State weighs opioid pain medication dangers against patient needs

Palm Coast Observer
News

The boat seemed perfect: A cabin cruiser big enough for retired charter captain Richard Hillibrand to live aboard with his two little poodles. He’d found it at a marina in Brunswick, Georgia. He bought it.

HOW PATIENTS BECOME ADDICTS

By: Brian McMillan, Executive Editor

A woman goes to the dentist and says she needs a tooth pulled — even though her tooth is just fine. But it’s a trade she’s willing to make: one tooth in exchange for one prescription for hydrocodone.

This is one example of what the five members of the Special Investigations Unit of the Flagler County Sheriff’s Office have discovered as they find and arrest drug abusers and dealers in the community.

“We’ve had people in the past who have had self-inflicted wounds,” Sgt. Bernie Woodward said. “One man shot himself in the leg or foot, a stabbing.”

All in a desperate attempt to get another prescription.

How it starts

It often starts innocently, according to Woodward and Cpl. Brian Finn, also of the SIU. Someone gets a legitimate prescription for pain, taking the pills on schedule. Some people don’t like the way the pills make them feel. But for those who like the side effects, it can be tempting to take an extra pill. Then, at the end of the month, they find themselves short a pill or two.

They might know someone who also takes the pills on prescription and will say, “I’m feeling sick. Can I borrow one?”

“They start to get their little circuit or network,” Finn said. “Pill communities.”

Some people in the network get their prescriptions filled on the first of the month, and their friends start showing up, asking for pills. Then everyone goes to visit the people who get their prescriptions filled on the 15th.

“People are owing people pills,” Finn said. Then, because everyone ends up short, they start buying the pills from a third-party dealer. People sometimes go to such lengths as going on the “dark web,” which uses special software to use the internet, and using bit coin for purchase to dodge investigators.

“It touches everyone,” Finn said. “When it comes to pills, you have old, poor, young rich. … We’ve charged grandmas selling their prescription to people. … White-haired, wearing a muumuu.”

He has put handcuffs on all walks of life, he said. People say, “I would never picture myself to be like this.”

Monitoring the pills

Many states have reduced pill abuse by creating what the Centers for Disease Control call prescription drug monitoring programs, which track prescription and delivery of controlled substances. In 2009, Florida created its own program, called the Electronic-Florida Online Reporting of Controlled Substance Evaluation Program.

Woodward said the EFORCSE Program has made it “harder for people to doctor shop” to get pain pills, and it has helped limit the influx of pills trafficked from South Florida to Flagler County. But, as has happened in past drug trends, the delivery methods evolve and create new problems.

There are three categories of opioids: legally prescribed painkillers like hydrocodone; synthetic opioids like fentanyl, which are extremely potent and can be prescribed for pain but are also increasingly being used illegally; and heroin, an illegal opioid.

Heroin was a drug of choice in the 1980s, when Mark Strobridge was on patrol in Central Florida. Strobridge, now the chief of the Organizational Services Division at the Flagler County Sheriff’s Office, said the heroine was mixed with other filler substances so dealers could stretch their supplies and make more money. But now, heroin mixtures are being laced with fentanyl, which can also lead to overdoses more easily, such as the case of 23-year-old Savannah DeAngelis, who died Oct. 28, in Flagler County. The man whom deputies say sold her drugs, Joseph Colon, has been charged with murder.

Woodward said drug dealers are aware of the dangers of fentanyl. He has approached dealers who have said, “I’m not selling that stuff. That’s crazy.”

“It is ridiculous what people will put in their veins and down their throat to get that high,” Strobridge said.

‘Making an impact’

Woodward started working in the SIU in 2007, investigating drugs. He was promoted in 2014 and left the unit, going on patrol instead, which is a typical route for promotions. But when the role of sergeant opened in the SIU, he applied to get back in, and he got it. He has led the unit for a year.

