IV. PROSECUTING DEALERS, REHABILITATING ADDICTS
Changing attitudes toward prescription medication also requires changing our perception of addiction. Without proper treatment or oversight, patients can become addicted to prescription narcotics in just seven days. That timeframe dwindles to just days if someone alters the drug into a form wherein he or she can snort or inject it.
“People with addiction who could be perfectly good people will do all sorts of horrible things to maintain their supply,” said Dr. Andrew Kolodny, President of Physicians for Responsible Opioid Prescribing.
This desperation, coupled with an inability to perceive danger, makes this population even more susceptible. These people do not always know where to turn for treatment, and unscrupulous doctors and pharmacists exploit this vulnerability. The best artillery against those addicted and the bad actors feeding these chemical dependencies is to strengthen compassionate reforms for addicts and heighten penalties for drug dealers.
A. Prosecuting “Licensed” Drug Dealers
Like many solutions, we must be cautious with criminal penalties for New York medical professionals. The vast majority work diligently to provide the best medical care possible; however, there are a few very bad actors who abuse their power. Traditionally, we think of drug dealers in terms of cinema clichés, but these dealers hold professional licenses, which give them access to powerful narcotics. A doctor illegally selling painkiller prescriptions received a six-month jail sentence after two of his patients fatally overdosed. This penalty has not caught up with, nor does it line up offenses for merely possessing opiates — someone possessing heroin will be sentenced to years in prison.
If these professionals illegally sell prescriptions, they should be punished the same way as any other drug dealer. One doctor, Stan Li, ran a pain clinic in Queens for two years, and during that time, patients would reportedly line up outside his practice. Prosecutors allege he saw 120 patients per day. As many as nine people died as a result of Dr. Li’s illegal prescribing. He also prescribed more than 2,500 pain pills to the gunman in the Medford, Long Island pharmacy shooting. [The gunman shot and killed four people, before making off with 10,000 Hydrocodone pills.] This example illustrates why some prosecutors question the comprehensiveness of current New York penal laws.
“It is difficult to prosecute unscrupulous pharmacists under current New York law,” said Nassau County ADA Jane Zwirn-Turkin, Chief of the Pharmaceutical Diversion Unit. “The Nassau County’s Pharmaceutical Diversion Unit investigated a pharmacist who filled narcotic prescriptions for customers he knew were addicts, but we were unable to prosecute him until he sold controlled substances to customers without prescriptions.”
Current general statutory provisions prohibit the sale of narcotics. Other provisions specifically address the sale of prescription drugs by physicians. There are specific provisions to handle physicians who illegally prescribe — sell — controlled substances. There are not specific provisions addressing when pharmacists illegally dispense narcotics. We need statutes clarifying and ensuring all licensed medical professionals who illegally prescribe or dispense controlled substances will face criminal penalties. Future laws must focus on practitioners acting outside the scope of their professions, namely those who knowingly and illegally dispense controlled substances.
Further, changes to the scheduling of Tramadol and Hydrocodone will enhance the tools available to prosecutors. They will provide stiffer penalties for practitioners illegally peddling these medications.
B. Rehabilitating Addicts
Across the country, users of prescription pain medication suffer from addiction. However, there are not enough resources in place to help these patients transition out of addiction. “In 2006, 692,000 reported misusing prescription drugs for non-medical purposes,” but three years later, only 19,182 people entered rehabilitation programs for opioid addiction.
In many cases, health insurance plans cover prescription pain medication, but it can be difficult access to adequate coverage for rehabilitative services stemming from a later addiction to those same medications. In order to eliminate and prevent addiction, plans should cover drug rehabilitation for prescription drugs.
According to a 2011 study by Columbia University, local, state, and federal governments spend almost $500 billion on the effects of substance abuse.
Between 1999 and 2009, New York treatment admission rates for prescription opioids rose 450% —20% more than the national average.
At first glance, this number would seem to indicate rehabilitation rates are steadily increasing, but it does not reflect the massive number of people who need, but still do not have access to this intervention. Nor do these statistics adequately illustrate the pain and terror families face when a loved one cannot find a safe place to go through detoxification.
1. Examine Detoxification & Rehabilitation in New York
According to recent information from the CDC, “for every unintentional overdose death related to an opioid analgesic, nine persons are admitted for substances abuse treatment, 35 visit emergency departments, 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics.”
