UNINTENDED CONSEQUENCES

Feds’ Pill Crackdown Drives Pain Patients to Heroin

The war on prescription-drug abuse has created ‘opioid refugees’ who can’t get prescriptions for legal painkillers filled and turn to illegal ones instead.

It would be an exaggeration to say the government drove Christopher Baltz to break the law, but it definitely built the highway that took him there.

On April 9, 2014, Baltz was arrested in a sting operation in the Dania Beach area of Fort Lauderdale, Florida, after a longtime acquaintance requested his help stealing a safe containing money and heroin out of a motel room that he said belonged to a drug dealer. Baltz was addicted to heroin and in desperate need of money to fuel his habit.

Unbeknownst to Baltz, his accomplice was working as a confidential informant for the Broward County Sheriff’s Office.

The informant made it easy: chauffeuring Baltz door-to-door from his house to the motel and even giving him the key card he’d need to gain access to the room. The informant claimed he got it from a girl he was dating who worked at the motel as a maid.

Sheriff’s deputies recorded the burglary from a surveillance post in a room next door, the second time they’d run the scheme that week.

Baltz was charged with three felony offenses, including armed burglary after the deputies planted an unloaded firearm in the safe. He wound up pleading his case down; but it cost him $15,000 in lawyer’s fees to narrowly avoid a felony conviction. He served eight months on house arrest and remains on supervised release until September.

To the casual observer, Baltz, 33, fell prey to a string of bad choices, helped along by a shady associate and some overeager cops. But the theatrics that led to his only serious run-in with the law was the final act in a drama that began years earlier, when Baltz became collateral damage in a growing war against prescription drug abuse.

Baltz began using heroin after the opioid painkiller he was being prescribed for chronic pain became harder to obtain.

Policymakers have redoubled their efforts to win the war on opioid abuse, as an unprecedented number of Americans continue to die of prescription drug overdoses.

The Centers for Disease Control and Prevention issued a broad set of recommendations in March for physicians and treatment facilities that dispense opiate medications. The same week Massachusetts Gov. Charlie Baker signed into law some of the most restrictive regulations ever governing the therapeutic use of narcotic drugs—including limiting first-time prescriptions for opioid pain medication to seven days worth of pills. At least six states have passed similar measures restricting the amount and potency of narcotic medications doctors can prescribe.

The goal is to keep potentially dangerous substances out of the hands of people who shouldn’t have them, but Baltz’s story is a reminder that sweeping public policy changes—even those with noble goals—often have unintended consequences.

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Baltz was in his third year of treatment for chronic pain resulting from a severe motorcycle accident and was being prescribed a high dose of oxycodone when Florida Gov. Rick Scott declared war on the state’s robust pain management industry in 2011.

Florida had acquired a reputation as America’s pill mill capital. Nearly nine out of every ten oxycodone pills dispensed in the U.S. was prescribed by a doctor in the Sunshine State. Things were so bad that the media had taken to calling the interstate highway system in Florida the “Oxy Express.”

Scott’s crackdown led to the closure of some 400 pain management clinics almost overnight, while a coordinated effort by the Drug Enforcement Administration targeted pharmacies suspected of over-dispensing controlled substances.

This took the form of more aggressive enforcement of a decades-old federal mandate known as “corresponding responsibility” that holds pharmacies legally accountable for ensuring the drugs they dispense are being used for a “legitimate medical purpose.”

In theory, the policy is designed to add another check in the process of preventing drug abuse and diversion. In practice, it places pharmacists in the unwarranted position of policing doctors, and discriminating against patients on the basis of often arbitrary red flags (for instance, paying for their prescriptions in cash).

The net effect of the crackdown in Florida was profound and acute. Prescription drug deaths dropped precipitously within the first year-—but heroin deaths rose 39 percent, as patients cut off from legal opioids turned to illegal drugs for relief.

At medical conferences, physicians began discussing the plight of these new “opioid refugees.” These are patients, like Baltz, who had been using narcotic medication for an extended period of time under a doctor’s care—usually for chronic pain—and now faced nearly insurmountable hurdles to accessing their drugs. Some of these patients were also abusing their pills (legitimate need and addiction are not mutually exclusive). Others followed rigidly to their doctor’s prescribing guidelines. They were all punished just the same.

News trickled out of Florida of patients traveling miles from home to find a doctor to prescribe their medication or a pharmacy to dispense it.

“Before you know it you’re driving around for three days going from pharmacy to pharmacy, taking off work and fighting off withdrawal looking for a place that will give you your medicine,” Baltz told The Daily Beast.

