http://www.tillamookheadlightherald.com/news/article_73afbd02-0571-11e1-b703-001cc4c002e0.html
Proof of Pain
Posted: Wednesday, November 2, 2011 9:39 am | Updated: 9:47 am, Wed Nov 2, 2011.
By Samantha Swindler
WHEELER - A prominent north county doctor's efforts to ease his patients' suffering have gained him statewide recognition as a "Pioneer in Pain."
But he's also drawn the attention of local law enforcement.
"It's incredibly controversial," said Dr. Harry Rinehart, medical director of the Rinehart Clinic. "There are people who hate me because I take care of people with chronic pain and addictions."
Rinehart feels we have "undermedicated" pain patients. But Tillamook County District Attorney William Porter fears too many prescription narcotics end up with drug addicts.
Porter said he's filed several complaints against Rinehart to the Board of Medicine.
All of them have been dismissed.
"The aim here is not to prevent anyone who is legitimately receiving treatment," Porter said. "But there's also a significant question of at what point do you look at non-narcotic alternatives?"
Law enforcement deals with the addicts and abusers of narcotic prescriptions. Rinehart said he sees a different side of the drug - people in pain and unable to get help from other doctors.
"People with chronic pain, if they're treated appropriately so they're not overmedicated, and they're not undermedicated, so they can be more functional, are some of the most appreciative patients, and they're really great, great people to work with," Rinehart said.
In April, Rinehart began prescribing narcotics in group sessions rather than during individual appointments. Once every three months, patients must attend a group pain management meeting to have their prescriptions refilled.
He's believed to be the only doctor in the state with such a practice.
"Groups for other conditions have been shown to be really pretty dramatic as far as people doing better with whatever their condition is," Rinehart said. "And because people form bonds, they have camaraderie, they help each other."
Rinehart said the groups allow him to spend more time teaching broader concepts about coping with chronic pain - exercises, dietary changes and understanding why the body registers pain in a certain way.
He has more than 300 pain patients.
"Most people are concerned about the group sessions the first time around, but we have people who just love groups. They think it's the best thing we've done."
THE GROUP MEETING
On a Friday morning, 11 people gather in a room at the Nehalem Bay Health District for a chronic pain management meeting. Rinehart opens the meeting by requiring all attendees to show him pictures of their home safes with their pills inside, or otherwise to bring in the lock box in which they hold their medications.
Rinehart has always required his patients to lock up their narcotic prescriptions. But one man was not happy about this new requirement of photographic evidence. He wanted to talk to his attorney and said "where it (the medication) is at, it's private. It's taking it too far."
But Rinehart was adamant. He lifted his wrist, displaying a silicone wristband with "Megpie" written across it.
"That's the bracelet for the little 15-year-old who died because she got methadone," he said. "Now that's ‘carried away.' So when it comes to some teenager's life or your concern, her life takes precedence...
"These drugs are absolutely lethal, and we have a responsibly in the community to keep them safe."
Megan Price died from an overdose after getting access to her step-mother's prescribed methadone. The family is now selling memorial wristbands for $4 each. The money will go toward making an anti-drug video to be shown to area students.
Rinehart makes all his pain patients sign an agreement - they will lock up their drugs, they won't share them and they won't see another doctor for additional prescriptions.
There's no doubt that the narcotics being prescribed are powerful. So are the patients' stories. Every one of them in the group session says "Doc" - as they affectionately call Dr. Rinehart - has changed their lives.
"I had gone to many, many, many doctors and the last doctor told me that 98 percent of people in U.S. have back pain," one patient said. "You felt they were blowing you off. I have more medical history of being blown off than anything else."
Many doctors opt not to treat chronic pain patients because of the added federal scrutiny and potential for narcotic abuse.
"It's a stigma," said one young man who comes to see Rinehart from Astoria. "I've been to a few doctors and all they want to do is surgery, it's your only answer. And with this doctor, there's always something new to try. Most of the other doctors said ‘you're either faking it or you're a junkie.'"
The man from Astoria just turned 30. He played football and threw discus in high school and had back surgery at age 17. Rinehart has prescribed him methadone. "I take them on the hour," he said. "I just get a nice pile in my system and I can deal. It's not like I'm high.. it takes that pain from a level 5 to a 2 or 3 so where if there's something that's worth doing, I'll get up and go do it."
He also takes lithium, a mood stabilizing drug; morphine at night to sleep; and has a medical marijuana card.
He says Rinehart's treatments have changed his life for the better.
Another patient - a middle-aged, overweight man who said he's had four back surgeries - takes six oxycodone pills daily, but has "breakthrough" pain every day. "Breakthrough" pain comes on suddenly, and is above and beyond the regular level of chronic pain.
