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home : most recent : statewide implications November 15, 2018


3/8/2018 11:38:00 AM
How early prescribing set the stage for opioid addiction after back injury in car crash
Sean Martin, left, and his girlfriend of four years, Kelley Kinnaird, get close for a photo during a University of Louisville football game on Dec. 30, 2017. Submitted photo
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Sean Martin, left, and his girlfriend of four years, Kelley Kinnaird, get close for a photo during a University of Louisville football game on Dec. 30, 2017. Submitted photo

Aprile Rickert, News and Tribune Crime and Courts Reporter

SOUTHERN INDIANA — When he was growing up, Sean Martin said he didn't have issues with drugs or alcohol beyond the average teenager — drinking at parties on weekends, smoking marijuana at times. It wasn't anything he had a problem with, he said.

But a car accident in his mid-20s would send him down a dark path of which he's just now climbing out.

FIRST DOSE 

At the hospital, Martin was given Lortabs for pain from the back injury he'd sustained in the crash and was referred to a family doctor in Charlestown to follow up.

“He asked how I was feeling and, of course, I said I was hurting,” Martin, now in his early 40s, recalled.

Although he wasn't given an MRI or X-ray to determine the extent of his injury, the doctor prescribed a 30-day supply of Percocet — 30 mg a day. If he was still in pain after the supply ran out, he could get another prescription the next month.

At first, Martin didn't realize he was becoming addicted to opioids. As he kept going back to the doctor seeking more pills, his addiction was growing.

PILLS TRANSITION

Eventually, Martin would run out of his medication before he was scheduled to get another prescription. In pain, he turned to the streets to get more. That's when he stumbled upon the stronger Oxycontin.

He went back to his doctor and asked for the new drug.

“Whatever I wanted, the doctors would give me,” he said. “I never showed an MRI, I never showed X-Rays. I was paying $100 for a doctor visit. They were fine — they didn't care.”

Martin said his doctor gave him 90 Oxycontin-80s at the same time as 10 50-mg fentanyl patches for the pain. This would last only a week or so before he was looking again on the street. He fell into Opana the same way.

While Martin might have started to realize he was addicted, he reasoned that it was medicine that came by way of a doctor most of the time.

“I had the mindset of 'well, it's not cocaine, it's not crack, it's not methamphetamine,'" he said. "And ... I'm getting prescribed this by a doctor.”

NEAR DEATH

Soon, Martin's world began to slip away. His job, his family, his relationship, his sense of self all were being compromised by his daily drive to get high.

He would go to the dentist and have a tooth pulled, or go to the emergency room saying he fell off a ladder and hurt his back — just to get his pills.

“Eventually, it was harder to get,” he said. “And heroin was cheaper. When I got to heroin, it ruined my life.”

Martin was at work the last time he overdosed, and if it wasn't for co-workers who became concerned and knocked the door down, he might not be alive. Now 10 months sober, it's a second chance he's not taking for granted.

A BROADER ISSUE

Martin's car accident was in the early 2000s, the same time that Oxycontin was entering the market, before lawmakers and physicians started taking a closer look at the effects of the drugs.

Oxycontin and Opana were both reformulated to deter abuse, but lack of guidelines and education for physicians on the drugs' affects, and laws dictating how to prescribe, made for inconsistencies.

Centers for Disease Control and Prevention data shows that from 2007 to 2012, opioid prescriptions rose more for certain specialties than others. Family practitioners, general practice physicians and those practicing internal medicine had a 7.3 percent per capita growth in prescribing opioids.

In Southern Indiana, prescribers' rates between 2013 and 2015 show high rates for Medicare part D opioid prescriptions, across several specialties.

According to the data, Dr. James Brent, a board-certified New Albany anesthesiologist specializing in pain medicine, wrote 10,891 opioid prescriptions to 1,233 patients between 2013 and 2015, with a total claim cost of $654,886.

Brent was not available for comment but a statement sent by Baptist Health Floyd said that he is in good standing with the Medical Licensing Board and has an Indiana Controlled Substance registration and a Federal Drug Enforcement Administration registration.

“Dr. Brent adheres to Indiana's regulations and guidelines for opioid prescriptions,” the statement reads, adding that he participates in both Indiana and Kentucky prescription monitoring databases — the Indiana Scheduled Prescription Electronic Collection and Tracking program, or INSPECT, and the Kentucky Prescription Monitoring Program.

