In 2013, 2,537 people received schedule II opioids on Martha's Vineyard; the hospital has begun new program offering patients alternative to pills.
Timothy Johnson

Dukes County Ranks High in State Study on Opiate Use

<p>As opiate addiction continues to devastate communities across the commonwealth, the state has released data showing prescription rates and overdose deaths for Dukes County.

As opiate addiction continues to devastate communities across the commonwealth, the state department of public health has released data showing prescription rates and overdose deaths for Dukes County.

During 2013, 2,537 people received prescriptions for schedule II opioids, a category that includes oxycodone, morphine, fentanyl, transdermal, hydromorphone, oxymorphone, and methadone.

According to the report, Dukes County ranks second among counties in the state, with 14.7 per cent of the population receiving opioid prescriptions, although this number is likely misleading since transient individuals, who make up a significant portion of those receiving prescriptions on the Vineyard, are included. The state uses the year-round population, as determined by the latest U.S. census, to calculate percentages.

Statewide, 741,908 people received opioid prescriptions in 2013, or 11.1 per cent of the population.

The data also show that prescriptions in Dukes County are on the decline. In 2009, 2,873 people received opioid medication in Dukes County.

The data was released this month as part of an effort to address a growing opioid crisis, according to a state press release that accompanied the data.

“The best tool we have in this fight against opioid addiction is information,” Secretary of Health and Human services Marylou Sudders said in the release. “We can use this data to better inform how we distribute resources so we can help individuals and families that are at greatest risk get the help they need.”

Another data set released this month shows that between 2000 and 2013, 11 people died from opiate overdoses in Dukes County.

Statewide, there were 7,929 overdose fatalities between 2000 and 2013. Over that 14-year period, annual fatalities nearly tripled, from 338 in 2000 to 978 deaths in 2013.

The state has been tracking this data for more than a decade, but the public release of the information marks a new strategy.

“It’s a response to the opiate crisis,” said Thomas Land, director of the state office of Data Management and Outcomes Assessment. “I think we have been gathering information over the past year in order to prepare ourselves to do a much more timely and regular reporting schedule.”

Though confirmed deaths are not available since 2013 due to a backlog at the medical examiner’s office, the upward trend in fatalities has apparently continued in recent years.

State police counted 243 suspected opiate fatalities since Dec. 1; none were recorded for Dukes County.

But Vineyard psychiatrist Dr. Charles Silberstein, who began tracking overdose fatalities on the Island in August of 2013, says he’s counted 10 overdose deaths.

“I am counting close to a death every other month,” Dr. Silberstein told the Gazette this week.

For a large portion of his patients under treatment for addiction, he said prescription drugs were their introduction to opiates.

Doctors were once more naive about the risks involved in prescribing painkillers, but awareness has since grown, including among Vineyard physicians, Dr. Silberstein said.

“They [the prescriptions] are now much harder to get from Island MDs,” he said.

All doctors are now mandated to participate in the state’s prescription monitoring program, an online database that went live in December and allows doctors to review a patient’s prescription history before writing a new script.

“It’s basically a database of every substance that is prescribed in Massachusetts,” said Dr. Pieter M. Pil, a general surgeon at the Martha’s Vineyard Hospital. “Whenever we give a new prescription, a narcotic or a benzodiazepine, we visit that database and look up the patient we are prescribing for.”

The database is designed to curb doctor shopping, when patients seek medication from doctors in multiple locations to increase their dosages.

Now, those scripts can be tracked, as long as they stay within the state of Massachusetts.

“It becomes quickly obvious if the patient is seeking medication for resale as opposed to their own use,” Dr. Pil said. “Before this database was available, you had no idea if a patient had seen a doctor somewhere else.”

The state keeps track of so-called “individuals with activity of concern” who receive prescriptions from different prescribers. In Dukes County, the state has identified 32 such people, though that group may include visitors and seasonal residents.

Dr. Pil said pain is a somewhat nebulous phenomenon, impossible to measure or verify.

As a surgeon, he said he is fully aware that he causes pain and often prescribes painkillers for short-term relief from acute pain. But he says narcotics are not the best way to treat chronic pain. Over time, patients develop a tolerance to the dosages they are given, and begin to need more and more medication.

Up until the early 2000s, narcotics were seen as the front line in pain treatment.

“Everything was narcotics, narcotics, but now that we have learned what the side effects are that weren’t predicted, we are working with alternative approaches,” Dr. Pil said.

A new program at the Island hospital gives patients an alternative to pills. The Center for Pain Medicine connects Island patients with doctors at Massachusetts General Hospital, who can recommend alternative therapies for chronic pain, such as steroid injections, joint injections, trigger point injections, nerve blocks, and radio frequency lesioning, according to the hospital website.

Prescription monitoring began at the state in 1992, but only recently has this data been available to physicians.

Gosnold on Cape Cod, an addiction treatment center in Falmouth, works with physicians to raise awareness about the pitfalls of painkillers.

“It’s working with the medical field not in a punitive way, but working together to see what we can do and what they can do to help with the abuse potential,” said Lori J. McCarthy, director of clinical outreach at Gosnold, in an interview this week.

