Misuse of OxyContin stalls effective pain care

Fear of scrutiny can lead to underuse

In the vast expanse of cyberspace, there is a photo of Eddie Bisch, a cherub-faced 18-year-old with blue eyes and cropped platinum-blond hair. The picture shows him dressed in a tuxedo, mingling among family and friends during a family wedding. As it turns out, the picture would take on a higher meaning as it captured the face of an Everyboy, whose boyish features belied his fate.

But just months after the snapshot was taken, Eddie and friends spent an evening popping Xanax, drinking beer, and splitting a 40 mg tablet of OxyContin. On Feb. 19, 2001, Eddie Bisch became the 21st person to die from an OxyContin overdose in three months.

The growing number of Eddie Bisches has caused law enforcement to step up their efforts to combat OxyContin abuse. Caught in the middle are the thousands of patients who suffer from chronic or disease-related pain but who don’t receive adequate pain relief because physicians are unwilling to prescribe the drug or refill prescriptions out fear of being labeled dope dealers.

The federal Drug Enforcement Agency (DEA) has tried to placate physicians by acknowledging that OxyContin and similar drugs are valuable tools that physicians should use when appropriate. Still, the DEA blames OxyContin for 464 drug overdose deaths in the past two years, and there is talk of placing tighter restrictions on prescription and use of the drug.

Father aims to hamper street trade

Even Eddie Bisch’s father doesn’t have a problem with OxyContin when prescribed by a physician for a patient suffering from severe pain. But he has nothing but resentment for those who hand out prescriptions knowing that the person he or she is writing it for intends to use or sell the drug for illicit purposes.

As a memorial to his son, Bisch built a web site (www.oxyabusekills.com) to remember Eddie and others who died as a result of oxycodone overdose, and to warn others of the dangers of using the drug outside of its intended use.

"When Eddie died I lost about a year and a half of my life," says Ed Bisch, Eddie’s father. "By putting up this web site, my goal is to slow down the street supply of Oxy."

Like hospices, Ed Bisch has found himself in the middle of a controversy he neither started nor wants to be a part of. He vigorously denounces physicians who prescribe the drug indiscriminately or illegally. But his stance has caused some to see him as an adversary to the pain management movement.

"I was shocked by the amount of hate mail I got from people who said I was making it harder for them to get the drugs they need for pain. I’m not against Oxy for severe pain. If I get cancer and I’m in pain, I’ll take it and I’ll be glad to take it."

Sadly, stories like the Bisches are becoming commonplace. Diversion of the prescription medication has prompted law enforcement officials to step up their efforts to root out rogue physicians who see the latest drug craze as an opportunity to make a fast buck. Other physicians fear guilt by association. If they prescribe the drug, say some physicians, then it could lead to scrutiny, and perhaps unfair prosecution.

Before OxyContin was national news, the pain management movement was enjoying momentum, with more and more physicians and nurses taking the time to educate themselves about available drugs and therapies to improve patient outcomes and improve quality of life. It seems, however, that the momentum has slowed or been halted.

"Patients with true needs are being denied access [to OxyContin]," says Marc Hahn, DO, president of the Glenview, IL-based American Academy of Pain Medicine and dean of the Texas College of Osteopathic Medicine in Fort Worth, TX. "Whether we’re losing ground, we don’t know for sure."

Earlier this year, the American Medical Association released its "Annual Review of State Pain Policies: 2001," which found a steady adoption of state pain policies that ease constraints surrounding the use of opioid analgesics for the treatment of pain. While state regulators are taking unprecedented steps to help physicians provide relief to cancer patients and others suffering from chronic pain, pain remains inadequately managed, due in part to concerns about addiction and legal sanctions, according to pain policy expert Aaron M. Gilson, PhD, chief policy researcher and assistant director of the University of Wisconsin Pain & Policy Studies Group in Madison.

In 1998, the Federation of State Medical Boards developed model guidelines that encourage the use of controlled substances for pain therapy and provide physicians guidance for use of controlled substances. The policy was disseminated to medical boards in each state. The new report found that state policies addressing the appropriate use of controlled substances for pain management increased from six in 1989 to more than 80 in 2001, with some states having more than one policy.

