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By Rose Hoban
In August 2014, I had major abdominal surgery on a Tuesday. By Friday, the doctors took me off the pain pump, I took one oxycodone that afternoon. For the rest of my hospital stay, my pain was managed using ibuprofen and another anti-inflammatory drug called toradol.
On Monday, as I was being discharged, the chief resident asked if I needed “anything for pain.” I responded, “Why don’t you give me something, just in case.”
What I was given was a vial with 90 oxycodone pills. I needed only one.
In the past two years, I’ve told and retold that story to lawmakers, physicians, harm reduction advocates and others who have almost all had similar stories of receiving vials filled with dozens of pain pills after surgeries, emergency room visits and dental procedures.
Stories like those are what’s driving a new bill filed in the General Assembly this week, which addresses the issue of practitioners such as doctors and dentists prescribing dozens of pills when only a handful would do.
Senate Bill 175, and a companion bill in the House of Representatives, would limit the number of days for which a prescriber can give opioid pain pills. The Strengthen Opioid Misuse Prevention (STOP) Act creates exceptions for cancer and hospice patients, people with documented chronic pain and others.
The bill stipulates that patients can get refills after their initial prescription. But when health care providers pull out their pads, the bill creates a mandate for them to report opioid prescriptions they write to North Carolina’s controlled substances reporting system (CSRS) within a day of writing for the drug.
Bill sponsor Sen. Jim Davis (R-Franklin) said the bill is intended to “address this [overdose] crisis by promoting smarter prescribing of painkillers and other prescription drugs.”
Broken bones, extracted teeth
Sen. Tom McInnis’ (R-Rockingham) stepson, Trenton Wood, was prescribed opioids after a car accident.
“He was given a vial of these horrid, horrid addictive drugs and he started a downhill spiral that ended with the loss of his life,” McInnis told people gathered at a press conference at the legislative building to talk about the initiative on Thursday morning. “It started because he was given about 30 of these pills.
“If you get these pills for any reason, you’re either going to hate the first five or you’ll love all 30 of them.”
The young man was 21 years old when he died from overdose about five years ago.
Davis and McInnis said the bill was the product of work by many agencies: Attorney General Josh Stein’s office, the Federal and the State Bureaus of Investigation, the Medical, Pharmaceutical and Dental Societies and others. The bill also includes $10 million for the Department of Health and Human Services for treatment services.
“This is only a first start,” said McInnis, who called efforts to curb opioid addiction a work in progress.
“We’re not going to stop here, we’re going to make sure our citizens are protected and that justice is brought to those who are bringing these drugs illegally into the community, and also to help those who are addicted through no fault of their own other than just going to a doctor or a dentist and getting too much of these addictive drugs.”
Several of the people at the press conference talked of physicians who might be adhering to pain protocols that require them to give more pills than needed. But anesthesiologist and pain specialist Chris Grubb said that’s not quite the case.
He talked about the fact that, often, doctors don’t do a great job managing pain. Pain is a subjective thing, unlike blood pressure or temperature, and it takes time and skill busy physicians often don’t have to assess and tinker, finding just the right dose for patients to get relief.
In the past, doctors didn’t use opioids as much as they do now. But in the 1980s there was a push to treat people’s pain adequately.
“I think the problem originated with a fear that started maybe 20 or 30 years ago that the Medical Board and regulatory agencies would criticize [doctors] for undertreating pain,” Grubb said. “And certainly patients have been known to complain… if they didn’t get the Percocet that they wanted, in some cases, to the Medical Board.”
There are few protocols for pain management. In 2016, the Centers for Disease Control produced guidelines for treating chronic pain, but they are not requirements. Grubb said there’s a wide range to how physicians treat acute pain.
“One doctor might want to give 90 [pills] another might want to give 20,” for the same thing,” he said. “There’s just no real guidance.”
In 2015, the legislature required that physicians get one hour of instruction on managing pain and safe prescribing. Since then, Grubb has been teaching his peers how to manage pain with drugs such as anti-inflammatories, Tylenol and nerve blocks.
“You’ll see more education come out about this now that they’re doing something more restrictive,” he said.
Physicians’ groups have resisted being mandated to use the CSRS in the past, saying it would add yet another task to their busy practices, but this year they’ve gotten on board.
Sheriff Buck said he believed that if doctors always check the CSRS, word will get around among people who are looking for just another vial of pills.
“Once everyone starts using the system, i believe it’ll go a long way to probably almost eliminating doctor shopping,” Buck said. ” I think it will end up saving [physicians] time on the back end.”
Cooperation among many
The 10-page bill extends standing orders for naloxone, similar to the statewide standing order passed last year, to community organizations.
More law enforcement agencies are now getting on board with having their officers carry the drug, which can almost immediately reverse an opioid overdose.
Deputy Sheriff Brian Jones from Durham County said his agency is exploring implementing a naloxone program as well as developing a law enforcement assisted diversion (LEAD) program.
Jones is also an attorney who in the past was a prosecutor. He said simply arresting and prosecuting drug users is not the most effective way to deal with the opioid issue.
“The more ways we can try to combat this issue the better,” Jones said.
Carteret County Sheriff Asa Buck said he never imagined he’d be so deeply involved in getting people using narcotics into treatment instead of jail. But he’s one of the many North Carolina sheriffs who saw more people, including members of his own family, die as a result of opioid addiction.
“We’re in the pill collecting business, we’re in the naloxone carrying business, I mean, you name it, it’s just fallen on us at the local level to deal with this issue,” Buck said.
“We didn’t get here overnight, we won’t get out of it overnight,” he said. “But with the help of law enforcement, medical prescribers, the public health community, the substance use and recovery treatment [community], survivors and policymakers, we will make a difference.”