The state hopes that releasing the data will bring attention to the opiate crisis, and better inform efforts to combat it.

“The more information that people have, the more informed they are,” said Deborah S. Allwes, director of the bureau of health care safety and quality. “By having this be in the spotlight and part of the conversation, it just makes everyone more aware.”

Statewide, opioid prescriptions have leveled off in recent years, after showing an upward trend for many years.

The state is still trying to figure out how to interpret the data.

“What we don’t know is even though the number [of prescriptions] is maintaining the same, we don’t know if that is the right number to begin with,” Ms. Allwes said.

While the prescription monitoring program gives the state a preventative indicator, the fatality data shows the tragic consequences of drug availability.

“It informs the public about the magnitude of the problem and the burden on families in the state,” Mr. Land said. “The fact that we can produce this more regularly also allows us to look at underlying patterns, what types of communities, individuals, policies and programs are affected . . . so we can deliver our resources more effectively.”

Comments

Submitted by Anonymous (not verified) on Thu, 02/26/2015 - 19:10

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sue tisbury

It's sad for the people that don't abuse them. My husband went thru all the items listed above at a pain clinic in Boston. He is now worse off then if he would've stayed on a low dosage. I've watched the decline first hand and do not believe everyone is a candidate for some of these treatments. Such as a person with a history of cancer and blood clots. Dr. Silberstein puts people on many meds too. There is no easy answer to pain management.

Submitted by Anonymous (not verified) on Fri, 02/27/2015 - 13:58

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Bob Chilmark

It is very unfortunate that the pervasive attitude that Island doctors have regarding the use of prescription pain medications requires Island residents to use the services of off Island doctors. I have had two hip replacements, disc compression, spinal stenosis and other injuries from playing college football and two motorcycle accidents. I workout and stay active and as such have pain after each workout. I have tried non opiate medications, physical therapy, joint injections, steroid injections and radio frequency ablation. Partial relief from these procedures but never the less, always in some state of pain. If it were not for the recognition of my off Island doctor of my continuous need for pain meds I would not be able to live a normal life. Only those who live in constant pain know the benefit of prolonged periods without pain. Not all people who take opiate medications on a regular basis are addicts and fortunately not all doctors are closed minded and truly have the best interest of their patient in mind before they say no.

Spenser Edgartown

Bob you hit the nail on the head with a king size hammer. I like yourself have had countless surgeries as a result of auto accidents and work related injuries and still I continued to deal with and try to live with chronic pain. I tried every way, shape and form of rehabilitation over many years. From over the counter meds to numerous joint injections to acupuncture, chiropractic and homeopathic methods to physical therapy not to mention some really wild things like apitherapy (the use of bee venom). When relief was finally found in the form of prescription pain medication I began to slowly regain my life and found relief using a somewhat mild level of medication by today's standards all the while not feeling one bit euphoric. I am with you as to those who never live with prolonged periods of pain will never understand what it's like to live with prolonged periods of relief.

Here are a few things I will say about the article. First none of the estimated deaths as tragic as they were are being connected to prescriptions issued on island. If they were then perhaps those doctors should be investigated. The Vineyard is flooded by illegal and illicit drugs every year a fact that is left out of the above article and deaths that occur from overdosing often occur as a mixture of more potent illegal drugs used along with the legal meds if they were in fact prescribed legally. Secondly as to the physicians being basically bullied by the state to decrease the dispensing of medication the doctors themselves can easily figure out who is either abusing their medication or selling it. First the doctors need to do pop urine screens and if the patient refuses then action should be taken immediately. Next require the patient to supply at any time they are asked with a pill count in person. If the patient cannot show up in person with the amount of pills they should have left then again action should be taken immediately. Yes this will take some time on the behalf of the physicians but wouldn't it be a better solution then lumping all pain patients into the same mold? We (pain patients) are not all alike. We all require different pain management plans for our future. We are not all addicts. We don't all abuse medications, sell medications or take the same type or amount. If we cannot find a physician on island with an open mind then we will seek one who is trained in pain and who will require us to fulfill the requirements of our pain management contract. If we can't find one here because they have been bullied and scared into thinking that not treating us will be more beneficial for their practice then treating us then great. But to flag pain patients for seeking better care? God help us all who only want to live pain free life.

Aerik Oak Bluffs

Right on Spenser! And, of course, we know that even with the assistance of opiate pain analgesics, we who suffer with chronic pain are never truly pain-free. The hope is to manage our pain in such a way that we can have a more functional life. Doctors on the island have said to me: "You will probably be on these meds for the rest of your life," to "Your physical trauma and subsequent surgeries is just bad luck, and there is nothing I can do for you," to "You have never shown any indication of prescription pain med abuse and addiction over the last ten years, but because of other cooccurring disorders we think you're a high risk."

Look, I was a medic in the U.S. Army, and have a great respect for the medical community, for they got me up on my feet and walking again after I survived a deadly car accident over ten years ago. However, the way most of the doctors on this island have refused to treat real chronic pain over the last three years is almost a dereliction of their ethical responsibility to "do no harm" to their patients.