Then things got even worse.

In spring 2013—two days after receiving a courtesy call confirming his monthly appointment—Baltz showed up at his pain management clinic only to find it had been closed down. Within weeks he was making regular trips to Miami to buy heroin.

“The government wants to prevent people abusing pain medication, but there’s no exit strategy,” said Baltz. “I never even saw heroin until this happened.”

No one would deny keeping dangerous drugs off the illicit market is an important goal. Opioid-based medications are powerfully addictive and can be fatal if improperly used. But patient advocates worry about the impact of blunt-force policies designed to curb abuse.

According to the United Nations, 5.5 billion people around the world already suffer from inadequate pain treatment. This includes roughly a third of all cancer patients in the U.S.

When the UN General Assembly meets in New York later this month to discuss global drug policy, protecting pain patients from the fallout of the war on drugs will be high on its agenda.

“Over the years I’ve seen the chronic-pain pendulum swing in both directions, now the pendulum has swung extremely over toward the prohibitionist model,” said Dee Green, who spent 25 years as a registered nurse in Georgia, which replaced Florida as the pill mill capital after Gov. Scott’s crackdown.

Green says she and her spouse both suffer from chronic pain issues and blames “media sensationalism” for focusing on addiction and abuse while largely ignoring the consequences of restrictive policies.

“We have seen many negative changes in treatment options over the last few years. It is scary,” she said.

Dr. Lynn Webster, a board-certified anesthesiologist who has been using opioids to treat chronic pain for more than three decades, says the aggressive anti-opioid messaging is having a chilling effect on the doctor-patient relationship.

“Physicians across the country are saying they are not going to prescribe opioids to any patient,” he said.

Webster is internationally respected in his field. From 2013 until last year he served as president of the American Academy of Pain Medicine. But detractors have criticized the AAPM for receiving financial backing from drug companies like Purdue Pharma, maker of OxyContin. They accuse providers like Webster of colluding with pharmaceutical giants to get millions of Americans hooked on drugs.

For a time, that view appeared to be shared by the DEA, which in 2010 sent nearly a dozen armed agents to raid the Salt Lake City pain management clinic Webster ran after several of his patients suffered fatal overdoses. Webster spent the next four years in legal limbo, and was vilified in the press. In a December 2013 CNN story reported by Dr. Sanjay Gupta Webster is repeatedly referred to as “Dr. Death.”

Then, in June 2014, the DEA quietly withdrew its investigation after the U.S. Attorney for Utah declined to file charges against Webster.

“We have declined prosecution in that case and have concluded that we could not prove criminal wrongdoing beyond a reasonable doubt,” Melodie Rydalch, a spokeswoman for the U.S. attorney in Utah, told the Salt Lake Tribune.

Though he was cleared of any wrongdoing, Webster says the experience took a toll.

“It was probably the most costly experience, both personally or professionally, of my entire life,” he said. “My reputation was tarnished forever.”

Dr. Webster is one of hundreds of doctors and pharmacies that have been investigated by the DEA since it launched its OxyContin Action Plan in 2001. The plan signaled a shift in federal enforcement tactics away from a focus on illicit street drugs and toward preventing controlled pharmaceuticals from falling into the wrong hands. Over the next 13 years the DEA added more than 1,500 personnel and more than doubled its budget. It also significantly ramped up administrative audits of registrants authorized to dispense controlled substances. (As The Daily Beast reported last year, over the same period the DEA was increasing its quotas of Schedule II pharmaceuticals approved for commercial sale).

During one year alone (2009-2010) the number of regulatory investigations conducted by the DEA’s Office of Diversion Control (responsible for policing prescription drugs) more than tripled, according to the Government Accountability Office.

How many DEA audits actually lead to a formal sanction cannot be determined from available data, but the agency’s aggressive enforcement stance is having an effect on both the medical community and the agency itself. A law firm in Texas that specializes in medical licensing reported a ten-fold increase in inquiries in 2011 from physicians concerned about DEA sanctions.

Meanwhile a government audit from 2014 found that that agency became so proactive in policing prescription drugs that it had created a backlog in cases that actually increased the time it takes to shut down the most problematic prescribers.

Federal law requires that all prescriptions for controlled substances be for a “legitimate medical purpose,” but it doesn’t define the term.

In December The Daily Beast filed a detailed Freedom of Information Act request seeking, among other things, any guidelines the DEA uses in determining if a physician or pharmacy has violated that rule. In its reply the agency said that such a consideration is made on a case-by-case basis, but cited a policy statement from 2005 denying that it must meet “some arbitrary standard or threshold evidentiary requirement to commence an investigation.”

