Kentucky ranks in the top five states in the number of opiate painkiller prescriptions written per 100 people.
In a report released this month from the Centers for Disease Control and Prevention, doctors nationally wrote 259 million prescriptions for painkillers in 2012, “enough for every American adult to have a bottle of pills.”
Joining Kentucky in the top five are Tennessee, Alabama, West Virginia and Oklahoma. For every 100 people in Kentucky in 2012, 128 painkiller prescriptions were written.
In Warren County, the number of doses of controlled substances prescribed rose from 8.3 million in 2004 to 13.3 million doses last year. Controlled substances include narcotics, amphetamines, benzodiazepines and other drugs with the potential for abuse.
“Certainly research has borne out that having a glut of supply leads to problems,” said Van Ingram, executive director of the Kentucky Office of Drug Control Policy.
However, Ingram points out that the CDC report does not include a full year’s worth of data on Kentucky after the state enacted legislation, House Bill 1, that became effective in the third quarter of 2012 placing more stringent requirements on controlled substance prescribers.
House Bill 1, which was approved in April 2012, mandated that Kentucky prescribers who write prescriptions for controlled substances run a Kentucky All Schedule Prescription Electronic Reporting report on their patients to try to prevent doctor shopping and to deter prescription pill abusers from obtaining and/or diverting controlled substances such as narcotic painkillers.
KASPER is an electronic prescription drug monitoring database that allows prescribers to find out if their patients have obtained a controlled substance from another Kentucky prescriber. Prior to HB 1, prescribers’ participation in the program was not mandatory.
“Although I’m not disputing the accuracy of this (CDC) report, I wish we had 2013 data included in it,” Ingram said. “I think that would have made a difference in where our state fell as far as prescribing. We have seen a 10.5 percent decline in oxycodone and a 11 percent decline in hydrocodone” since House Bill 1 went into effect.
Even though those numbers are falling, the number of Kentuckians dying every month from drug overdoses remains steady at about 82. The number of drug-addicted babies born with neonatal abstinence syndrome has climbed significantly from 28 in 2000 to 955 last year, Ingram said.
“Drug overdose deaths, neonatal abstinence syndrome and drug overdose hospital and emergency room visits are all symptoms of having too many prescription narcotics available,” Ingram said.
Ingram also cited heroin as another contributing factor to drug-addicted newborns and overdose deaths. “Of drug overdose patients (in 2013) investigated by the Kentucky Medical Examiner’s Office, 32 percent of the decedents had heroin in their bloodstreams,” he said.
“All of the things in House Bill 1 are having an impact. Are we seeing as much as we would like to see as fast as we would like to see it? No. But we’ve got to stay the course,” Ingram said.
Dr. Ram Pasupuleti, a Bowling Green pain management physician, agrees that the reforms in House Bill 1 have started making a dent in the availability of prescription pills. He believes that the number of overdose deaths will in time decrease as the amount of pain killer prescriptions decreases.
“Unfortunately, Kentucky has always had the dubious distinction of being in the top five or 10 in use, abuse or misuse,” Pasupuleti said.
Pasupuleti’s patient load has grown significantly since House Bill 1 went into effect because many primary care physicians have either reduced the number of opiate prescriptions they write or have stopped writing them altogether and are referring patients to specialty pain physicians such as Pasupuleti.
He requires his patients to undergo routine drug screening and has become adept at determining the difference between a person who needs pain treatment and a person who only wants pills. Pasupuleti offers multimodality pain treatment, and pills are not his first choice.
“A big advantage (of House Bill 1) is a patient is seeing a pain specialist to cut down on inappropriate prescriptions,” he said. The disadvantage is the access to narcotic pain medication has declined overall and affects people who may only need short-term pain management for something such as a broken bone.
While opiate abuse is nothing new, Pasupuleti points to pain management standards that changed in 2001 as one of the causes leading to overuse and abuse of prescription pain pills.
The Joint Commission that accredits and certifies health care organizations and programs in the United States changed pain management standards Jan. 1, 2001.
“When they came out and said that pain is not being assessed, it created a paradigm shift in physicians treating pain,” Pasupuleti said. “They introduced pain as a fifth vital sign.”
That’s when hospitals and doctors began asking people to describe their pain on a number scale from one to 10 and physicians were required to recognize the right of patients to appropriate assessment and management of pain. While physicians are required to treat and assess pain and follow increasing regulations in prescribing practices, they are at the same time having to deal with less Medicaid reimbursement for interventional pain treatments such as epidural injections that are narcotic free.
“You are damned if you do and you are damned if you do not,” Pasupuleti said. “That’s where doctors are today. Five years ago I was on a tightrope. Now I am on a unicycle juggling five balls on a tightrope.”
Tommy Loving, Bowling Green-Warren County Drug Task Force director, said the Joint Commission requirements came about as a result of a study funded by a pharmaceutical company that produces narcotic pain medication, and he agrees that the 2001 regulations contributed to the flood of narcotic prescriptions.
“I believe the overprescribing by some physicians has needlessly addicted many individuals to opiates that otherwise would not have become addicted,” he said.
“The bulk of the problem has to be addressed by physicians because police can’t write prescriptions. That’s not to say that there are certainly not drugs on the street and prescriptions being diverted, but again we come back to the source,” Loving said.
Pasupuleti would like to see a national scheduled drug prescription database that works like KASPER in Kentucky. For cities like Louisville that are within a close driving distance to Indiana, a national database that states all share could be helpful in identifying doctor shoppers, he said.
“It needs to be done,” he said.
In law enforcement, Loving sees the human cost of opiate addiction.
“You see neglected children,” he said. “You see abused children because of this. In eastern Kentucky, this problem is much worse there, and my counterparts tell me they have lost an entire generation because of this.
“You have injured children and injured adults. You have DUI on pills. The problem is once people become addicted, the only thing they really concentrate on is getting more drugs, not on taking care of their household or the children or anything else. You see bankruptcies because of this – a lot of spinoff crimes, your thefts, your burglaries.
“Things have improved. I think these sort of things are going to improve over time,” Loving said. “We didn’t get into the mess overnight, and we’re not going to get out of it overnight.”