Pennsylvania is experiencing an overdose epidemic.
Allegheny County alone has seen its number fatal drug overdoses nearly double over the past five years, from 227 in 2010 to 409 in 2015. Neighboring West Virginia, where more than 35 residents out of every 100,000 died of drug overdoses in 2014, is home to the highest rate of drug overdose deaths in the country.
While a growing number of those deaths are linked to the increasing use of heroin, both regionally and across the country, the Centers for Disease Control report about 40 percent of fatal drug overdoses nationally in 2014 were directly related to abuse of prescription opioid painkillers.
So, how did we get to this point?
A Pittsburgh Post-Gazette investigative series published this week lays at least part of the blame on doctors who’ve been willing to liberally prescribe potent painkillers, and a state regulatory system that lacks the resources to adequately respond.
90.5 WESA's Josh Raulerson spoke with the Post-Gazette’s Rich Lord about the series.
Josh Raulerson: Can we start with the subtitle for the first story in your series, which is "How Doctors Wrote the Script for an Epidemic." Can you explain what you mean by that?
Rich Lord: Yeah, sure. We sat down in October and took a look at the opioid and heroin epidemic and realized that there had been a ton written by the pharmaceutical industry and how it had profited from and, perhaps, manipulated data in relation to painkillers; there had been a lot written about the heroin coming up from Mexico.
But there was a missing link. That was the doctors.
Other than the odd burglary of a pharmacy, in order for a painkiller to get out there on the street or to get into the wrong hands, a doctor has to first have scribbled their signature on a prescription.
And we decided to zoom in on the doctors and how they've behaved, particularly in the last five years, and how the regulators have dealt with that.
JR: So, if we try to get to the question of how this started, one case that you cite in this series is this lawsuit in California in 2001 in which the children of a patient sued his physician for allegedly not overprescribing, but underprescribing, pain medications for the patient. They won in court; the outcome was that the doctor was ordered to pay more than a $1 million in damages.
So, how did that case affect doctors' attitudes when it comes to prescribing these drugs?
RL: Yeah, that was an interesting piece of reporting by my colleague Brady McCollough who wrote a lot of this series too. We were looking at the rise in Oxycontin starting in the mid-90s, and the change in the medical culture, which started to emphasize aggressively addressing pain with opioids.
We weren't aware of all the little touchstones on the way between the mid-90s introduction of Oxycontin and the mess we're in now. When Brady started interviewing doctors in Ohio, they started bringing up this case from California in which a doctor was sued for not mitigating the pain of a patient who later did die during the treatment of that patient.
And when a doctor is sued and there's a $1 million judgment on that doctor … that gets attention in the medical community. So, doctors saw that as a message that, "Hey, if we don't accede to the patient's demands, if we don't accede to the increasing emphasis on pain treatment, we're going to get nailed."
JR: You looked at seven states in the Appalachia region and how they've variously approached overprescription of opioids, and, obviously, Pennsylvania is one of those states.
First, how did you determine which states to focus on, then which states have been more aggressive in their approach and which less so?
RL: We picked the seven states because they comprise the bulk of Appalachia, and, even though the opioid and heroin problem is national, it's arguably taken its deepest roots in Appalachia.
We tried to figure out how we would weigh the states' reactions against each other. We decided to go through medical disciplinary documents. Every state has boards that license and, when necessary, discipline doctors.
We looked through 4,200 disciplinary reports in those seven states and said, "OK, how many doctors in each state were disciplined -- anything from a reprimand to a license revocation -- because they prescribed too much painkillers, particularly the opioids?”
We then weighed the number of doctors disciplined over five years versus the number of doctors in that state practicing, and up with sort of a metric, I guess: doctors disciplined per (one) thousand (practicing doctors).
In Kentucky, which we featured in Tuesday's edition, more than 12 doctors out of every 1,000 were disciplined over five years for overprescribing these opioids and other narcotics.
In Pennsylvania, by contrast, it was roughly one out of every 1,000 (doctors disciplined per one thousand practicing doctors).
So, there were really big differences in how aggressively the states went after doctors who were viewed as over-prescribing.
JR: You mentioned that Kentucky, in particular, is cracking down on the physicians. So, you found that seems to have had an effect on overdose rates generally or fatalities specifically?
RL: Yeah. And I should note that in any state, including Kentucky, it's been a fraction, a minority, of the physicians who've gone off the reservation, as they say, in regards to prescribing these drugs. But certainly in Kentucky the approach was most aggressive of the seven states with more than 1 percent of the doctors disciplined for narcotics prescribing, and there the prescribing of opioids dropped about 12 percent over two years, and, contrary to all the other states in the national trends, the level of drug overdoses plateaued and actually declined slightly in Kentucky.
JR: So that suggests that Pennsylvania has some work to do when it comes to fighting abuse of these drugs. This is something that Governor Wolf has talked about a considerable amount. What more needs to be done for Pennsylvania?
RL: Hopefully by the end of this year we'll be the 49th state to have a database with which doctors can check their patients' drug histories and, frankly, with which the regulators can check the doctors' prescribing practices.
Our state regulators are also looking at adopting guidelines for opioid prescribing. When is it appropriate? How much? When do you stop? Many other states have adopted guidelines; we have very voluntary unofficial guidelines, but, hopefully, by the end of the year our medical boards will be making them official.
And one thing we haven't touched yet in Pennsylvania is mandatory doctor education related to opioid prescribing. In Kentucky, every doctor has to take four-and-a-half hours of ongoing education in that subject every two years; in Pennsylvania, there's no such requirement. So, there's a lot left to do.
JR: So, going back to where we started and the role of doctors in contributing to this epidemic. You spoke with several doctors over of the course of this series. Is there any concern among them, among the medical community broadly, of an over-correction that the pendulum could swing, you know, too far back in the other direction and physicians would again be reluctant to prescribe drugs that patients might really need?
RL: Oh, there's loads of very thoughtful concern about that, sure. And anybody, like me, who's watched a loved one die of cancer knows that there's a place for pain medication.
We've been getting calls, and, in fact, we've interviewed many doctors who've said, "Yeah there's a problem, but, you know what? If you in the media, then the regulators at the state level go too far in the other direction, then there's going to be a scarcity of these drugs for people who really need them.”
And, yeah, we've been hearing from patients the last couple of days as we've published this series saying, "You know, I see your point, but, boy, my doctor's already skittish, and now, after what you guys are publishing, he's going to cut me off completely. And I have legitimate needs, and these drugs help me to participate in life and enjoy life."