Forensic, General & Medical
Expert Witnesses

Prescription Drug Abuse: In the US and Florida


     By Comprehensive Pain Medicine Pain Management and Addiction Medicine Expert Witness

PhoneCall Sanford M. Silverman, MD and Lora Brown, MD at (954) 545-0106


According to the Broward County Commission on Substance Abuse, United Way, 2008, in 2007 there was a daily average of 9 lethal overdose reports in the state of Florida that involved the non-medical or illegal use of prescription medications , total of 3,317 fatal overdose reports, a 19% increase over the 2,780 fatal overdose from the previous year. According to DEA-ARCOS reports, Florida physicians dispense five times more oxycodone than the national average of dispensing physicians.
Reasons for Prescription Drug Abuse

There are many reasons why people abuse prescription drugs. There is a false sense of safety because a doctor prescribes these medications. Pharmaceutical grade drugs are felt to be less dangerous than illegal drugs. Many mistakenly think that abuse of prescriptive drugs is not a crime or, at least, a lesser crime because these drugs have a legitimate legal use. There is also relative ease in obtaining prescriptive drugs. When surveyed, most teens admitted that they obtained abused prescriptive drugs rather easily from the medicine cabinets of family and friends 2.
The medical establishment is also partially responsible for the problem. The recent epidemic is a byproduct of compassion and lack of understanding of the complexities of pain, chemical dependency and opioid pharmacology 2.

Pain Management and Prescription Drug Abuse

The increased demand for pain management has also helped fuel this epidemic . Opioid prescribing for chronic nonmalignant pain has experienced a paradigm shift. Twenty–five years ago opioid prescribing was deterred due to fear of causing addiction. It was reserved for primarily the treatment of cancer pain, and not non-malignant pain.

Then a shift in favor of improved patient quality-of-life occurred as our knowledge of chronic pain mechanisms developed. In the mid-late 90s, physicians were encouraged to prescribe liberally for all pain maladies. The “decade of pain” was established by congress. JAHCO created “pain as a fifth vital sign”, now an integral part of facility credentialing. On the coattails of this movement was the pharmaceutical industry with blockbuster new drugs and millions of dollars spent on marketing. Unfortunately, the money spent did not include guidelines for appropriate opioid prescribing, risk management tools for physicians nor addiction medicine education that most physicians lacked.

The most commonly diverted or abused prescription drugs include opioids, central nervous system depressants, and stimulants. Oxycontin, oxycodone and Vicoden, which are used most often to treat pain, are among the opioid drugs most commonly prescribed and abused. Medications used to treat anxiety and sleep disorders include the CNS depressants such as Valium and Xanax. Stimulants such as Ritalin and Adderall are commonly prescribed for attention deficit disorder as well as certain sleep disorders. Very effective for treatment of their respective indicated diseases, these medications have gained popularity as recreational drugs.

Popular amongst teens, “PHARM PARTIES” have replaced smoking in the bathroom and drinking beer at the drive-in. Pharm (pronounced “farm”) parties involve teens meeting at a given location and dumping pharmaceuticals of all kinds into a common bucket or bowl and then blindly taking a mix of pills for recreational purposes. Imagine mixing opioids, amphetamines, depressants, Tylenol, sleep agents in one gulp…..a potentially deadly recipe 2.

“Pain Clinics”

Over the past several years, there has been a proliferation of medication only pain clinics. These facilities are often non-physician owned and operate just inside the law. The physicians who practice in these facilities are rarely accredited through recognized fellowships and board certification processes. Many of these facilities take no insurance and advertise confidential, cash only services. Some advertise armed guards in the waiting rooms. With no oversight, these facilities serve as a source for a continuous supply of controlled substances to often times addicted and sometimes naďve people. It is not uncommon to find patients of these facilities receiving tens of thousands of milligrams of opioid medication each month.

Opioid over-prescribing sets the stage for the development of “doctor and pharmacy shopping” and illegal Internet sales. Doctor shopping involves a person posing as a patient who presents to multiple medical providers, obtaining prescriptions from each. These prescriptions are then filled and the medications are either abused or diverted for profit. This means of obtaining prescription drugs has evolved into a very specialized skill. Web sites and chat rooms exist for the sole purpose of teaching others how to realistically pose as legitimate patients including what medical histories to give and what physical exam signs to fake.

Due to its lack of regulation and a PDMP, Florida has become a prescription drug trafficking preferred site. Specifically, Florida has become a major distribution center for oxycodone 4.

