Commentary: Give doctors tools to fight drug epidemic

By Shoshana Feiner

I am bombarded by the prescription drug abuse epidemic. As a parent, I've attended programs at our local high school. As a citizen, I read about it in our local papers. As a daughter of elderly parents, I've watched them be casually handed prescriptions for Percocet every time they complain of arthritis pain. And as a primary-care physician, I've interacted with many drug-seeking patients. Some have come and gone quickly when they didn't get what they wanted; others faced their addiction with honesty, professional help, and a lot of hard work.

Recently, Patient M came to me with some concerns about back pain. When I entered the exam room to introduce myself, she was sitting on the table with a black back brace strapped over her clothing and was wincing in pain. I took a history and learned that she had been healthy until six months earlier, when she developed back pain out of the blue. The pain was often excruciating and had forced her to give up her job as a hairdresser. She told me she had been uninsured until a few weeks before our visit but had been paying cash to see a local doctor who gave her Motrin and a few Percocets for when the pain got really bad. She said she had had no imaging studies, no bloodwork, and no physical therapy.

Upon further questioning, I learned that she had gone through a difficult divorce and was barely able to see her children. She was living with a boyfriend and struggling financially. She became teary during the exam but denied feeling stressed or depressed. She assured me that everything in her life would fall back into place if only she could get to the bottom of this back pain.

As a clinician, I was intrigued. Although her exam was normal, her story was compelling. I wanted to determine whether the pain was the cause or the result of her life stressors. I ordered an MRI of her spine and some bloodwork to look for other systemic causes of pain, and I sent an order for high-dose anti-inflammatories to her pharmacy. I told her we would have the testing completed within five days and could then get started with a treatment plan.

I could sense her panic immediately. "But what about the pain I am having now?" She was asking for narcotics. I explained that painkillers are not generally the best medication for musculoskeletal pain and that I wanted her to try the anti-inflammatories first. She hesitated and pushed harder. She wanted the narcotics. Having been in this situation many times before, I exited the room and looked her up in the New Jersey Prescription Monitoring Program.

After 20 years in practice, I expected to see that she had been getting narcotics from a variety of pharmacies prescribed by a variety of doctors. This is a situation that I know how to deal with. Instead, when I pulled up her report, I was shocked to see that a single doctor had written her 20 prescriptions for narcotics and benzodiazepines, dispensing 90 tablets at a time over the prior eight months. This woman had received almost 2,000 pills over 240 days for back pain with no diagnosis.

The Prescription Monitoring Program is an amazing tool for clinicians because it takes the guesswork out of identifying drug-seeking patients. I confronted Patient M with her report and offered her help to address her overuse of narcotics. We had an emotional but honest conversation, and I felt good about our interaction. Now I was left to deal with the fact that I had inadvertently stumbled upon a potential "dirty doctor." As a doctor, I felt obliged to take action, but should I get involved? Could I live with myself if I didn't? Would I put myself in harm's way if I did?

I called my state medical board to determine the protocol for reporting potential professional narcotics abuse. Surely, amid the epidemic of prescription drug abuse, there would be a simple mechanism to report professional misconduct. It turns out there is not.

My state medical board, which spends so much time and money educating and regulating me about safe prescribing practices, has no system in place to receive anonymous complaints or concerns. My only option is to use my name and file a formal report through legal channels against a physician I have never met based on his prescribing pattern with one patient.

So I sit with the knowledge that there may be a physician profiting from the addiction of his patients. I hope I'm wrong, but all it would take to confirm or dispel my suspicion is a simple click by someone at the New Jersey State Board of Medical Examiners to look up his prescribing patterns. Thanks to technology, this information is all readily available. The database is intended to help doctors and pharmacies identify narcotic-seeking patients, but it can just as easily flag high-volume prescribers. A state regulator should be empowered to determine if someone is liberally providing narcotics to people like Patient M.

I was thrilled when New Jersey introduced the Prescription Monitoring Program in 2012. It is a powerful data collection tool that has helped me immensely when I discuss the use of potentially addictive prescription drugs with patients. But it could also be used to examine physician prescribing habits. Pharmacists, nurses, and other doctors are often better positioned to identify outlier practitioners than regulators or law enforcement. There should be a safe and private mechanism by which they can tip off regulators to take a closer look at the prescription histories of potential offenders without having to make formal accusations in the legal system.

This epidemic does not discriminate. It is reaching broadly across age, race, and socioeconomic class. Our approach to identifying and fighting the abuse needs to broaden also. It's time for our monitoring systems to include prescribing doctors and pharmacies, not just the patients themselves.

Shoshana Feiner, M.D., a graduate of the University of Pennsylvania Perelman School of Medicine, is an internist in Bergen County. shoshanafeiner@yahoo.com