public, and doctors, about the dangers of narcotic pain pills.

“It’s a constant life challenge with addiction and chronic panic,” Green said. “We have to make sure that we’re trying to improve the quality of people’s lives.”

Six weeks after Michaels received her script for Vicodin for her hand injury, she called her brother. He was incredulous.

“He said, ‘What are you doing?’ As drug addicts, we’re deceitful and manipulative,” Michaels said. “I ripped up the script.”

Three years sober, Michaels, now 56, still has pain, but she doesn’t take any pain medications regularly — just Motrin when she needs it. She also works as a house manager at Solutions Recovery, in the home where she used to live.

“In sobriety, you get the opportunity to re-create yourself,” Michaels said. “I admire places like this. They give us a chance to have a life. It’s such a privilege and what a sterling opportunity to give back like this.”

••••••••••••••••••••••••••••••

How prescription painkillers affect the body

When painkillers are used for an extended period, the body produces fewer neurotransmitters, decreasing its natural ability to relieve pain. That’s why some patients feel more pain while taking narcotic painkillers, a condition known as hyperalgesia.

Painkillers also depress the brain and nerves, resulting in slower breathing, slurred speech and slower reaction times.

As the body becomes dependent on the drugs, patients may feel withdrawal symptoms as soon as four to six hours after their last use.

Physical signs

• Sleep deprivation or nodding

• Constricted pupils and watery or droopy eyes

• Nausea, vomiting or constipation

• Slow, slurred speech

• A slow gait

• Dry skin, itching or skin infections

• Constant flu-like symptoms

Behavioral signs

• Irritability, a negative attitude or personality changes

• A new group of friends or hanging out in a new place

• Forgetfulness or clumsiness

• Lying, skipping school or work, or avoiding eye contact

• Losing interest in personal appearance and activities

• Changes in appetite

• Poor performance at work or school

• Borrowing money or having extra money

• Acting angry or abusive, or engaging in reckless behavior

••••••••••••••••••••••••••••••

Number of prescriptions written for pain medicine by zip code, January 2010-June 2012

Experts don’t know why Nevada has higher rates of prescription painkiller use than other states, and no study has been done to examine why some zip codes have more prescriptions than others. However, higher prescribing zip codes generally tend to have higher concentrations of doctors, not necessarily larger populations.

89001: 141

89002: 203

89003: 87

89005: 4,698

89008: 2,481

89009: 626

89011: 486

89012: 4,372

89014: 17,552

89015: 13,598

89016: 322

89020: 187

89021: 687

89023: 16

89024: 93

89027: 6,031

89029: 78

89030: 17,612

89031: 1,290

89032: 4,717

89036: 124

89040: 607

89041: 0

89042: 94

89044: 1,498

89045: 40

89048: 16,372

89049: 988

89052: 60,171

89053: 63

89060: 98

89070: 27

89074: 27,118

89081: 437

89084: 392

89101: 2,457

89102: 49,225

89103: 23,563

89104: 7,640

89106: 47,093

89107: 21,346

89108: 926

89109: 30,737

89110: 6,112

89111: 22

89112: 1

89113: 16,806

89114: 25,208

89115: 327

89117: 37,145

89118: 21,254

89119: 34,165

89120: 3,424

89121: 21,015

89122: 1,310

89123: 10,359

89125: 754

89126: 443

89128: 82,019

89129: 13,977

89130: 10,597

89131: 831

89133: 176

89134: 7,638

89135: 3,576

89136: 435

89137: 361

89138: 143

89139: 1,572

89141: 1,058

89142: 104

89143: 79

89144: 13,393

89145: 10,491

89146: 23,874

89147: 6,526

89148: 23,833

89149: 15,685

89154: 480

89156: 46

89157: 5

89160: 299

89169: 12,535

89178: 527

89180: 291

89183: 5,419

89191: 1,349

89193: 2

89301: 4,410

89310: 63

89316: 583

89403: 1,804

89406: 8,218

89407: 1,001

89408: 1,449

89410: 5,774

89413: 10

89415: 3,579

89419: 421

89421: 16

89423: 4,337

89424: 83

89427: 115

89429: 415

89430: 81

89431: 7,404

89432: 50

89433: 91

89434: 16,567

89435: 29

89436: 7,300

89440: 195

89441: 223

89442: 0

89444: 1,067

89445: 3,235

89446: 356

89447: 2,852

89448: 1,486

89449: 1,267

89450: 489

89451: 2,248

89452: 3

89460: 798

89496: 9

89501: 3,181

89502: 76,688

89503: 34,752

89506: 3,071

89507: 35

89509: 23,427

89511: 32,671

89512: 1,895

89513: 203

89515: 901

89519: 2,127

89520: 792

89521: 13,993

89523: 9,114

89533: 58

89557: 6,363

89701: 3,576

89702: 456

89703: 23,762

89704: 440

89705: 7,149

89706: 5,953

89801: 18,817

89815: 285

89820: 1,687

89821: 207

89822: 722

89823: 133

89825: 324

89834: 121

89835: 183

89883: 624

Total: 1,133,697

Source: UNR professor Emmanuel Barthe, Reno PD Deputy Chief Mac Venzon, Drug Abuse Prevention Coordinator Stacy Ward