During the same time period, Richard Spalding, internal medicine, Clarksville, wrote 5,156 prescriptions for 883 patients, for a total claim cost of $235,290. Spalding was unable to be reached and staff from his former practice advised that the doctor retired in 2017. George McGhee, a Charlestown family practitioner, wrote 5,039 prescriptions to 645 patients.

Karen Doggett, a nurse practitioner in Jeffersonville, wrote 6,356 prescriptions for 1,134 patients for a total claim cost of $979,325. While nurse practitioners generally show lower numbers, Doggett is in practice at a pain center, making her numbers higher.

PUTTING THE NUMBERS INTO CONTEXT

Certain specialties, such as emergency medicine, are prone to have lower numbers because doctors often see patients one time. Those practicing pain management are apt to have longer-term patients who are prescribed pain medication, including opioids.

“What I look for when I look at [prescription numbers] is consistency,” said Dr. Eric Yazel, emergency medicine physician and Clark County health officer. “If a patient is going to the same provider and every month they fill 60 pain pills and don't go anywhere else, that's a more reasonable practice.

“[If] they do big numbers with refills and they're bouncing around to the ERs in between, those are kind of red-flag prescribers that I see when I look things up.”

Yazel wrote 379 prescriptions for 368 people between 2013 and 2015, for a total $1,860 claim cost.

ATTENTION TO RESPONSIBILITY

Across the state, physicians are becoming more educated on the risks of opioid use and being more vigilant about doing so. 

Dr. James Murphy, a board certified anesthesiologist and pain specialist, is in practice with Doggett at the Murphy Pain Center in New Albany. The two moved from a Jeffersonville practice around two years ago.

Murphy's prescriptions between 2013 and 2015 were 733 to 398 patients, with a total claim cost of $109,338.

He said the two doctors see many of the same patients. Doggett handles most of the follow-ups, but it's a collaboration, Murphy said. He added that they both adhere to the same philosophy, which is consistent with the 2016 Centers for Disease Control and Prevention Guidelines for Prescribing Opioids for Chronic Pain.

They also regularly refer to the book "First Do No Harm," an online tool kit for providers to responsibly prescribe opioids. It was first introduced by the state in April 2013.

The book, meant to “inform and support the practitioner while prioritizing patient safety,” encourages physicians to put a system of checks in place to quell prescriptions. This includes evaluations on patients' history, mental health status and risk for abuse.

The use of chronic opioids in high-risk patients is strongly discouraged, according to the book, and for others, non-opioids and non-pharmacological treatment should be tried first, before opioids. It also notes that fewer pills given at one time with more frequent follow-ups can reduce the chance of risk.

INSPECT and urine drug monitoring should be used to screen patients against potential misuse or abuse of the drugs, the book states.

"I've actually told patients if you want to know how I'm going to treat you, look at that ... textbook," Murphy said. "And I'm pretty much going to do what that says."

INTO THE LIGHT

Martin said he appreciates the reduction in prescribing and, although he's no longer looking, he's heard that it's harder to get pills from doctors than it was 15 or 20 years ago.

While he owns up to his addiction and is ready to keeping working through it, Martin can't help but think about what might have happened had there been more barriers in place to keep him from getting pills. He said he holds both the doctors from that time and the manufacturers accountable.

“I don't think I should have been prescribed opiates at all,” he said. “Some people do need opiates. If you need it, I'm all for it. But I was just sent there from a referral and I tell him I'm hurting and it was like 'OK, here you go.'”

He's been clean now for 10 months, and ready to keep it going. He's back with his girlfriend, he's got a steady job, he's going to therapy and working on himself and the relationships that were damaged by his abuse.

His main goals, he said, are to stay sober, and help others who may be going through what he has.

“I don't want to see anybody die anymore,” he said. “There's all kinds of places you can go to get help these days. It's a disease. And it only ends two places — death or jail.”

He said he might still have some pain from time to time — he played a lot of sports, too. But he's not going after opioids.

"I have pains," he said. "But nothing I can't deal with."

Related Stories:
• What local physicians have learned from the opioid crisis
• Floyd County obstetrician: Number of addicted moms is 'staggering'
• Study: Chronic pain patients may do as well without use of possibly addictive opiates
• How to solve the NWI Region's opioid crisis? Conference tries to find out

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