“I always had an interest in making an impact in the drug world locally,” Woodward said. “ … I can think of people who are doing time right now who were put away early in my career, and that is gratifying.”

The SIU is “one place where you can impact people’s lives every day,” Strobridge said. “If (Finn) goes out there and makes an arrest, they’re taking one person off the street that’s selling drugs. Then, it might not be that guy that my neighbor’s son buys drugs from.”

“We save people’s lives,” Finn added, “but you’ll never know it.”

BOX: What are opioids?

PRESCRIPTION OPIOIDS can be prescribed by doctors to treat moderate to severe pain, but can also have serious risks and side effects. Common types are oxycodone (OxyContin), hydrocodone (Vicodin), morphine, and methadone.

FENTANYL is a synthetic opioid pain reliever. It is many times more powerful than other opioids and is approved for treating severe pain, typically advanced cancer pain.1Illegally made and distributed fentanyl has been on the rise in several states.

HEROIN is an illegal opioid. Heroin use has increased across the U.S. among men and women, most age groups, and all income levels.

Source: CDC

“I was thinking if I sell this (house), I’ll just move aboard the boat and enjoy myself with the little time I’ve got left,” said Hillibrand, a Palm Coast resident.

But after Hillibrand made the purchase, his doctors at the VA cut him off of the pain medication that he says he needs to function — part of a widescale cutback designed to curb opioid abuse.

“And the boat is still sitting up there,” he said. “I’m pretty much a recliner vegetable. It has destroyed that aspect of my life.”

Not enough

Hillibrand’s situation, he said, illustrates how pain medication restrictions designed to combat opioid overdoses — like the bills working their way through the state Legislature — can affect ordinary patients.

Hillibrand’s back is stooped. He’s had multiple back surgeries to combat a degenerative disk disease and severe scoliosis.

As his medical condition declined, the VA had, previously, increased his supply of oxycodone to keep up with it. But then, the VA started cutting his pain medications back. The cutbacks were administration-wide and began in 2012.

These were “swift, mandated cutoffs regardless of patient well-being and with virtually no evidence that it’s a safe approach,” wrote Art Levine in “How The VA Fueled The National Opioid Crisis And Is Killing Thousands Of Veterans,” published in Newsweek.

As doctors tapered down Hillibrand’s supply, he found that the lessened amount that he was prescribed per day was no longer enough to get him through the day without pain.

So he began taking more than he was supposed to in the mornings. Otherwise, he said, he couldn’t get anything done around the house.

But that left him short at the end of the month, so he’d go cold turkey and again find himself nonfunctional until he got a refill.

He was frank about this with his doctors, who told him that he was misusing his prescription drugs and refused to prescribe more, instead having him scheduled for a surgery they believed would resolve his pain problems.

In the meantime, he’s relied on over-the-counter drugs — making it hard to do everyday things like drive and keep up with household chores. He uses a medical scooter to walk Ella and Edith — two dainty poodles, one white and one black, named after the singers Ella Fitzgerald and Edith Piaf.

“All around the outside’s a disaster, and I used to be meticulous,” he said.

Legislature takes action

Opioid-related deaths in Florida jumped to 5,725 in 2016, an increase of 35% over 2015, according to the Florida Department of Law Enforcement. Drug overdoses, most involving an opioid, are the leading cause of accidental death in the country.

In 2017, Gov. Rick Scott declared the opioid crisis a public health emergency. The increase in overdose deaths spurred the Florida House and Senate to craft bills to restrict how doctors can prescribe certain pain medications.

But the proposed legislation pits patients like Hillibrand, who have genuine pain problems and fear new restrictions will affect their quality of life, against people trying to fight the overdose epidemic.

The House’s bill, which passed unanimously on March 2, limits prescriptions to a three-day supply — seven days if deemed necessary by a physician and appropriately documented — and requires doctors to check the Prescription Drug Monitoring Program Database before prescribing medications, in order to ensure that patients aren’t “doctor shopping” to get medications through multiple doctors.

