Prescription pill abuse 'a holocaust' in Kentucky, hitting 1 in 16; big drug firms and even well-meaning doctors are to blame

Another in-depth look at Kentucky's prescription drug abuse problem hit the pages of The Courier-Journal yesterday, this time exploring the history of OxyContin and how well-meaning doctors started over-prescribing opioids in the 1990s in response to vigorous marketing campaigns. 

The problem continues to be gargantuan, with Laura Ungar reporting about one in 16 Kentuckians misused prescription painkillers in the past year. Kentucky ranks "as the fourth-most-medicated state in a nation that fills enough painkiller prescriptions each year to keep every American adult medicated around the clock for a month," Ungar writes.

A review published in the journal Pain Physician last year found evidence is lacking for how effective opioids are in treating long-term pain. "They're not M&Ms," said Dr. Lee Tannenbaum, founder of the Bel Air Center for Addictions in Maryland. "As physicians, we need to be really, really, really careful as to when we put someone on these drugs. Cancer pain may need opioids, but someone out shoveling snow who hurt his back doesn't. We have created so many addicts."

A C-J investigation found physicians fuel the problem in three ways. First, they do not screen patients adequately. They prescribe powerful pills for moderate pain. And they do not use the state's monitoring program, Kentucky All Schedule Prescription Electronic Reporting, known as KASPER.

The problem started in the 1990s when "medical organizations, concerned that pain wasn't being treated adequately, encouraged doctors to do more to relieve suffering," Ungar reports. OxyContin was approved by the Federal Food and Drug Administration in 1995, with OxyContin prescriptions for noncancer pain increasing by tenfold between 1997 and 2002. A report found the drug's maker, Purdue Pharma "directed its drug representatives to focus on physicians in their sales territories who were high opioid prescribers, while also issuing OxyContin 'starter coupons' for patients and distributing promotional items, such as fishing hats and plush toys," Ungar reports.

In October 2007, Kentucky and Pike County sued Purdue Pharma for its deceptive marketing campaign, alleging it misled doctors about the potency of the drug, which is twice as powerful as morphine. U.S. Rep. Harold "Hal" Rogers, R-5th District, called OxyContin "the guilty party that got this epidemic going." In Kentucky, the retail distribution of oxycodone grew from 83,000 grams in 1997 to 950,000 grams in 2010.

Part of the problem is that doctors do not have the time they need to properly assess patients for potential abuse. "You've got an awful lot of doctors prescribing not out of ill intents. They've got a limited amount of time, and pain patients require a lot of time," said Robert Walker, assistant professor of behavioral science at University of Kentucky's Center on Drug and Alcohol Research. "The easiest solution is the opioid."

While easy, they are not necessarily effective for all pain. Evidence is "very, very mixed" on whether the drugs work in the long term on chronic pain and "the evidence is pretty scant" that they are effective against treating chronic lower back pain, said Dr. Timothy Ives of the University of North Carolina.

Though the problem is never expected to be solved completely, there are steps being taken to combat the issue. In 2010, the FDA approved a reformulation of OxyContin which makes it more resistant to being cut, chewed, crushed or dissolved — methods that make the drug more powerful. The Kentucky Board of Medical Licensure has spelled out "the steps physicians need to take as they seek to help patients control pain unrelated to terminal illness," Ungar reports. And the Kentucky General Assembly passed a comprehensive bill that requires doctors to use KASPER when prescribing certain drugs and take a full medical history of patients to whom they are considering prescribing drugs. (Read more)

To fight meds-for-meth bill, Consumer Healthcare Products Association spent almost $500,000 in last session, a record

The biggest spender to lobby the Kentucky legislature in the 2012 session was the Consumer Healthcare Products Association, which represents the over-the-counter drug industry. Of the $8.8 million spent in 2012 overall, the group spent nearly $500,000, breaking the record it set in 2010 by spending $311,000.

The group was fighting a bill that would have made cold medicines that contain pseudoephedrine, the key ingredient to make methamphetamine, available only by prescription. Its report did not include several hundred thousand dollars spent on advertising to the general public, asking citizens to contact legislators. That does not fall under the state's legal definition of lobbying, which does include other methods CHPA used, such as phone banks, social media and other Internet activities.

The Senate and House ultimately passed a compromise bill that lowers the amount of pseudoephedrine a person can buy in a month from 9 grams to 7.2 grams. The maximum a person can buy in a year without a prescription is 24 grams. For a story from the Lexington Herald-Leader, click here. Gor one from The Courier-Journal, go here.

