Drug overdoses kill more Americans every year than car accidents, according to the Centers for Disease Control and Prevention. In 2010, the most recent year that data is available, 38,329 people died from a drug overdose in the United States, compared with 32,885 automobile fatalities, and the numbers have been rising for the past two decades.
A steady increase in prescription drug abuse is a nationwide trend, and examples and ramifications of that trend can be found right here in western Montana.
For the past month, the staff at the Partnership Health Center, a community clinic in Missoula, has been dealing with an influx of patients who suddenly found themselves without access to prescription painkillers and sedatives after a Florence doctor’s office was raided and closed.
Ravalli County, state and federal authorities, including Drug Enforcement Administration agents, executed a search warrant at Big Creek Family Medicine and Urgent Care on April 1 as a result of a two-year investigation into the prescription-writing practices of Chris Christensen.
Christensen’s medical license was also suspended after an investigation by the state medical board determined that he had been improperly distributing controlled substances and running a cash-only business. No charges have yet been filed in the case.
The closure of Christensen’s Bitterroot Valley practice left a large number of patients without immediate access to the prescription painkillers that he allegedly had been doling out in massive quantities. The Ravalli County Public Health Office even issued a warning to Christensen’s former patients, advising them to wean themselves off the drugs before withdrawal symptoms set in.
Dr. John Miller, the medical director at Partnership Health Center, said that his staff now has to treat a number of Christensen’s patients and they have developed a protocol to avoid exacerbating the problem.
“We do have several patients who we had been kind of co-managing with Dr. Christensen, who had been getting the bulk of their care here,” he said. “A lot of patients went to Dr. Christensen’s office to get pain medications. I know of at least one case like that, in which that person had actually been working with us on their chronic pain, and there had been a little bit of a feeling that we were being a little too stringent or controlling of these controlled medications.
“And so they went to Dr. Christensen to get higher doses. And then subsequently, that patient I heard about, has come back and felt like probably what was going on with Dr. Christensen was wrong and that the patient wanted to get off the medication and wanted our support. So I think a lot of our interactions with Dr. Christensen’s patients have been to help them get off these medications or to reduce their dose to a safer level.”
Deaths from drug overdoses have been rising steadily over the past few decades, according to the CDC. In 2010, there were 22,134 drug overdose deaths related to pharmaceuticals. Of those, 75 percent involved prescription opioid painkillers and 30 percent involved benzodiazepines (sedatives).
“Opiates are the majority of prescriptions,” Miller said. “It’s a major cause of death, especially when they are added to benzodiazepines. They alter people’s judgement and they lose track of how much they take in.”
He explained that his staff members approach all requests for opiates and pain medications the same way, whether they are a new patient or a current patient.
“We do the same thing for benzodiazepines, stimulants or any controlled substance,” he said. “The reason they’re controlled is because they have risk associated with them. So, we have a really well-thought-out protocol developed for that.”
The first part of the process is to understand the patient’s history.
“What’s this problem that we’re trying to treat, what things have been tried in the past, how did those treatments go?” he said. “The second part is to assess the risk, because different people have different risks of abusing or having problems with these medications. There are really well-designed and well-validated tools to prove who is at a high risk for certain medications and who is at a lower risk.”
Partnership is a primary care clinic, and Miller said his staff members are not pain specialists.
“We are not able to take on a lot of risk,” he explained. “We prescribe to a lot of low-risk patients at low-risk doses. That’s kind of our approach to chronic pain. There are primary clinics in the country that have stopped prescribing opiates altogether. We’re trying to use evidence-based approaches to identify which patients are likely to benefit from controlled substances and who have risks that are too great, so they need to be referred to pain specialists or we need to find a treatment path that takes them away from the controlled substance.”
Miller said there are a lot of alternative treatments for chronic pain besides opiates, such as physical therapy.
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“There is also some good evidence that there are different counseling or teaching/coping techniques around chronic pain that help people a lot,” he said. “So we are not even talking about medications at that point, but just working with our partners in health care to help these folks. Like at Montana Spine and Pain, one of the pain specialty clinics in town, that’s their focus, is working on the behavioral aspects of pain.”
There are many medications that are non-controlled and are far less risky that are actually more effective in the long term for controlling pain and improving a patient’s function over time, Miller explained.
“That’s the ironic thing about opiates, the sadly ironic thing,” he said. “They work well in the short term. When the patient takes it, it helps take their pain away, but in the long run, they become reliant on it, there’s a huge potential for abuse and then because they are reliant on it and some of the effects it has on the pain centers of the brain, the pain is actually worse over time by taking those medications. Even though it works better in the short term, in the long term it’s not an effective treatment.”
Miller said some of the patients his staff has seen who have transitioned off opiates have actually functioned better three to six months after their last pill, and the amount of pain they feel has decreased.
“Our goal is for them to be as functioning as possible in their lives and enjoy wellness and reasonable health,” he said.
Many of the patients that came to Partnership after Christensen’s office closed were exhibiting withdrawal symptoms, but Miller said they won’t find a supply of opiates at PHC.
“There’s good non-opiate treatments for opiate withdrawal,” he said. “So we don’t have to prescribe opiates to get somebody out of withdrawal. And as uncomfortable as opiate withdrawal is, it’s not life-threatening. So that’s one of the key things to know about that. Alcohol withdrawal is different than opiate withdrawal.”
Unlike Montana, the state of Washington has set a limit on the amount of opiates a primary care doctor or specialist can prescribe. There, the limit is 120 milligrams of morphine equivalent doses per day. Montana has no limit.
“If you go beyond that dose in Washington, people need to go to a pain specialist,” Miller said. “The way they came to that is because the risks associated with higher doses is a little bit dose-dependent, but actually starts to tick up around 100 mg morphine equivalent doses per day.”
At PHC, they have determined that 60 mg of morphine equivalent doses per day is the highest safe limit.
Miller said that PHC is in its third year of adopting a protocol where it gets the message out that patients shouldn’t expect pain medications on their first visit.
“Most of the people we’ve seen now from Dr. Christensen’s office are people who we’ve already known, and they kind of know our approach and the limits we’ve put in place,” he said. “And they decided to go elsewhere for their pain medications. And now that they’ve come back, they know that we’re not going to prescribe those higher limits of pain medications.”
Every doctor, every clinic and every hospital has a different protocol on prescribing pain medications. One doctor might prescribe opiates to a patient, but another doctor might prescribe physical therapy for the same ailment. Miller said that disparity can sometimes cause confusion for the patients when they are forced to switch caregivers.
“I think there is still a broad range of prescribing patterns in Missoula County that we see,” he said. “What we do is try to take an evidence-based approach based on what we see. We review old records. Because these medications are so high risk, there’s not many patients that are good candidates for these medications long term.”
Miller said that there is an effort underway to get all medical facilities on the same page as far as prescription-writing practices. Marc Mentel, the medical director at Community Medical Center, has started a safe prescribing network, and St. Patrick Hospital in Missoula is hosting a pain conference at the end of May.
Miller said the stakes are high with opiate prescription abuse, mainly because the doses are so great and how dangerous they are when combined with alcohol.
Countless patients who have been on opiates long term haven’t improved their functions or mobility. That’s why primary caregivers have to be extremely careful when prescribing those medications.
“People have pain, people have chronic pain,” he said. “When people aren’t willing to prescribe, I think there’s this false perception that the prescriber doesn’t care or they don’t believe they have pain. But, even for somebody who I believe they have pain, it’s documented in their history, the fact is these medications aren’t good for them long term.”