"It would be perfectly reasonable to give you another two oxycodone to take if you're going to go mow the lawn," Rinehart told him.
In street value, these drugs would be worth plenty - a single 80 milligram oxycodone pill sells illegally for about $80.
"A lot of people who aren't involved in chronic pain are surprised by how much they are taking," Rinehart said of his patients' doses. In the state of Washington, he said 120 milligrams a day of morphine is the maximum allowed for those on workers compensation, "and Oregon is beginning to follow suit. As many of you know, that wouldn't touch what you're doing," he told the group.
The meeting isn't just about narcotics. Group members talk about other ways to ease their pain. One woman shared how eating a "clean diet" has helped. Fewer processed foods and sugars seemed to have positive effects on pain, she said.
During the meeting, Rinehart also encourages his patients to put a few pills away in case of winter storms, which might prevent them from reaching the pharmacist.
"If you have a really good day, you have to put a pill away," he told them. "That's perfectly, absolutely reasonable and if you have some left over, we don't say that's underutilized, we would like you to have a few so you don't go into withdrawal."
At the end of the meeting, before he starts to sign off on all the prescriptions for the next three months, Rinehart asks the group, "Anybody have side-effects? Constipation? Sexual disfunction?"
No one says a word.
‘OPIATE PHOBIA'
On Oct. 1, Rinehart was awarded the annual Pioneer in Pain award by the Oregon Pain Society. While the group pain sessions weren't the reason he was awarded the honor, Jennifer Wagner, executive director of the Western Pain Society and the Pain Society of Oregon, said it is another example of Rinehart's dedication to his patients.
"It's a pretty new thing that he's starting to do... I haven't heard of any practice doing that," she said. "I think it shows Harry is innovating in a rural community where there are not a lot of other providers. He is constantly thinking of ways to treat patients."
Rinehart received the award for his long history of treating pain. He began his practice in Prineville in 1978 after he got out of the Army. In 1992, he returned to Wheeler, to take over the medial practice begun by his grandparents in 1913. Today, the Rinehart Clinic is a 501c3 non-profit clinic that treats patients regardless of their ability to pay.
From the beginning of his practice in Prineville, pain management has been an important part of Rinehart's family practice.
"I hadn't been in town two years when I was investigated by the Board of Medical Examiners for prescribing about four 5-milligram Percocets a day to an elderly woman in a nursing home with arthritis of her knees," Rinehart said.
"The investigator was here in town three days, went through all the pharmacy records, and he met with me and he said that was the problem, I was prescribing four Percocet a day to this woman who was nearing the end of her life in a nursing home, which today it's just laughable because that is such a small dose."
Wagner said Rinehart has been investigated by the Oregon Medical Board more than a dozen times, but has never had any disciplinary action taken against him. She sees it as an example of Rinehart's commitment to patient care, regardless of the obstacles.
"The Institute of Medicine just released a report," Wagner said. "They estimate that 116 million Americans have chronic pain - that's more than cancer, diabetes and heart disease combined. In my opinion we have two public health crises happening - the hospitalization and deaths related to opiate overdose and abuse. At the same time, we have a public health crisis with the under-treatment to pain. And one is the response to the other, and we need to be careful about it."
Part of the problem is the subjective nature of pain. There's no test to determine a person's pain level. And the same injury could result in very different feelings of pain in two different individuals.
"We could have the same injury and I could have a pain level of a 4 and you could have a 2, and both are true and valid, but it's different based on us," Wagner said.
Treating chronic pain then becomes particularly problematic, because the most effective drugs for that treatment are addictive and can be diverted to illegal street use.
"At this point in time, one in five adult Americans have some chronic pain," Rinehart said. "Not every one of them needs a pain pill. But many of them are able to function far better if they have pain control. And so throughout the 1980s and 1990s there was a realization that people were being undermedicated. And there were a lot of educational programs about use of opioids for pain."
But, he says, the "pendulum swung" in the other direction as the problem of abuse became more prevalent.
"People are afraid of opiates," Rinehart said, "and this country has not had a rational approach to the treatment of pain or the issue of pain since the get-go. In the 1960s the DEA was scheduling drugs - so when around 30 percent of the population is having trouble with alcohol, 5 percent with opioids, what did they schedule? Opioids. They said this is the bug-a-boo. But we know that's not the case, it's alcohol..."
Rinehart is also one of 19 volunteer members of the Oregon Pain Management Commission, a state organization that seeks to "improve pain management... through education, development of pain management recommendations, development of a multi-discipline pain management practice program for providers, research, policy analysis and model projects."