The current treatment of chronic pain patients on the island pushes against two basic principals of medical ethics, primarily the second and third principals. The second principal falls under the Beneficence heading: "All healthcare providers must strive to improve their patient’s health, to do the most good for the patient in every situation. But what is good for one patient may not be good for another, so each situation should be considered individually. And other values that might conflict with beneficence may need to be considered."
Treating Vineyard patients individually has apparently fallen to the wayside when it comes to pain patients--we are all looked at as addicts and abusers first rather than individual patients.

The third principal of medical ethics is Nonmaleficence: “First, do no harm” is the bedrock of medical ethics. In every situation, healthcare providers should avoid causing harm to their patients. You should also be aware of the doctrine of double effect, where a treatment intended for good unintentionally causes harm. This doctrine helps you make difficult decisions about whether actions with double effects can be undertaken." The doctrine of double effect has usurped the first part of the principal. Doctors acting in fear tend to be concerned more with the double effect issue than the actual suffering of the legitimate chronic pain patient. In essence, they'd rather do harm to their patients than have to navigate the double effect issue with their patients and, if needed, substance abuse specialists who can assist the doctor in protecting the patient from any cooccurring disorders.

Submitted by Anonymous (not verified) on Fri, 02/27/2015 - 20:10

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sue tisbury

Bob and Spencer understand what we are going thru. I think the first clue for doctors is if people are asking early or on the exact day they r scheduled to run out. Ours always last at least an extra week. Another sign are the ones sitting waiting for them to be filled. I understand if the person just came from the ER, but if it's a monthly script people should not be standing there tapping their foot. As far as the deaths, I heard a really dangerous strain of heroin is killing a lot of people (that's what my dentist told me).

Submitted by Anonymous (not verified) on Sat, 02/28/2015 - 21:36

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Aerik Oak Bluffs

The headline here should have been, "Despite opiate pain medication use remaining high in Dukes County, total usage is on the decline."

Such headlines don't make it onto the front page despite what the data sets actually show. The continued misinformation on the issue of opiate pain medications reflects the knee-jerk reaction of the medical community, disproportionately blamed by law-enforcement for the sad state of a failed drug war and an industry-wide lack of understanding of addiction, substance abuse treatment and chronic pain on the whole.

As noted by Bob, Spencer, and Sue above, the medical community on the island is failing patients who have legitimate chronic pain and no history of abusing opiate pain medications. The fact that a patient has to seek proper treatment for his chronic pain caused by various surgeries over the years from an off island doctor is frustrating to say the least.

Vineyard doctors are now refusing to treat patients with chronic pain with opiate pain medications regardless of the legitimacy of such pain. Because of the fear felt by doctors over losing their licenses, they would rather see some patients unnecessarily suffer rather than treat them with what are still considered one of the best treatments for pain.

One also has to take what Dr. Silberstein counts as an overdose with a grain of salt. He neglects to say that most overdoses don't just include one substance but many. The good doctor isn't alone in this.

When journalists cover “opiate related deaths” they tend not to break down what the opiates were that contributed to the poor soul’s demise. Was it a cocktail of heroin, and painkillers, and alcohol, or benzodiazepines, that also contributed to that death? It’s usually not said. Also, the tendency by reporters to not put opiate related deaths in comparison to other pharmaceutical related deaths—like benzodiazepines, sleeping pills, and anti-anxiety meds— shows a lack of perspective, leaving the reader with the thought that only painkillers are the scourge they are being portrayed to be.

There’s more to the story.

For instance, on the CDC webpage detailing figures related to opiate painkillers, the agency reports that in 2011, about 1.4 million Emergency Department (ED) visits involved the non-medical use of pharmaceuticals. Among those ED visits, 501,207 were related to anti-anxiety and insomnia medications (sleeping pills), and 420,040 visits were related to opioid analgesics.

Also in 2011, according to the CDC, of the 22,810 deaths relating to pharmaceutical overdose that year, 16,917 (74%) involved opioid analgesics (also called opioid pain relievers or prescription painkillers), and 6,872 (30%) involved benzodiazepines. (Some deaths include more than one type of drug), the agency states.

Not surprisingly, the agency does what journalists fail to do and gives even more perspective. Don’t get me wrong, 16,917 deaths is one too many. But that’s 16,917 deaths out of over 200 million prescriptions for opiate analgesics written in 2011.

Other patients falling through the cracks are the unfortunate souls who, indeed, have some substance abuse in their past and who are in specialized treatment for that cooccurring disorder but who are refused opiate pain medications despite what government protocols and guidelines instruct doctors to do..

The Substance Abuse and Mental Health Services Administration (SAMHSA) recently published Treatment Improvement Protocol (TIP) 54, a framework for treating patients who are in specialized treatment for substance abuse while also suffering from chronic pain. In essence it states that a patient who is in specialized treatment for Substance Abuse should be treated like any other pain patient rather than stigmatized and refused opiate pain med treatment.

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