LAWRENCEVILLE - Spotting a pain medication abuser is just one trick of the trade Carter Gorman has learned in his 25 years as owner and head pharmacist at Monfort Drugs.
By simply asking for their driver's license, he can deter "meds shoppers," people well versed in the illegal act of floating from doctor to doctor gathering pain medication prescriptions and then visiting different pharmacies to fill them.
"Inevitably when you ask this (to a pain medication abuser) they'll say they left it in the car, they disappear and then you never see them again," Gorman said. "The crooks are smarter than I am, but there's always one that slips through the cracks."
But abusers who slip through the cracks concern doctors. Physicians have become more and more reluctant to pull out their prescription pads due to an increase in pain medication misuse cases, making the 50 million Americans living in chronic pain jump through more hoops for relief.
"Doctors don't want to prescribe opiates because doctors don't want to have a patient in their practice who is abusing drugs," said Dr. Richard Reisman, medical director of the Gwinnett Hospital System pain management center.
Not surprisingly, physicians are referring patients to pain specialists - doctors who work full time in the treatment of ongoing pain ranging from cancer pains to chronic back pain.
Pain specialists exercise a variety of measures to prevent pain medication abuse such as triple carbon copy prescription pads and patient contracts outlining only one pain-medication-prescribing doctor may be visited, yet still it's an issue.
"Pain pill abuse is on the rise," said Cindi Patterson, an investigator with the Gwinnett County Police narcotics unit. "People will go doctor shopping (or "meds shopping") somewhere, and then they'll go to Walgreens or Eckerd, and there's no database keeping up with it."
Pharmacies try to keep tabs
on pain medication users
Despite detailed record keeping and strict federal government regulations, Georgia pharmacies ultimately lack a prescription drug-monitoring program that would allow a patient's details to be cross checked against other pharmacy databases for duplicated prescriptions, thus revealing meds shoppers easily.
However, President Bush in August signed into law the National All Schedules Prescription Electronic Reporting Act.
This bill, proposed by the American Society of Interventional Pain Physicians, establishes a controlled-substance monitoring program in each state or provides each state the ability to improve their controlled-substance monitoring program through a grant.
According to Reisman, 21 states have an active prescription-drug monitoring program, and four are in the start-up phase. There are no signs Georgia will be entering the program in the near future.
"It's still unclear if the prescription-monitoring programs actually significantly decreases the abuse and diversion," Reisman said. "I think there's still debate over it in terms of actual literature."
While prescription drug monitoring programs may simplify his job, Gorman is skeptical if the right people are being targeted.
"The problem is we have legislation in place for controlled substances now but (prescription drugs) are still in the street," Gorman said. "I don't know if they're going for the right people."
If prescription drug abusers aren't obtaining their meds at the pharmacy/physician level and police are still confiscating them in the streets, they must be getting them somewhere else.
Whether it's Codeine, Lortab, Vicodin or any of the other high level prescription drugs, it's only a click away.
"The problem is the Internet," said Gorman. "You can buy Lortab and anything else. Evidently there is a 'doctor' on the premises who approves the prescription and they mail it out to you."
At www.allmedspharmacy.net, consumers can buy 150 tablets of Xanax - one of the most abused prescription drugs today - for $399 without a prescription.
Although chronic pain sufferers can avoid the specialty physician regulations with a few clicks online, the drugs are not always regulated by the Food and Drug Administration or the Drug Enforcement Administration and can, therefore, be risky to consume.
"I've got companies off the American coast calling me and trying to sell me prescription drugs over the phone, which is not governed by the DEA," Patterson said. "Prescription drug abuse is a big problem."
In today's fast-paced, electronically ruled world, the Internet floodgates have been opened and prescription drugs are easier to obtain - if the person knows how to skirt around the authorities and checkpoints.
But unfortunately for chronic pain sufferers who play by the rules, getting prescription medication is becoming that much tougher.
Doctors who refer patients to specialists instead of writing prescriptions themselves may avoid complications, but this "passing the buck" could have side effects. It could result in more time off from work and longer periods of suffering for people already in pain as they wait for a specialist to squeeze them into their schedules - if the patient's insurance plan will cover it.
Insurance companies picky about pain treatment
Some big insurance companies such as Blue Cross-Blue Shield and Aetna cover visits to a pain specialist but have strict specialty treatment guidelines.
At Blue Cross-Blue Shield, for instance, patients have to follow procedures before they even step foot in a pain specialist's clinic.
First they must visit their primary care physician, then be referred to a qualified pain specialist within the Blue Cross-Blue Shield network.
However, not any pain specialist will suffice. Insurance companies do not generally cover hypnosis and acupuncture treatments.
Reisman said Gwinnett Anesthesia Services PC, a group operating within the Gwinnett Hospital System, lists three accepted pain treatments for chronic pain: traditional treatment (i.e. prescription drugs, nerve blocks, physical therapy and psychological support), acupuncture/hypnosis and nutritional supplementation.
Most insurance plans, however, will only allow patients to receive traditional treatments and cut out acupuncture and hypnosis all together, even though the National Institute of Health reports there is good research to support those treatments, Reisman said.
"We insure people on a case-by-case basis if we determine it's medically necessary (for them to visit a pain specialist)," said Cindy Sanders, director of communications at Blue Cross-Blue Shield. "It's evidence-based guided by an evaluation committee, which is how we review for any speciality."
Aetna's policy is even more strict and rigidly defined. As a policy, to enter into an outpatient pain management program the patient must be referred by their primary care physician, must have experienced pain for six months or more, must undergo a mental health evaluation to make sure psychiatric conditions have been evaluated and treated and the member must have failed conventional methods of treatment. Walt Cherniak, Aetna spokesman, said
a "conventional method" would be prescription pain medication.
If patients work for big corporations, such as Coca-Cola, Home Depot and Delta, it can be even trickier finding specialized pain insurance coverage. Large employers are often self-insured and will contract out to other health insurance agencies, where the paperwork is processed.
"Delta has Delta Health Insurance and Georgia-Pacific has Georgia-Pacific health Insurance," Georgia Insurance Commissioner John Oxendine said. "They get to make up the rules because it's their money and they're not governed by Georgia insurance law."
The future of
Although insurance coverage may be used as a way to curtail pain medication misuse, another solution might be to expand current drug abuse laws.
"We need a trafficking charge if you possess so many prescription pills without the benefit of a prescription," Patterson said.
Abusers can be charged for possession with intent, she said, but since there is no state charge or drug charge for possessing a high quantity it's difficult to press the issue.
When the U.S. House and Senate reconvene in 2006, they may evaluate an amendment to an existing bill.
The possible amendment says "a health care facility or hospice should not forbid or restrict the use of controlled substances appropriately administered to relieve pain."
This amendment may decrease doctors' patient referrals to specialists and simplify the process, something chronic pain sufferers might find refreshing.