Shots - Health News
1:29 am
Wed January 23, 2013

Painkiller Paradox: Feds Struggle To Control Drugs That Help And Harm

Originally published on Wed January 23, 2013 11:38 am

A few years ago, a doctor started prescribing Michael Israel painkillers for bad cramps in his gut. Israel had been struggling with Crohn's disease, a chronic digestive disorder, since he was a teenager.

"So he was prescribed, you know, Lortab, or Vicodin or whatever. You know, they would flip-flop it from one to another," says Avi Israel, Michael's father.

Then one day, Michael confessed that something was wrong.

"Michael came over to my bedroom one night and said, 'Pops, I have a problem with the pills,' " says Israel.

Michael admitted that he was taking more pills than he was supposed to. He was even crushing and snorting them. He was addicted. That started a long, hard fight to try to break his addiction. But nothing worked. He started losing hope. And then one day, something terrible happened.

"Michael walked into my bedroom, and he had a shotgun that he used to use for target practice, because that was one of his favorite things. Locked the door, and I kept calling him, 'Mike, Mike,' " Israel says.

Israel ran to the door and heard his son cock the gun. And then, the blast.

"I kicked the door open. There was my boy, laying on the floor."

Michael was just 20 years old.

Israel, who lives in Buffalo, N.Y., is now on a mission to prevent more people from dying from their addiction to prescription painkillers. And he's far from alone.

These drugs have been a godsend for millions of people in pain. But they are narcotics, which means they can make people high. As a result, they are abused by millions of people. And many patients who take them for pain become dependent.

"What we're seeing, increasingly, over the last few years has been widespread abuse, and the abuse just keeps increasing," says Joseph Rannazzisi of the Drug Enforcement Administration. "It's a huge problem. And I think we're at epidemic proportions right now."

Overdoses have been rising rapidly, now killing more than 15,000 Americans every year.

"It's not a white or black or Hispanic issue. It's not a male or female issue. It's everyone," Rannazzisi says. "We see kids as young as 12 years old, elderly patients."

The DEA wants something done about the most commonly used group of these drugs: those containing an opioid called hydrocodone, of which the most well-known is probably Vicodin.

These drugs are not as tightly controlled as similar medications, and the DEA wants to put them in the same legal category as drugs like Oxycontin and Percocet.

"There's this idea that a drug like hydrocodone, it's not as dangerous, it's not as addictive," Rannazzisi says. "That's just a fallacy."

The change would stop doctors from writing prescriptions for more than one month's supply at a time or calling in new prescriptions without seeing their patients.

But some doctors want even more restrictions. Addiction specialist Andrew Kolodny of Maimonides Medical Center in Brooklyn, N.Y., says all of these drugs should only be used for patients who really need them, such as cancer patients. They should not be handed out casually, he says.

"This epidemic has been fueled by overprescribing of opioids, particularly for chronic noncancer pain, whether it's low back pain, headaches," says Kolodny, who leads Physicians for Responsible Opioid Prescribing. "I think that's really created a public health crisis."

PROP wants the Food and Drug Administration to rewrite the labels on all opioids to say that doctors should write prescriptions only for severe pain and at much lower doses, and that patients should be kept on the medications for no longer than 90 days at a time.

"The way to begin to turn the epidemic around is by getting doctors to prescribe more cautiously," Kolodny says.

But that's terrifying to many pain patients and their doctors. They worry that these changes may make it impossible for many patients to get the drugs they need.

"We have millions of people who are totally disabled because of their pain," says Lynn Webster, president of the American Academy of Pain Medicine. "Many people who do not have access to aggressive pain management may simply not be able to survive."

One of those patients is Carolyn Tuft. She has been suffering constant pain since a terrible day in 2007. She had gone shopping with her 15-year-old daughter, Kirsten, near their home in Salt Lake City.

"I took my youngest daughter to the mall to buy valentines. And there was a shooter that came into the mall and ... shot both of us. Shot me three times and shot her twice," she says.

Carolyn's daughter was one of five people killed that day. Carolyn was one of four victims who survived. But she says she has been in unrelenting pain ever since.