Coventry offers to keep paying ARH, but less, for treating Medicaid patients; asks Danville chain to renegotiate

Coventry Cares has offered to pay for treatments at Appalachian Regional Healthcare as a "non-contracted provider," which would mean ARH would be paid far less than it is now, but coverage for ARH's 25,000 Medicaid patient members would not be interrupted.

"Medicaid's rates pay 75 percent of the cost of treating patients on an in-patient basis," reports Valarie Honeycutt Spears for the Lexington Herald-Leader. "Coventry has asked for a further reduction."

"The ultimate issue is whether patients in that region are going to have access to care or not. ARH needs to be paid if they are going to treat these patients," said Steve Price, an attorney for ARH.

Stephen Amato, Coventry's attorney, said Coventry's offer is a sign the company "remains committed to the best interest of its members in hopes that its willingness to preserve its members' access to ARH takes its members out of the middle of the contract dispute."

Coventry is one of four companies chosen by the state to provide care to Medicaid recipients. ARH sued Coventry, and another managed-care company, saying they owed the hospital chain more than $18 million for services. But Coventry says the state allowed another managed-care company not to include ARH in its network, which means a lot of higher-risk, higher-cost patients covered by Coventry.

Meanwhile, Coventry has given notice to the Ephraim McDowell Health System, which has facilities in six counties including hospitals in Danville and Stanford, that it wants to renegotiate its contract. (Read more)

Bluegrass mental-health nonprofit flush with cash, despite cuts in public health; spends big on executive pay and lobbying

The new Eastern State Hospital being built in Lexington. The
Bluegrass Regional MH-MR Board runs the existing facility
and wants to run the new one. (Pablo Alcla, Herald-Leader)

Despite deep cuts in state public-health funding, the non-profit Bluegrass Regional Mental Health-Mental Retardation Board, which serves 17 counties in central Kentucky, is flush with cash, making some critics question whether it is transparent enough with its finances.

"In 2011, it reported having $33.7 million in cash reserves and similar assets — more money than 10 of the state's 13 other regional mental health boards had in their entire budgets," reports John Cheeves for the Lexington Herald-Leader.

The board spends freely in executive pay (four top executives collected nearly $2 million in 2010 for compensation), political lobbying (since 2008 it has spent nearly $500,000 to pay four lobbyists in Frankfort) and real estate (it bought a $295,000 home near Lake Cumberland for its senior management team to use when in Somerset).

"We have received some concerns regarding the Bluegrass board in the last few days, and we're going to be looking into those," state auditor spokeswoman Stephenie Steitzer told Cheves.

Scott Gould, who chairs the 25-member Bluegrass MH-MR Board, said "there has been no inappropriate practice or action taken by any board member, CEO or staff member."

But one former employee, Eleisha Kiefer, said the company cuts costs in unfair ways, saying there was a weekly lunch budget of $100 at a therapeutic rehabilitation program for about 20 mentally handicapped adults in Harrison County. "We had a lot of soup beans and corn bread," she said.

Gould disputed the allegation, saying there has "never, ever" been a weekly budget placed on client meals.

Mental health experts praise the work Bluegrass does. "I'd have to put them high up on the star chart in terms of what they provide their consumers and their family members," said Sheila Schuster, executive director of the Kentucky Mental Health Coalition. "It's one thing to deliver quality care, but I feel that Bluegrass goes the extra mile."

Though is it chiefly funded by the Cabinet for Health and Family Services, Bluegrass considers itself part of the private sector. Its executive pay reflects that approach. In 2010, its current and previous chief executive officers — who are married to each other —"took home more than $1 million in total compensation," Cheeves reports.

Comparatively, Howard Bracco, the recently retired CEO of the mental health board in Louisville, Seven Counties Services, made $179,868. "We had different cultures," Bracco said. "They operate on a business model, a corporate model, versus the social model. I think, frankly, they were better business people than many of us. They lobbied hard to win contracts, they fulfilled those contracts, and they've been very successful." (Read more)

With crackdown on pill abuse, will legitimate patients be able to get the prescriptions they need?

The crackdown on prescription-pill abuse has some patients worried they won't be able to get the medicine they need because doctors are fearful of over-prescribing. "It's a huge concern in a nation where chronic pain afflicts 116 million American adults and is associated with up to $635 billion in health care costs," reports Laura Ungar in an ongoing series for The Courier-Journal.

"Pain patients feel ashamed or weak that they have to take these medications ... (and) shy away from being treated," said Dr. James Murphy, a pain specialist in Louisville. 