"Inadequate pain relief is a serious public health problem in the United States," reads the 2006 statement on Pain Management by the Oregon Pain Management Commission. "Estimates of Americans suffering from chronic pain range from 20-30 percent of the population... Pain continues to be under-treated. This causes unnecessary suffering and reduced function and quality of life in people with pain as well as increased healthcare utilization and lost workforce productivity."
DEPENDENCE & ADDICTION
One of the biggest misconceptions about chronic pain is the difference between dependence and addiction.
A diabetic who abruptly stopped taking his insulin would go into serious withdrawals, Wagner said. That patient is dependent on the insulin drug. And yet, a pain patient dependent on opioids faces far different scrutiny.
The American Society of Addiction Medicine defines addiction by the characteristics displayed: "impaired control over drug use, compulsive use, continued use despite harm, and craving."
Properly medicated patients may be dependent on their drugs - simply meaning they may face withdrawal symptoms if abruptly taken off the drug. Those who are addicted have a continued craving for the drug; they may take it to the point that they are unable to work or function normally.
Additionally, Rinehart believes an over-criminalization of prescription pills has led some patients to become "pseudo-addicts." They display some traits of addicts - such as forging prescriptions or doctor shopping - only because doctors aren't adequately treating the pain they have.
Rinehart doesn't treat addicts within the same group sessions as his chronic pain patients, nor with the same drugs.
He is one of the only doctors on the coast currently allowed to prescribe Suboxone.
The brand Suboxone, which contains the drug buprenorphine, was approved by the Food & Drug Administration in 2002 for use in opioid addiction treatment. It's also a Schedule III narcotic, making its illegal sale a felony.
Buprenorphine is a "opioid partial agonist," which means it doesn't have the maximum euphoric effects of drugs such as heroin, oxycodone or methadone. At low doses for addicts, it curbs withdrawal symptoms without giving a high. And unlike methadone, buprenorphine has a "ceiling effect" of about four pills, so higher dosages have no effect on a user. Supporters say the chemical properties of the drug make it less likely to be abused than other opioids.
Still, police warn that Suboxone is rapidly becoming a street drug among addicts.
"Suboxone, if used properly, can be a great tool for helping an opiate addict," said Detective Paul Fournier with the Tillamook Sheriff's Office. "The problem is that the diversion of Suboxone is similar to the diversion of the opiate in the first place. We find them selling, trading Suboxone. It becomes a commodity in the drug trade. A user who has no intention of getting clean will stockpile them, and when heroin becomes unavailable they take it to not get sick."
As an officer, Fournier sees a growing number of pain pill addicts. And it's not just a problem in Tillamook County.
In the past few years, Americans' trips to the emergency room because of prescription painkillers have more than doubled - from 144,644 in 2004 to 305,885 in 2008.
"The majority of opiate abuse in this county is of prescribed medication," Fournier said. "We are seeing people that may not be smoking it, may not be shooting it up, but they are so addicted to their pain killers that ... they are a shell of the person they were."
THE JAIL'S POLICY
Even with a valid prescription, if you're arrested and end up in the Tillamook County Jail, you'll quickly be weaned from your narcotics.
That's because at the jail, powerful prescription narcotics can be a problem.
"I'd say probably between 40-60 percent of the patients (at the jail) who come in are claiming to be using some kind of a prescription narcotic," said Dr. John Zimmerman, the medical director of the Tillamook County Health Department.
Zimmerman is contracted to provide medical services for the county inmate population. He's taken a strong stand to cut the high use of prescription narcotics among the inmates.
"When inmates come into the jail, they may or may not be on narcotic prescriptions. A lot of them claim to be, but they're really not," Zimmerman said. "With the problems that exist among the inmate population anyway - drug abuse and all those kinds of things, as well as alcohol abuse - (opioid use) is not a situation that is amenable to the jail population... The policy at the jail has been for quite a while to wean these people off their narcotics in a safe and reasonable way, using medication to treat their side effects."
Inmates are treated with over the counter medications - ibuprofen, Tylenol and aspirin. Patients will go through withdrawals for the first few days, he said, but opioid withdrawal is not life-threatening.
"Many times... when I do an evaluation of what's going on with them, I find an entirely inappropriate prescription in the first place, and that their medical condition doesn't warrant chronic narcotics anyway," Zimmerman said.
He added that the jail staff's medical care focus - which is paid for with public monies used to operate the jail - is on acute or life-threatening problems.
"For the most part, medications that are administered on a daily basis at the jail are for chronic medical conditions that could cause serious situations if they're not treated," Zimmerman said. "Chronic pain does not fall into that category."
But Wagner has serious concerns about the jail's policy.
