Published April 30. 2014 4:00AM Updated April 30. 2014 11:52PM
New London — Starting with the premise that "we're the problem here," a panel of doctors and a pharmacist urged colleagues to stop overprescribing prescription painkillers, which is at the root of the growing problem of abuse of and addiction to legal and illegal opiates, including heroin.
"More people are dying from opiate overdoses than from car crashes," Dr. Gail D'onofrio, professor and chairwoman of the Department of Emergency Medicine at the Yale School of Medicine, said during her presentation Tuesday. "We need to be very judicious in prescribing. The last thing we want to do is not treat pain, but people can become addicted after a very short course of narcotics."
D'onofrio gave the first of five talks on various aspects of prescription drug abuse during a forum organized by Ledge Light Health District at Lawrence + Memorial Hospital. Kerensa Mansfield, senior program coordinator at Ledge Light, said the forum is one of several initiatives the public health agency is taking to address the abuse problem, including promoting use of drug take-back boxes at local police departments, lunchtime meetings with doctors and the "Bust the Myth" campaign for schools and community groups to educate the public about the risks of prescription narcotics.
"Prescription painkillers are often the gateway for heroin use," she said. "We need a call to action."
Dr. Samuel Silverman, medical director of substance abuse service at Rushford Center and assistant clinical professor at the University of Connecticut School of Medicine, began his talk by showing a photograph of a squirrel at a bird feeder.
"Has anybody every tried to get a squirrel away from a bird feeder?" he asked.
People who get addicted to narcotics, he said, become ruled by uncontrollable impulses just like that squirrel. Successful treatment requires that their condition be treated as a "brain disease" that will need lifelong vigilance to keep at bay, he said.
"Nobody starts off wanting to be an addict," he said, adding that about 10 percent of the population is particularly susceptible. "It's a disease of the brain's reward system. It's not about the drug, it's about the brain."
Treatment with buprenorphine, the main ingredient in Suboxone, effectively supplants the brain's cravings for opiates, Silverman said, but must be given in combination with counseling "to teach them what they have to do to live a life with an addictive disorder."
"It takes long-term focus and mindfulness," he said, adding that there are "three Ts" essential for patients to beat addiction: "taking responsibility, tolerating discomfort, and telling the truth."
Before prescribing narcotics, doctors must establish a specific, appropriate diagnosis, document the objectives for treatment, educate patients about the risks and benefits of narcotics, monitor them closely and do follow-up urine testing, said Dr. Mustapha Kemal, who specializes in pain management at L+M. Non-narcotic medications and alternative therapies including physical therapy, acupuncture, yoga and massage should be used more frequently to treat chronic pain, he and other panelists said.
"We need to engage insurance companies to provide coverage for alternative therapies," Mansfield added.
Kemal also advocated doctors use an opiate risk assessment screening tool to assess patients who may be misusing prescription drugs, and to be aware of how powerful these drugs can be.
"Do not exceed 120 mg ... without consultation (with other doctors)," he said. "Patients become tolerant and progress toward addiction at higher doses than that. After just a week of these medications, people can develop tolerance, and can have withdrawal symptoms when they're taken off."
Silverman said doctors should consider prescribing medications to alleviate withdrawal symptoms whenever they take someone off narcotics, so that they don't end up turning to heroin.
One of the best tools doctors can use is the Connecticut Pain Management Program, said Dr. John Paggioli of the Eastern Connecticut Pain Treatment Center in Norwich. The online registry enables doctors to check whether patients have been "doctor shopping" - going to multiple doctors and pharmacies to obtain narcotics - and to also check emergency department records.
He recalled one patient in a three-piece suit and gold watch who was director of admissions at a private school. The man was prescribed Oxycontin for back pain and soon asked for a refill, claiming he had accidentally left his medication in a hotel room. Paggioli realized the man was probably an addict and didn't refill the prescription.
"You can't tell by looking at a patient who's going to be a problem," he said. "'It can be the people you think are model patients. I had one patient who sold lobsters out of his truck and was also selling Oxycontin out of his truck."
Jeff Messina, owner of Fort Hill Pharmacy in Groton, said he and other pharmacists have to be aware of strong financial motivation people have for trying to obtain narcotics.
"There's a pretty strong market for opioids. Oxycontin sells for about $1 per mg," he said, recalling one customer whose multiple prescriptions from different doctors had a street value of $4,000 to $5,000 per month.
"Be wary of anyone who's quite assertive or very flattering," he said. "Oftentimes, they try to schedule appointments later in the day, when you may be pressed for time, or they may come to the pharmacy right at the end of the day."
Addicts use several tricks to try to obtain narcotics, Messina said. Some will try to get a prescription for narcotics by calling a doctor's after-hours emergency line or by calling a dentist after hours and complaining of a severe toothache.
"Sometimes people will try to legitimize a visit by coming in with a young child or an elderly person, or they'll sidestep their insurer and pay cash" so there won't be a record of the transaction.
In the last year or so, he said, the pharmacy has seen numerous prescriptions from doctors in Florida and New York state, where several "pain mills" are located. The pharmacy now has a strict policy against filling those prescriptions.
"If the doctor of (a) patient isn't from our area, they'll have to go somewhere else," he said.