"I have a really hard time just getting up in the morning. Because the pain is so, so severe that it takes at least three hours just to put clothes on and make myself stand up and get moving for the day," Tuft says.

Even after she manages to get moving, the pain never eases.

"In my arm, it's like having a severe sunburn but also like it's frozen," she says, "the kind of pain when you have your hand in ice for too long."

The only thing keeping her going is her pain medication.

"I have so little fight left in me, just surviving every day. I don't think I would survive if I couldn't get them," Tuft says. "I don't know if I would survive life at all."

Tuft is far from alone. The fear is that some patients — such as the elderly with arthritis or rural workers with severe back pain — may not be able to get to a doctor for new prescriptions or afford extra doctor's bills.

Many physicians who are worried about getting into trouble may just stop prescribing opioids altogether, Webster says. And insurance companies may stop paying for them. Webster wonders what desperate patients might do.

"They'll look for alternative medications that may be less effective. They may be more risky. We can't anticipate the consequences [from] this proposed change," Webster says.

Advocates for tightening the rules say none of the changes would prevent doctors from getting the drugs to patients who really need them. For example, Kolodny says, doctors could write prescriptions "off-label" and give patients several prescriptions at a time.

For their part, officials at the FDA say they're trying to figure out how to help without causing harm. The agency wants to find the balance between helping prevent more patients like Israel from dying and protecting pain patients like Tuft.

"It is as complex an issue as I've worked on, just for the variety of social, medical, scientific, legal things that are influencing the choices people are making," says Douglas Throckmorton of the FDA.

The FDA recently took steps to get drug companies to make the drugs in new ways that would make them harder to abuse. And the agency is holding two hearings — one starts Thursday, the other next month — to try to figure out how to walk that fine line of preventing abuse without causing more suffering for people in terrible pain.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

RENEE MONTAGNE, HOST:

Over the next few minutes, we're taking a look at an emotional debate over the most widely prescribed drugs: painkillers. Among them: Oxycontin, Percocet, Vicodin. Millions of people depend on these drugs to help them cope with terrible pain. There are also millions who are addicted to these narcotics, and thousands die from overdoses.

As NPR's Rob Stein reports, officials are struggling to fight prescription painkiller abuse without harming those who need them. And a word of warning: These tragic stories may be difficult to hear.

ROB STEIN, BYLINE: A few years ago, a doctor started prescribing Michael Israel pills for really bad cramps in his gut. His father, Ari, says Michael had been struggling with Crohn's disease, a chronic digestive disorder, since he was a teenager. [POST-BROADCAST CORRECTION: Michael Israel's father was incorrectly identified. He is Avi Israel.]

AVI ISRAEL: So he was prescribed, you know, Lortab or Vicodin, or whatever. They would flip-flop it, you know, from one to another.

STEIN: Then one day, Michael confessed that something was wrong, really wrong.

ISRAEL: And what happened, Michael came over to my bedroom one night and said, Pops, I have a - problems with the pills.

STEIN: Michael admitted that he was taking way more pills than he was supposed to. He was even crushing and snorting them. He was addicted. That started a long, hard fight to break his addiction, but nothing worked. He started losing hope. And then one day, something terrible happened.

ISRAEL: Michael walked into my bedroom; and he had a shotgun that he used to use for target practice 'cause that was one of his favorite things; locked the door; and I kept calling him - Mike, Mike.

STEIN: Ari Israel ran to the door, and heard his son cock the gun. And then, the blast.

ISRAEL: I kicked the door open. (Crying) There was my boy, laying on the floor.

STEIN: Michael was just 20 years old. Ari Israel, who lives in Buffalo, is now on a mission, a mission to prevent more people from dying from their addiction to prescription painkillers. And he's far from alone. These drugs have been a godsend for millions of people in pain, but millions of people are also addicted. Joseph Rannazzisi, of the Drug Enforcement Agency, says that's because they're opioids. They can make people high, and easily get people hooked.

JOSEPH RANNAZZISI: What we're seeing, increasingly over the last few years, has been widespread abuse. And the abuse just keeps increasing. It's a huge problem.

STEIN: Overdoses have been rising rapidly. More than 15,000 are now dying every year.