"If a chronic pain patient has chronic pain, you can't just remove them from their pain medication and think they're fine," she said. "That person is indefinitely suffering... There's no reason to take them off their medication. It should be the same as other medication that a patient has."
Wagner and the Oregon Pain Society have advocated for better access to pain management care for patients - including access to opioid narcotics. She believes doctors are under-medicating pain patients because of the stigmas of prescribing narcotics.
But Zimmerman disagrees. Asked if doctors in general are overprescribing narcotics, Zimmerman, who also has a family practice, said, "I would say yes, in a lot of respects.
"I think the biggest problem has to do with the chronic prescription of narcotics," he said. "It's hard to argue with somebody who falls off their porch and has a gash in their leg and a huge bruise... It's when people are prescribed narcotics on a chronic basis without certain guidelines being observed before this stuff is prescribed."
Drug abuse or over-use appears to be growing. In the past few years, Americans' trips to the emergency room because of prescription overdose have more than doubled - from 144,644 in 2004 to 305,885 in 2008.
State-wide, 53 percent of drug overdoses are associated with prescription opioids.
PREVENTING DIVERSION
Local drug-related crime statistics are kept by class of drug without distinguishing between legal and illegal drugs, so the district attorney's office can't provide a breakdown of exactly how many criminal cases in the area involve prescribed narcotics.
But Tillamook District Attorney William Porter said, "I can tell you that of the non-marijuana unlawful use drugs, prescription drugs are sneaking up on probably 50 percent of the possession case load."
Most of the cases that end up before the district attorney's office are people stopped for an unrelated crime who are found under the influence or illegally in possession of a narcotic.
"The majority of opiate abuse in this county is of prescribed medication," said Det. Fournier.
Fournier had no comment on the practices of any specific doctors in Tillamook County. "I would say that I still believe that opiates are prescribed for longer period of times and at a higher volume than are therapeutically necessary," he said. "Doctors and pharmacists should be aware that these things should be treated like loaded weapons."
MONITORING PRECRIPTION DRUGS
The state has taken some steps to prevent "doctor shopping"- patients seeking prescriptions from multiple doctors and filling them at multiple pharmacies.
The extra pills can be sold on the street, or abused for a high by the patient.
Up until recently, no state system tracked the dispensation of these narcotics. But the Oregon Prescription Drug Monitoring Program went online Sept. 1. The program requires pharmacies to electronically report prescription data for Schedule II, III and IV controlled substances. That includes opioids.
The program is in its infancy and still uploading data. But law enforcement is optimistic that it may make it harder for patients to abuse prescription drugs.
Additionally, Fournier hopes healthcare professionals realize the affects of prescription drug abuse. Pain pill addicts, he said, live in a fog and become "a shell of the person they were.
"Maybe (doctors) are not seeing what we're seeing - the overdosing or the grandchildren and children of these patients who are using it," he said. "I don't think there's enough care being given with these prescriptions."
http://www.painsociety.com/conference/annual/pioneeraward.php
http://www.lanecounty.org/departmen...egon_hidta_threat_assessment_final_062112.pdf
Controlled Prescription Drug Use
The threat posed by misuse of controlled prescription drugs (CPDs)
has grown dramatically in in the United States in recent years.53 The most recent federal data shows that non-medical use of
prescription drugs grew nearly sixfold nationally between 1992 and 2009, with opioid pain relievers
responsible for more drug-related deaths than heroin and cocaine combined.54 In addition, hospital
emergency department visits involving nonmedical use of prescription pain relievers nearly doubled
between 2004 and 2009 in the United States, the latest data available.
55
The misuse of prescription drugs has resulted in an emerging market in Oregon (Table 1). Over
70 percent of Oregon law enforcement officers surveyed in early 2012 reported a high level of illicit
prescription drugs available in their area, with one agency in Tillamook County reporting CPDs as the
area's greatest drug threat (Figure 1, page 5). Most officers surveyed (76%) indicated a high level of
narcotics, such as oxycodone (e.g., Oxycontin) and hydrocodone (e.g., Vicodin), were diverted in their
region, with slightly fewer reporting high levels of depressants (11%) and stimulants (6%).
56 According to a 2011 federal study, Oregon's rate of non-medical opioid use is second highest in the
nation and fourth in the quantity of kilograms sold (per 10,000 residents) in
2008.57 Treatment admissions for CPDs increased
more than threefold in Oregon in the last nine years
(CY 03-CY11, Figure 9, page 14), 58 with the reported
number of unintentional deaths (most due to
prescription drug poisoning) rising faster than any
other type of injury.59 Analysis of admission data for
the HIDTA region follows statewide trends with a
more than threefold rise in related admissions from
2003 through 2011 (Figure 4, page 7).60
suppl) ES67-ES92