Rep. Paul Renner, who represents District 24 including Flagler County, voted in favor of the House bill.

Sen. Travis Hutson, who represents Senate District 7 including Flagler County, said he plans to vote for its Senate companion bill, SB 8.

“While I am sensitive to the constraints SB 8 could put on some patients and doctors, I voted for the bill in committee and will vote for it on the floor because I ultimately believe the bill will help Floridans,” Hutson wrote in a March 7 email to the Observer. “The current opioid crisis in our state is so severe, any burdens on some that help curb addiction and abuse for many are worth bearing.”

Pushback

Hillibrand said the proposal punishes pain patients for the behavior of addicts who are often overdosing on street drugs, not legitimately obtained prescription medicines.

“The honest, hard-working chronic pain patient is the one that’s paying the price for it,” he said.

Many doctors have opposed the legislation.

“I think it is too restrictive,” said Frank Farmer, an Ormond Beach doctor who served as the state’s surgeon general in 2011 and 2012. “Giving only a three-day supply — I know the intentions are good, but I think it needs to be individualized. ... Someone who’s had a complex orthopedic surgery with multiple breaks, etc., etc. — seven days may not be enough.”

The House bill has exemptions for cancer patients and patients with traumatic injuries or who are terminally ill. A Senate version was amended March 7 to include exemptions for pain related to palliative care, cancer, severe trauma or a terminal condition, Hutson said. “I believe this addresses concerns of burden on patients who truly need longer prescriptions,” he wrote to the Observer.

Farmer said someone with a serious chronic pain condition or who’s recently had surgery would have to make repeated trips to the pharmacy — difficult, Farmer said, if their condition affects mobility or their ability to drive, or they live far from a pharmacy. The Legislature, he said, could craft better bills by working in concert with the state’s board of medicine.

Other approaches

Most pain patients don’t end up abusing their prescribed opioid pain medication. But large portions of opioid addicts began the path to addition by taking medication that had been prescribed — either to them or to others.

“In primary care settings, prevalence of opioid abuse ranged from 0.6% to 8% and prevalence of dependence from 3% to 26%,” a 2016 CDC guideline states. “In pain clinic settings, prevalence of misuse ranged from 8% to 16% and addiction from 2% to 14%.” The CDC guidelines suggest that opioid pain medications not be the first choice for chronic pain.

Florida Hospital Flagler, said spokeswoman Lindsay Cashio, doesn’t support the prescription limits in the state bills, but does support the bills’ requirement that doctors consult the Prescription Drug Monitoring Program Database.

She agreed with Farmer that the Legislature could work more closely with medical experts to craft legislation.

Florida Hospital favors prescription duration guidelines rather than legislation, she said.

Joe Mullins, a Palm Coast businessman and former Georgia resident who still serves on Georgia’s Statewide Opioid Task Force, said he’d like to see more focus on funding recovery efforts.

“You’ve got to kill the demand, and the way you kill the demand is through treatment,” he said.

Mullins is eight years into recovery from prescription pain pills himself. If someone is an addict, he said, “They’re going to find a way to get it. Without introducing the person to some kind of recovery mechanism, they’re just going to find another drug.”

Cutting down on the prescription pills that make their way into the black market could have unintended consequences, he said — prices for the pills on the streets could rise, pushing more addicts to turn to cheaper, and potentially more deadly, alternatives. (See the story at the top left.)

There’s not a perfectly linear correlation between opioid pain medication prescribing and overdose deaths as a whole: The number of opioid prescriptions decreased by 16.9% from 2012 to 2016, according to the American Medical Association, while the number of drug overdose deaths has steadily climbed as addicts have switched to heroin and fentanyl.

“I think there is a legitimate concern that doctors too freely prescribe opioids when they could use something less addictive. Or, they overprescribe,” Farmer said. But, he added, “The laws could recognize that there are differences in recovery time. ... I think the legislation has the possibility of just inappropriately hurting people who are innocent.”