INDIANAPOLIS -- Certain painkillers soon could require more than a doctor's prescription in Indiana. Patients might also have to sign an agreement that they will use the medicines responsibly and submit to periodic drug tests.
The Indiana Medical Licensing Board, at the behest of the state legislature, is considering guidelines that would require doctors to take additional steps when prescribing painkillers. The board will discuss a draft of these emergency rules, scheduled to go into effect in December, at a meeting Thursday.
Concerns over what many have termed an epidemic of prescription drug abuse have fueled the call for action. Overdoses of drugs such as Vicodin, Percocet and OxyContin now cause more deaths than car accidents.
Many states, along with Indiana, are exploring ways to reduce that abuse, such as passing new rules for doctors and launching public education campaigns about the dangers of misusing these powerful medicines.
"The hope is that there will be greater attention paid to when and where these (medicines) are appropriate," said state Attorney General Greg Zoeller, whose office prosecutes doctors who fail to abide by the law.
In recent years, the attorney general's office has brought action against more than 15 doctors in Indiana who practiced in "pill mills," prescribing large quantities of pain medicines, often without any medical reason.
Under the proposed guidelines, doctors would be expected to ask patients to sign an agreement in which they consent to toxicology screening, agree not to share the drugs, take them as prescribed and allow the doctor to conduct random pill counts. Physicians would be expected to tell patients about some of the potential serious side effects and explore alternatives.
In addition, doctors would be expected to see patients taking these medicines at least every four months and conduct annual saliva or urine tests to make sure they are taking the drug. Doctors also would be expected to run patients' names at least once a year through the state database that tracks which individuals hold prescriptions for the medicines most likely to be abused.
Some physicians have concerns about the new guidelines.
As a palliative care specialist with St. Vincent Health, Dr. Colleen Brown sees many patients dealing with intense pain. While the proposed rules exclude patients who are terminal, they could apply to patients who live with cancer for many years and experience intermittent or constant pain.
Up to 40 percent of cancer patients already report untreated pain, Brown said.
Many cancer patients shy away from these medicines, afraid of the hype about how addictive and dangerous they can be, she said. Asking Grandma to sign a treatment contract or submit to routine urine screens might scare her away from medicine that could alleviate her pain and improve her quality of life.
Elderly patients could be too debilitated to make a trip to a doctor's office to give an annual urine sample. Having pediatric patients submit to urine tests also could prove problematic, she said.
Besides, Brown added, oncologists and palliative care management specialists have received training in handling pain and work with other health professionals who assist with care.
"Appropriate pain management is not only a human right, it's a mandate of our professional groups. We want everybody for whatever their pain is to be treated appropriately," she said.
Others agree that rules such as the ones being considered in Indiana likely will lead to a drop in the number of patients who need these medications receiving them. Doctors will stop prescribing them, said Dr. Diane Meier, director of the Center to Advance Palliative Care in New York.
"The impact is going to be a huge public health problem. People with legitimate, medically appropriate needs for opioids, their odds of getting them will be much less," said Meier, also a professor of geriatrics and palliative care at Mount Sinai School of Medicine in New York.
Others say the requirements are not too much to ask of patients who may have cancer but are not terminal. Better medications have made it possible for many people to live years or even decades with cancer.
Doctors can still treat pain, the task force members say. They just have to take a little more care in doing so.
"Oncologist Joe can prescribe any opioid that he or she would like to for the patient. The only thing it requires is a little more discipline in the execution of providing that medication," said Dr. Palmer Mackie, director of the Integrative Pain Program at Eskenazi Health.
No one disputes that there's a need for greater oversight of pain medications.
About 15 years ago, doctors started considering pain as the fifth vital sign, taking it more seriously. However, as they increasingly relied on drugs to handle patients' pain, Meier said, they often failed to warn patients about keeping these drugs out of the hands of those who would misuse them.
Painkillers grew in popularity as recreational drugs. Today more people abuse prescription drugs than cocaine, heroin, hallucinogens and inhalants combined.
But the question is whether amending doctors' practices will put more than a dent in the problem, Meier said. She argues that doctors need far better education on how and when to prescribe these drugs than they currently receive.
"The people being punished are the people with legitimate medical reasons for pain," she said. "There are plenty of other streams we're not cutting off."
Indiana is taking a multipronged approach to the problem, others note. Zoeller and the Indiana Prescription Drug Abuse Prevention Task Force last week launched a website to educate the public about the dangers of prescription medicines.
Doctors, for instance, need to do a better job of teaching patients how to use these medicines responsibly, said Tracy Brooks, a pharmacist with the palliative care pharmacy at Parkview Regional Medical Center in Fort Wayne and a member of the education subcommittee of the Safe Prescribing Task Force for Indiana, which helped develop the new guidelines.
Patients often receive prescriptions for more painkillers than they use. Then when a friend has a minor pain, the first person passes along a few pills.
Or a teen or someone else may raid that original patient's medicine cabinet, pocketing the pills and either using them recreationally or selling them on the street, netting a nice profit, Zoeller said.
Asking doctors to take a few more steps to ensure that neither of these scenarios occurs is not unreasonable, Brooks said.
"We're not really asking these physicians to jump to the moon," she said. "We are asking them to do what I consider standard of practice."
Shari Rudavsky, The Indianapolis Star