The agency also provided responses to letters from concerned citizens strongly denying it is engaged in a “crackdown” on pain doctors. Whether intentional or not, the federal government’s own research shows DEA enforcement efforts are coming between patients and their medication.

The concern now is that policy changes like the CDC’s new guidelines on the prescribing of opioid medication will push even more desperate patients like Christopher Baltz into the illicit drug market.

The guidelines are comprised of 12 recommendations, including favoring non-opioid alternatives for the treatment or chronic pain, limiting opioid prescriptions for acute pain to three days, and always defaulting to the lowest effective dose when narcotics are necessary. They elicited a strong response from many pain management doctors, who accused the agency of stacking its professional advisory board with anti-opioid lobbyists. And prominent voices in the medical community—including the American Cancer Society—blasted the CDC’s methodology.

Ironically, there is evidence that restricting patient access to pain medicine could actually lead to more overdoses, not fewer. Medical examiners are already unsure of how many deaths attributed to “unintentional overdose” are actually suicides. Chronic pain patients frequently suffer from ancillary mental health problems—including depression, anxiety and insomnia—and are at least twice as likely to commit suicide.

In 2013, when the Department of Veterans Affairs responded to a runaway painkiller problem with a new Opioid Safety Initiative, reports surfaced of patients being cut off their medication without proper dose reductions. Within months the agency came under fire for its new policy when a 52-year-old Navy veteran shot himself in the head in front of an outpatient clinic in Virginia after he was forced off his pain meds.

“The medications were the only thing that was helping him, and when they took that away from him, his life just went downhill,” a friend of the dead man told a local paper.

There are, fortunately, effective policies that are likely to reduce overdose deaths without inflicting unnecessary suffering on patients. They include addressing the woeful lack of pain management and addiction experience among medical practitioners, many of whom have less knowledge about the properties of opiates than the average street addict.

“There is almost no training in this area,” said Dr. Webster, who in addition to treating pain is also a certified addiction specialist. “I can tell you that, for years, physicians recoiled from addicts. We didn’t want to deal with them, and even today many in the medical community view addiction of being a character flaw.”

It’s not uncommon for doctors to prescribe opiates to patients without bothering to mention that physical dependency is likely. Often these same doctors will irresponsibly cut a patient’s dosage—or even discharge them—without properly weaning them from their medication. It’s not that these doctors lack compassion; more often they simply underestimate the severity of opiate withdrawal or have no experience dealing with dependency.

Meanwhile, there is evidence that the majority of prescription opioids that are diverted for illicit use come from the acute care setting, not the treatment of chronic pain.

Dr. Daniel del Portal, who teaches emergency medicine at Temple University’s Lewis Katz School of Medicine, says the modern health care system often incentivizes doctors in acute care settings to find a quick fix for patient complaints.

“The pressure is on physicians to make patients happy at any costs,” he told The Daily Beast.

In January, the Journal of Emergency Medicine published a study he co-authored that found voluntary guidelines on opioid use introduced in at Temple University Hospital led to a sustained reduction in the number of patients going home with painkiller prescriptions and actually improved patient satisfaction.

Finally, doctors say there is little use in recommending alternative treatments for patients if they can’t afford them. Pain pills are cheap, and usually fully covered by insurance; physical therapy, chiropractic care, and yoga are expensive, and almost always include co-pays (if they are covered at all).

As for Baltz, he has been opioid free since his arrest in 2014. During the writing of this story his girlfriend gave birth to his first child, a boy.

Baltz said he values his sobriety but still holds policymakers responsible for recklessly targeting pain clinics like the one where he received treatment, without providing adequate support for patients. Unfortunately, the war on drugs is once again threatening to disrupt his life. Baltz said he recently discovered the herbal supplement Kratom is effective in treating his pain. Kratom, which works on the same brain receptors as some mild opiates, is sold over-the-counter in most states.

But thanks to pressure from anti-drug forces, state legislatures have begun considering banning it. In February, the Florida House passed a measure that would place Kratom in the DEA’s Schedule I category—just like heroin.

Given the lengths the state of Florida has already gone to keep him in needless pain, Baltz doesn’t seem surprised by the move. But he bristles at the hypocrisy.

“People will do anything not to be in pain, and this is something mild that’s non-narcotic to help,” he said. “The government has no problem approving all different types of hard synthetic drugs for people to get addicted to, and here is something totally natural and mild and they want to make it illegal. I think they just want to keep making arrests.”