The new report also found that since 1998, 22 states have developed policies addressing the use of controlled substances for pain that are based on the federation’s model guidelines. However, some state policies contain language that has the potential to impede the use of opioid analgesics and restrict patient access to adequate pain management, says Gilson.

Gilson has also reviewed trends in medical use of particular drugs to determine if the heightened attention surrounding the need for effective pain management is increasing the use of these medications. "According to our data, medical use of morphine in the U.S. has increased almost 2,000 percent since 1980. This suggests that it’s being used more and more, not only to treat cancer pain but also to treat other types of chronic pain," says Gilson. "However, patients are still experiencing inadequate pain control due to practitioner fear of investigation and discipline, as well as patient and practitioner concerns regarding addiction."

While the DEA acknowledges the value of OxyContin for patients in severe pain, many doctors are worried about prosecution and have adopted a "better safe than sorry" attitude. The challenge for hospices is how to bring physicians back to prescribing the drug when it is appropriate.

Older physicians unused to such scrutiny

Just a few miles away from where Eddie Bisch died, Taylor Hospice in Ridley Park, PA, has had to face just that sort of challenge. Physicians have told hospice officials that they have been subjected to inquiries regarding their prescribing patterns by law enforcement agencies, including the DEA.

"We deal with a lot of older physicians who are not used to this kind of scrutiny," says Janet Le, CHPN, clinical director for Taylor Hospice. "What we tell them is that as long as they show documentation, they should be okay."

In another part of metropolitan Philadelphia, Tina McMichael, MSN, the director of Hospice of the VNA of Greater Philadelphia, says the limited number of inner-city physicians with ties to the larger hospitals have showed little trepidation in prescribing OxyContin and other opioids for their hospice patients.

"We’ve got a good medical director who has done a good job of helping to educate referring physicians, and our referring physicians seem to be enlightened," she says.

While the two hospices have had starkly different experiences with their referring physicians, there is a common denominator that explains the absence of problems in one and the solution to the other’s problems: physician education.

Both hospices stress pain protocols developed by Hospice Pharmacia in Philadelphia, a supplier of pain drugs to hospices. In addition, there is ongoing education lead by hospice medical directors.

Clinical staff at Taylor Hospice guide referring physicians in improving documentation. The hospice stresses thorough pain assessments and keeping a record of the pain patients report by using pain scales and including detailed notes of pain symptoms, such as grimacing, restlessness, and agitation, in the patient record.

"We’ve worked one on one with our physicians, and they have become more familiar with documentation and are more confident about prescribing pain drugs," Le says.

Still, if physicians are not comfortable with prescribing OxyContin, the hospice suggests other equally powerful drugs, such as morphine or Percocet, which require more frequent doses that the time-released OxyContin.

Hahn says the way to gain back the momentum of the pain management movement is through better education and improved tracking systems to better distinguish between compliance and abuse.

Hospice Pharmacia, which works with both Taylor Hospice and the VNA Hospice, has about 40 peer-reviewed pain management protocols covering most kinds of pain, which in some cases direct physicians to rely less on opioid drugs than on adjuvant therapies such as nonsteroidal anti-inflammatory drugs in order to control a patient’s pain.

"The protocols drive people to use pain medication in steps," says Calvin Knowlton, PhD, chief executive officer of Hospice Pharmacia.

Hospice Pharmacia also provides technology that helps both physicians and the DEA track prescriptions. The firm offers a referral access system that tracks physician prescribing patterns by the DEA number assigned to prescribers. The system allows physicians to review their own referral patterns and review their own clinical practices if they notice any deviation from the norm.

From his home in a working-class neighborhood in Philadelphia, Ed Bisch will continue his crusade against OxyContin abuse. But he is quick to praise physicians who prescribe the drug to the thousands of people who are in extreme pain, which is a far cry from his healthy, athletic son and his friends whose pill-popping habits could be traced to a physician who wrote illegal prescriptions while his license was suspended.

"It’s literally a bad dream, and I’m just starting to wake up from it," says Bisch.