200 10-miligram Hydrocodones
90 80-miligram OxyContins
This is the prescription that Kristin Philips* received the first time she visited a pain management clinic right here in Knoxville, Tennessee. What kind of pain must she have been in to need so much medication for a single month? According to Philips’s own admission, none at all. In fact, Philips had just been told by the doctor who had been giving her a prescription for hydrocodone for six months after she had knee surgery that he could no longer medically justify renewing her prescription.
And how large was the original prescription that Philips no longer needed? Just 30 10-miligram hydrocodone pills per month, or one per day. But when her doctor cut her off, all she had to do was set up an appointment at the pain clinic, where a visit consisted of indicating her level of pain on a scale of 1 to 10. “You would always say 10, and he would always nod, because that’s what he wanted you to say,” says Philips, though she is convinced that the physician was aware that she was lying. Her first visit netted her the prescription described above—almost 16 times the number of pills prescribed to prepare for a real surgery.
Like the recovering addicts we spoke to in Part One of our series [“The Faces of Addiction,” March/April], Philips was a normal young woman living a normal life before she started taking opiates. By the time she entered recovery 10 years later, she had lied, stolen, and illegally sold drugs in order to feed her hydrocodone habit.
Sadly, she is just one of many addicts. Knox County Sheriff Jimmy “JJ” Jones told Cityview, “Right now, this is the downfall of our country. We’re headed in a bad direction with prescription drugs.” And according to the Sheriff’s Department, the side of town doesn’t matter when it comes to opiates. Prescription pain pills are everywhere in Knoxville—but where are they coming from?
There is no simple answer. According to experts, significant over-prescription of narcotics happens all the time. Several different factors have been identified as contributing to the high incidence of pain pill addiction in East Tennessee. Part of the blame must be assigned to the sometimes under-informed doctors who can legally operate pain clinics. Patient perception can also play a role. But these issues alone do not adequately explain the growing epidemic. The fact remains that some pain management clinics have far more nefarious reasons to keep pain pills flowing onto the streets of Knoxville.
In part, the proliferation of opiates has to do with a simple lack of continuing physician education. According to current Tennessee legislation, any licensed doctor can open and run a pain management clinic—even those who have no training in this specialty whatsoever. Though only a few specialties, combined with intensive fellowship training, qualify a medical student to be Board Certified in Pain Management, few doctors choose to pursue this relatively new specialty. A general practitioner or OBGYN might open a pain management practice because they themselves are chronic pain sufferers and have empathy for those dealing with pain on a daily basis, or because they have friends or family who have similarly suffered. These doctors often feel sorry for their patients and genuinely want to be of help to those in need.
The problem with chronic pain, however, is that it can be extremely difficult to diagnosis or confirm. Doctors can perform tests, X-rays, and MRIs, but ultimately doctors rely on patient testimony to determine what hurts and how much. Moreover, doctors are taught in medical school to believe a patient when he or she describes symptoms and to do what they can to help. “When you go to a doctor, your assumption is that he’s going to help you. And his assumption is that you’re going to tell him the truth because you want to be helped,” says Dr. Mark Nelson of Tennova Comprehensive Pain Center. Dr. Nelson specializes in anesthesiology, one of the few medical specialties that qualify a physician to become a Board Certified pain specialist.
“A lot of physicians have sympathy for their patients and can’t say no, and they give their patients what they want every single time. And they’ll have happy patients. But often saying no is better for the patient in the long run,” explains Dr. James Choo. “In chronic pain populations, you have to be able to say ‘no’ and to put restrictions on their medications, and that really goes counter to what we’ve all been taught in medical school.” Dr. Choo, a physician at Pain Consultants of East Tennessee, is a Board Certified pain specialist who has undergone rigorous training in the methods and complexities of treating chronic pain. But many doctors who are entering this field, he says, are ill prepared to deal with difficult or complex cases—and they are especially ill prepared to deal with patients who are lying or stretching the truth.
This philosophy on the part of doctors is only exacerbated in Knoxville by the long-standing patient beliefs about the efficacy of this medication. An understanding has grown up in the general populace that patients can go to their doctor and say, “I need something to help me now.” Patients are upset and disappointed when they can’t get a prescription that will quickly make them feel better and get them up to speed again. But sometimes chronic pain isn’t an easy problem to solve, and medical studies have now shown that there is a definite threshold to how much opiates can really do. “About 50 percent of chronic pain sufferers get up to a 50 percent reduction of their pain from narcotics. There is a peak in functionality,” says Dr. Nelson. It can be difficult for physicians to explain this to patients who believe that more pills will provide a solution to their problem. Unfortunately, however, no matter how far medical advances have come, some chronic pain sufferers have to endure the suffering from an injury or condition for the rest of their lives. Furthermore, doctors’ difficulties in helping patients to understand this is complicated by the necessity to be always watchful for addicts and drug-seekers masquerading as people who are truly in pain.
But sometimes ignorance and good intentions just aren’t enough to explain what goes on at pain clinics. As one officer on the narcotics force of the Knox County Sheriff’s Department put it, some doctors are “readily handing out the prescriptions.” According to the CDC, sales of opiates to providers such as pharmacies has increased by more than 300 percent since 1999. And there’s an enormous amount of profit to be made from opiates, which can sell on the street for as much as $1 per milligram—or $80 for a single high-dosage pill. Doctors who prescribe these drugs don’t make that much per pill, but by billing insurance or getting cash from patients, they can rack up as much as $7,000 to $10,000 per day, the Sheriff’s Department says.