But there is little evidence that pain patients who really need medicine are unable to find treatment. Ungar reports: "It may take longer for them to find a doctor, experts said, and they may be subjected to urine tests and pill counts to ensure they're not abusing their medicines. But most eventually are able to get the medication they need."

"I don't see any decrease in the amount of opioid prescribing in any jurisdiction," Dr. Nathaniel Katz, president and chief executive officer of the Masschusetts-based consulting firm Analgesic Solutions, told Ungar. "So it's difficult to justify a position that legitimate opioid prescribing is being chilled."

Some worry that making physicians use the state's prescription drug monitoring system — commonly known as KASPER — for new patients could create that chilling effect. A survey of controlled-substance prescribers made to use KASPER found about half didn't change their prescribing habits and about 13 percent said they actually prescribed more opioids. But 35 percent, or 190 prescribers, said they had decreased the amount of controlled substance they subscribed because of "media coverage of abuse, increased law enforcement activity related to prescription-drug abuse and fear of investigations by law enforcement or the medical board," Ungar reports.

Some are concerned that "if more doctors make that choice, desperate pain patients may feel forced to seek relief at unscrupulous pain clinics," Ungar reports. (Read more)

Couple shares 'horrible journey' of prescription drug abuse

Recovering pill addict Stacy Pennington
of Ashland is due to give birth next month.
(Courier-Journal photo by Matt Stone)

Stacy and James Pennington had to lose everything, including their children and home, before they were able to face their prescription drug abuse problem. Now in recovery at The Healing Place in Louisville, they spoke to The Courier-Journal's Laura Ungar of their downward spiral.

"It had gotten to the point where my prescription drugs were my everything. As long as I had them, I was OK," said James, 40, of Ashland. "Before, we had everything we could want. In the end, we were just feeding an addiction. We had lost everything."

Stacy Pennington said she took her first painkillers in 2002 after she cut her finger on a glass candle jar and needed two surgeries. "A year later, she was diagnosed with cervical cancer, then severe endometriosis, and she required several more surgeries," Ungar reports. "Each of her 14 operations brought another prescription for pain pills."

James Pennington took prescription drugs for the first time at age 14 after he dislocated his shoulder. After he broke his shoulder in a motorcycle accident when he was 25, he got a 30-day supply for Percocet and, later, was prescribed more of the drug after a knee injury. "Pain medications became my drug of choice from there on out," he said.

Soon, he was traveling to "pill mills" in Florida to fuel his addiction, pills he sold and shared with his wife. When Stacy gave birth to their daughter, she was heavily addicted and eventually lost custody of her. James' older daughter was also taken from the home. 

Before Stacy Pennington checked in to The Healing Place, she had sold her engagement ring, the Penningtons sold their home before they lost it, and they were spending $100 to $500 a day to feed their addiction. Now, Stacy is expecting another child and the couple is fighting for their sobriety. "It's a horrible journey. I had to absolutely lose everything. But I see that as a blessing," said James Pennington. "I'm so glad I'm on the other side today." (Read more)

Louisville has highest concentration of nursing-home and extended-care companies in U.S.

Louisville has the largest concentration of nursing-home and extended-care companies in the country. Of the 570,000 people who call Louisville home, 4,000 work in the industry and produce $28 billion in revenue, reports Frank Browning for Kaiser Health News. (Kaiser photo illustration)

Though the city didn't intend to become the leader in the long-term care industry, companies opted to cluster around each other, with Humana the nucleus of the movement. "As its influence grew, the health insurance giant created spinoffs and attracted like-minded businesses, including a growing number of companies dealing with long-term care," Browning writes, without noting that Humana itself began as a nursing-home company, Extendicare, then evolved into a hospital firm and an insurance company.

There are seven key players in theindustry who have headquarters in the city: Kindred Healthcare, Trilogy Health Services, Atria Senior Living Group, Elmcroft Senior Living, ResCare, and Signature Health Care. Those companies then attracted firms such as RecoverCare and PharMerica. "It's been an evolution," Christian Furman, a gerontologist at the University of Louisville medical school, told Browning.

One of the key moves was attracting Signature, which has 73 long-term care facilities in seven states, from Florida to Kentucky. A promise of up to $4 million of corporate income tax credits in 10 years helped, but "access to talent was most important. There's an incredible amount of expertise here," said CEO Joe Steier.

The clincher was "the whole alignment of public and private support, including the University of Louisville, that has made the city into a national and international center for aging care companies," Steier said. (Read more)