RANNAZZISI: It's not a white or black or Hispanic issue. It's not a male or female issue. It's everyone. We see kids as young as 12 years old; elderly patients.

STEIN: So the DEA wants something done about the most commonly used group of these drugs: those containing an opioid called hydrocodone. The most well-known is probably Vicodin. Right now, these drugs are not as tightly controlled as similar medications. Rannazzisi says the DEA wants to change that; to put drugs like Vicodin in the same legal category as drugs like Oxycontin and Percocet.

RANNAZZISI: There's this idea that a drug like hydrocodone, it's not as dangerous; it's not as addictive. And that's just a fallacy.

STEIN: The change would stop doctors from writing prescriptions for more than one month's supply at a time, and calling in new prescriptions without seeing their patients. But some doctors want even more restrictions. Addiction specialist Andrew Kolodny says all of these drugs should only be used for patients who really need them, like cancer patients; not handed out casually.

DR. ANDREW KOLODNY: This epidemic has been fueled by overprescribing of opioids, particularly for chronic, non-cancer pain - whether it's low back pain, headaches. I think that's really created a public health crisis.

STEIN: So Kolodny's group wants the FDA to rewrite the rules for how doctors should use these drugs; to say they should write prescriptions only for severe pain, at much lower doses, and for no more than three months.

KOLODNY: The way to begin to turn the epidemic around, is by getting doctors to prescribe more cautiously.

STEIN: But all this is terrifying many pain patients and their doctors. Lynn Webster, of the American Academy of Pain Medicine, worries these changes may make it impossible for many patients to get the drugs they need.

DR. LYNN WEBSTER: We have millions of people who are totally disabled because of their pain. Many people who do not have access to aggressive pain management may - simply - not be able to survive.

STEIN: Patients like Carolyn Tuft. She's been suffering constant pain since one terrible day in 2007, the day she went shopping with her 15-year-old daughter, Kirsten, near their home in Salt Lake City.

CAROLYN TUFT: I took my youngest daughter to the mall, to buy valentines. And there was a shooter that came into the mall and shot both of us; shot me three times, shot her twice.

STEIN: Carolyn's daughter was one of five people killed that day. Carolyn was one of four victims who survived. But she's been in unrelenting pain ever since.

TUFT: I have a really hard time just getting up in the morning because the pain is so, so severe that it takes me at least three hours just to put clothes on, and make myself stand up and get moving for the day.

STEIN: Even after she manages to get moving, the pain never eases; not for a moment, ever.

TUFT: In my arm, it's like having a severe sunburn but also, like it's frozen - the kind of pain when you have your hand in ice for too long. My shoulder just hurts all the time; it hurts to move it. And the pain in my back is just a constant, sharp, deep pain. It goes down my legs.

STEIN: The only thing keeping her going are her pain medications.

TUFT: I have so little fight left in me, just surviving every day. I don't think I would survive if I couldn't get them. I don't know that I would survive life at all.

STEIN: Carolyn Tuft is far from alone. The fear is that elderly arthritis patients; workers in rural places, with severe back pain; may not be able to get to a doctor for new prescriptions. Many doctors, worried about getting into trouble, may just stop prescribing them altogether; and insurance companies may stop paying for them. Carolyn's doctor, Lynn Webster, wonders: Who knows what desperate patients might do?

WEBSTER: They'll look for alternative medications, which may be less effective. They may be more risky. We can't anticipate the consequences by this proposed change.

STEIN: Advocates for tightening the rules say none of the changes would prevent doctors from getting the drugs to patients who really need them. For their part, officials at the FDA - like Douglas Throckmorton - say they're trying to figure out how to help without causing harm; to prevent more patients like Michael Israel from dying, while protecting pain patients like Carolyn Tuft.

DOUGLAS THROCKMORTON: It is as complex an issue as I've worked on; just for the variety of social, medical, scientific, legal things that are influencing the choices people are making.

STEIN: The FDA recently took steps to get drug companies to make the drugs in new ways, ways that would make them harder to abuse. And the agency is holding two hearings - one this week, and another next month - to try to figure out how to walk that fine line: preventing abuse without causing more suffering for people in terrible pain.

Rob Stein, NPR News. Transcript provided by NPR, Copyright NPR.