Prescription Drug Monitoring Programs (PDMP’s)

Today, in the United States, thirty-eight states have adopted legislation to create prescription drug monitoring programs (PDMP) to fight prescription drug abuse. To date, Florida is the largest state without such a program. These programs have been shown to deter doctor shopping and decrease prescription drug abuse by as much as 30% 1.

Broward County has the worst problem with respect to prescription drug abuse and proliferation of pain clinics. The Broward Commission on Substance Abuse has led the fight for over a decade to pass a PDMP in the state. Florida has been unsuccessful in passing PDMP legislation during this time. There have been special interest groups that have fought a PDMP on the unfounded grounds of “invasion of privacy”. Within the thirty-eight states with PDMP programs, there have been zero cases of privacy invasion. A precedent has been established of successful programs including the landmark program in Kentucky, KASPER (Kentucky All Schedule Prescription Electronic Reporting).

Based on Kentucky’s success, it was soon realized that interstate trafficking of prescription drugs was the next major issue. In 2005, President Bush signed into law NASPER (National All Scheduled Prescription Electronic Registry). This bill was initiated and passed with the efforts of the American Society of Interventional Pain Physicians and other interested groups. It created federal funds and standards for state initiated prescription drug monitoring programs. Unfortunately, this bill was never funded and remains so today. Fortunately federal money is available to Florida for implementation of a PDMP once legislation is passed through the Harold Rodgers Grant, in conjunction with the Bureau of Justice Assistance.

Florida Pain organizations, including the Florida Society of Interventional Pain Physicians, the Florida Academy of Pain Medicine, and the Florida Society of Anesthesiologists have worked tirelessly on this issue for several years. Also devoting significant effort is the Florida Office of Drug Control. Bill Janes, the executive director of the Office of Drug Control, hosted the first Statewide Awareness day on prescription drug monitoring. Over 130 people from all walks of life, representing many professions, attended this event with one common goal: to find a solution to prescription drug abuse. For the first time, the Florida Medical Association (FMA) has given its full support to the issue of prescription drug abuse. The FMA has listed the passage of prescription drug monitoring program legislation as a top legislative priority for 2009.

These organizations endorse prescription drug monitoring program legislation in Florida that supports the creation of a mandatory reporting system. This system would include the reporting of all scheduled prescription drugs at the point of dispensing. The database would only be accessible to physicians, pharmacists, law enforcement (with subpoena, and the Board of Medicine. The argument against increased regulation and onerous physician requirements has been voiced. Studies conducted in other states have proven physician acceptance and utilization of physician drug monitoring programs 1. Implemented appropriately, such a program would decrease doctor shopping and deter prescription drug abuse in Florida. Nearly all physicians, including pain management physicians believe that in order to ensure the availability of opioids for the treatment of chronic pain, to legitimate patients, we must be proactive in containing their illegitimate use.

Prescription drug abuse is a serious public health problem in the state of Florida and nationally. It costs lives, increases crime and misery from drug addiction, and accelerates costs connected to treatment, medical expenses, and Medicaid and insurance fraud. To best address the ills of this public health crisis, we need to have an appreciation of the drugs themselves, the illness that drives many people to abuse them and to protect ourselves, our practices and, most importantly, our patients from this growing epidemic. Over the next several issues, we will explore each of these topics in more detail.

Recently, SB 462 was passed unanimously by the Florida Senate and overwhelmingly by the House. It was recently signed into law by the Governor Crist on 6/18/2009. The law contains rule making authority which empowers the Florida Board of Medicine to regulate pain clinics.


References

1. Broward County Commission on Substance Abuse, United Way, 2008.
2. Manchikanti L. Pain Physician. 2006; 9:287-321.Prescription Drug Abuse: What is being done to address this new drug epidemic? Testimony before the subcommittee on Criminal Justice, Drug Policy and Human Resources
3. Birnbaum HG et al. Clin J Pain. 2006;22:667-676
4. Heit, Gourlay, Pain Medicine; 6, 2005. Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain
5. Misuse of Prescription Drugs: Data from the 2002, 2003, and 2004
National Surveys on Drug Use and Health, SAMHSA.

ABOUT THE AUTHOR: Sanford M. Silverman, MD and Lora Brown, MD
Lora L. Brown, MD, DAPM, ABIPP
Pain Management Specialist
Coastal Orthopedics an Pain Management

Sanford M. Silverman, MD
Pain and Addiction Medicine
Comprehensive Pain Medicine

Copyright Comprehensive Pain Medicine

More information about Comprehensive Pain Medicine


While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.
For specific technical or legal advice on the information provided and related topics, please contact the author.

Find an Expert Witness