Vermont tackles prescription drug abuse

Vermont tackles prescription drug abuse
(April 2009 Issue)

By Nan Shnitzler

Prescription drug abuse is on the rise in New England. Opioids, depressants and stimulants all pose addiction threats. Users obtain them through doctor shopping, forged prescriptions, raiding medicine cabinets, pharmacy theft and the fraudulent practices of a small number of unscrupulous or impaired physicians and pharmacists, according to the U.S. Drug Enforcement Agency.

In Vermont, alcohol and drug related deaths (both accidental and intentional) increased from 54 in 2002 to 85 in 2008, per data from the medical examiner's office. According to 2006 data from the DEA, Vermont ranks first nationally in per capita distribution of buprenorphine (Suboxone) for opioid addiction; third in hydromorphone (Dilaudid), a narcotic painkiller; and fourth in methylphenidate (Ritalin), a stimulant used to treat attention deficit disorders.

"Ritalin, Adderall, Concerta, those methamphetamine-type drugs are serious drugs of abuse," says Richard Barnett, Psy.D., LADC, public information officer for the Vermont Psychological Association. "People snort them and shoot them. They're known as poor man's coke because they're widely available and provide a stimulant effect."

But they are not necessarily prescribed by psychiatrists or knowledgeable practitioners, says Ken Libertoff, executive director of the Vermont Association for Mental Health.

"General practitioners often admit they have limited training and that the information they get about medications is frequently from drug marketing and pharmaceutical reps," Libertoff says. Lax prescribing practices and regulation lead to off-label uses with no clear scientific basis, he adds.

Libertoff is working to strengthen Vermont's 2002 pharmaceutical marketing disclosure law with a new bill working its way through the state legislature. Among other provisions, it will close the "trade secrets" loophole that prevents certain company disclosures and will require non-profit medical and mental health associations to report gifts. It will be the most extensive transparency bill in the country, he says.

"Our position is that while medication is part of the arsenal of treatment, we have created a culture of � an over reliance on medication that has diminished the importance of clinical interventions and counseling," Libertoff says.

From his Stowe, Vt.-based private practice, Barnett collaborates with physicians to provide the counseling that is a crucial component of the "gold standard" of care: medication plus talk therapy. Unfortunately, he says, therapy is not the norm due to drivers like insurance incentives that favor medication and lack of counselors.

Further, physicians' practices often don't have the resources to monitor medication compliance, Barnett says. If patients become users, it's a weakness they can exploit.

Barbara Cimaglio, deputy commissioner for Alcohol & Drug Abuse Programs (ADAP), says it's difficult to generalize around prescription drug abuse because as new drugs come on the market to treat pain or other problems, there can be a shakedown period as people learn to use them.

One new tool is the Vermont Prescription Drug Monitoring System that went online in January to help track prescribing and dispensing of controlled substances.

"The medical community is interested in learning about powerful medications, especially as they relate to addiction and diversion. We think we have a very aggressive response," Cimaglio says.

ADAP medical director Todd Mandell, M.D., is leading the charge with several initiatives. He is bringing an attorney and a police detective to every hospital in Vermont to address prescription drug use from medical, legal and public safety standpoints.

He secured a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) for a live multimedia course on prescribing opioids that he plans to teleconference in October to sites around New England. He successfully tested the teleconference method last year, up linking it from Maine to five sites in Vermont.

"Addictions and pain management is everyone's bugaboo," Mandell says. "This [course] is a concise, interesting and available way of teaching it. Every year is not too often for this information."

In addition, when Vermont prescribers renew their licenses, they get a copy of "Responsible Opioids Prescribing: A Physicians Guide" by Scott M. Fishman, M.D.

Proper disposal of medications is another front on the drug war. Vermont has piloted medication amnesty programs in three police stations. Residents can bring in medications to dispose of, no questions asked, to be destroyed by high-temperature incineration.

"That's a huge number of pills that are not out on the street and don't get into the water supply," Mandell says.

Perhaps Vermont's thorniest problem is treating addicts, despite having the most physicians per capita who are federally approved to prescribe buprenorphine, which has surpassed methadone for treating heroin and opioid addiction in the state.

Methadone for addiction treatment can only be dispensed in liquid form in a certified clinic. (It can also be prescribed by pill for pain). The methadone model hasn't been widely adopted because it's difficult for Vermont's largely rural population to access a clinic every day.

Buprenorphine, on the other hand, can be prescribed in the privacy of a physician's office and taken in pill form at home. Unlike methadone, whose effects increase with the quantity used, buprenorphine's response plateaus. At present, about 450 Vermonters take methadone and 1,200, buprenorphine, and it's still not enough, Mandell says.

"We haven't caught up yet. The calls keep coming in."