With that kind of financial incentive, it’s not difficult to see why unscrupulous individuals are taking advantage of the current crisis. The Sheriff’s Department reports that a pain clinic shut down in Blount County not long ago had nearly $900,000 stashed in the safe—exponentially more than a legitimate operation would be making. Though the doctors we spoke to were not eager to speak ill of their peers, they are acutely aware of the problems caused by doctors who over-prescribe. “There are some practices out there that are trying to make a quick buck and don’t really care about their patients,” says Dr. Choo, and according to Dr. Nelson the ultimate result of over-prescribing—whether the doctors have good intentions or not—is that patients “get large doses of the pain medications that we all know are getting abused.”
Pain sufferers, too, must be careful when seeking care for their conditions. Many primary care doctors are no longer willing to prescribe opiates at all, and chronic pain patients are forced to turn to pain-specific practices. “We had one guy that called a pain clinic around here and they said, ‘Bring us an MRI.’ So that sounds good, like they’re making sure that he has a documented problem. The staff member then followed up and said, ‘We don’t care whose MRI it is, just bring us any old MRI,’” says Dr. Ted Jones, the psychologist at Pain Consultants of East Tennessee. Nearly all of the experts revealed the same signs to watch for: clinics that move frequently, have irregular hours and long lines outside the building before opening, display banner ads touting their services, and have cars in the parking lot with out-of-state license plates are almost certainly “pill mills,” as unscrupulous clinics are commonly called.
There is only so much that legitimate pain specialists can do to try to reduce the harm from pill-seekers and diverted drugs. Dr. Jones has developed a new psychological evaluation for patients who are seeking treatment from opiates. This has been an enormous help to his organization in determining what patients are safe to take on, and which of those patients can be prescribed opiates in addition to the many other treatments and therapies available for dealing with pain. “If I don’t have a good feeling for the patient, they’ve lied to me and they’ve severed the patient-physician relationship, they are no longer a part of the practice,” says Dr. Choo. Similarly, Dr. Nelson reports, “If we find someone who has active addiction, we won’t treat them in our clinic.”
Still, “we’re not policemen,” says Dr. Nelson. Though his practice is to increase monitoring if he receives a tip about a patient seeking drugs, for instance, he can’t simply take those reports at face value. “We’ve had people call us and report that someone is selling pills just because they’re angry with their neighbor,” he says. But though evaluating patients and providing a safe place for chronic pain sufferers is a big step forward on the medical side of things, the problem with addiction rages on at the heart of Knoxville, and those patients turned away from legitimate services have plenty of other options available.
Legislators have been at work tightening up regulations on how these pain clinics can operate, requiring clinics to register and forbidding them from operating on a cash-only basis. However, those intent on violating the spirit of the law continually find new ways to work around the rules. “The bad pain clinics are where the big volume comes from,” says Dr. Nelson. “Sadly, it doesn’t take a great deal of work on the part of a doctor who wants to sell pain medicines to make it legitimate.”
And that’s something that Kristin Philips, now four years clean, can certain attest to. When she turned to shopping for pills online, she says, it was laughably easy to obtain a prescription. Telephone appointments with doctors from these web services lasted an average of about five minutes, and Philips would receive a shipment of drugs within two days—as long as she had her money order at the ready. Most of the online clinics didn’t last for long, but “when one shut down, you could find another,” says Philips.
But Philips’s first pain pills didn’t come from an online doctor, and they didn’t come from another state. They came from a pain clinic in the heart of Knoxville, and there are more and more of these pain clinics popping up in our city and our state every month. The Sheriff’s Department reveals that “several” investigations are ongoing in Knox County. Most will probably result in prosecutions for insurance or TennCare fraud, the easiest way to get a conviction for over-prescribing and unscrupulous clinics. The wheels turn slowly, however, and it usually takes at least six months to acquire the evidence needed to shut a bad clinic down.
And even if our law enforcement could shut down all of the “pill mills” taking up residence in Knoxville, more pills are pouring into Tennessee from across state borders. “Florida’s laws are more lax than ours, and ours are more lax than Georgia’s,” says Sheriff Jones. He describes how dealers here in Knoxville sponsor vans carrying eight or ten people on trips down to Florida, where each pilgrim can usually receive—and fill—a prescription for 800-1,200 pills. These individuals pay for their transportation either with money or with a portion of the pills, and each is free to sell whatever portion of their prescription that they don’t use themselves. This so-called “OxyContin Express” reaches throughout Appalachia, all the way from Florida through Tennessee to West Virginia. And though police can stop these vans at the state line, they can do nothing to stop people who have real prescriptions in their own names.
Legislators, concerned physicians, and law enforcement are working to combat the influx of pills into Knoxville and the surrounding area, but there is still an enormous amount of ground to cover. “These medicines are incredibly powerful, and they can have such a powerful addictive quality. Any of these medications is just as dangerous as heroin on the streets,” says Dr. Choo. And at any given moment, opiates are just a few clicks of a computer mouse or a phone call away from our streets.
*Not her real name.