Each of these represents a population that has or will have need of either detoxification (detox) or rehabilitation services. Many of those working in these fields dedicate their lives to helping others. These services are important, but they are also expensive, and inpatient treatment can be difficult to access through insurance coverage. New York must develop a thorough and ongoing process to evaluate and supervise both detox and rehabilitation services.There has been continuing discussion at the state and federal levels about decreasing the number of detox beds in New York because the service can often be conducted on an outpatient basis. We must require frank and full discussions about the appropriateness of this policy shift and explore alternate approaches. Many people suffer from a lack of detox beds; there have been reports of families across the state whose loved ones overdosed or committed suicide, and in some cases the reports indicate a link to an inability to access appropriate services. This is just one example of both the pain of addiction, and the necessity to clearly publicize how to access detox and support services. If we plan to change the way detox works in New York, the change must be comprehensive (i.e. it must be accompanied by educational materials about how to properly access new detox services).Moreover, there are several models for outpatient, non-medical settings to help people through detox and rehabilitation from opioid and other addictions. Detox from opioid addiction may not be fatal, but “detoxing on the floor of your bathroom can be difficult to endure, frightening for family members and provides no link to treatment.”
We also need to consider continuity of care for those affected by addiction. New Yorkers must recognize the link between the medical and emotional aspects of addiction. Mental health and primary care must work together to treat patients. However, we must consider alternate models. We must explore providing for very short-term, residential, and non-medical supports — sometimes called hospital diversion programs — for those suffering from addiction. New York should conduct a demonstration for the establishment of diversion programs around the state to aid in ameliorating the effects of opioid addiction.
2. Medicaid Recipient Restriction Program
Reports from the Unified Court System recognize many of those in drug courts are also Medicaid recipients. Due to various socio-economic factors, many patients suffering chronic pain are also Medicaid recipients.
According to reports, a “Medicaid patient with drug and alcohol problems costs $5,000 to $15,000 a year more in health-care costs than one without such problems. Most Medicaid hospital patients readmitted within 30 days are those with drug and alcohol problems.”
In 2010, the Senate Republican Task Force on Medicaid Fraud recognized the problems with doctor shopping “as a well documented form of Medicaid fraud.”
To combat this, the task force recommended requiring recipients to select one primary care physician and one pharmacy, which is similar to many managed care plan requirements. OMIG implemented this recommendation through the Recipient Restriction Program, which uses a team of physicians, nurses, and pharmacists to determine whether a recipient qualifies for the program. One investigative tool uses Salient data-mining technology to flag claims wherein a recipient receives a high-dose painkiller as their initial experience with the medication. From there, OMIG can research the patient file to determine whether the patient is doctor shopping or, perhaps, just needs better continuity of care. The local social service district will implement the restriction and help the recipient locate a convenient primary doctor and pharmacist. In 2010, OMIG conducted 5,864 reviews, leading to an average of 9,022 recipients restricted.
Not only did these recipients receive more coordinated care, but it also resulted in acost-savings to the Medicaid program of over $150 million.
3. Handling Overdoses
With prolonged, and often improper use, there is a high risk for overdose on opioid painkillers. Unlike some drugs, there are no maximum doses for opioids; however, higher doses can cause respiratory depression. In other words, the person’s respiratory system stops working, and he or she will eventually die from oxygen deprivation. In 2009, DOH and the New York State Office of Alcoholism and Substance Abuse Services (OASAS) released a health advisory with recommendations for opioid overdose. These recommendations included: (a) recognizing previous overdoses(s) as a risk factor for a future overdose; (b) instructing individuals and their friends and family on how to recognize and respond to an overdose, including the use of rescue breathing and Naloxone; and (c) providing take-home Naloxone.
These provide a good foundation, but reports indicate emergency room visits for opioid misuse and abuse continue to rise .Unlike other drug scenarios, those overdosing on opioids can be administered Naloxone. This medication counters the opioids’ effects on the body, and some cities are exploring handing out doses to heroin addicts. Without Naloxone, opioid overdose can be fatal. To avoid fatalities, we must explore ways to get Naloxone to those who need it, without regard to their setting. While medical professionals can administer Naloxone — or its generic counterpart — we should explore whether this could be administered in a non-medical setting. In 2006, New York created a law creating Opioid Overdose Prevention Programs and allowing non-medical personnel to administer Naloxone.
The Health Department should report on the efficacy of this program, providing data on the number of programs and participants. As discussed above, if Naloxone were available for non-medical personnel, and outside the hospital setting, this could provide additional help for those needing detoxification services when beds are not available. Moreover, we must foster an environment where those overdosing and those present while others overdose can call for medical attention without fear of prosecution. In 2011, New York took a step toward changing this attitude. A new law provides prosecutorial protection against a witness or victim of overdose.
This law will not hinder efforts to weed out drug trafficking. Instead, it will encourage witnesses and victims to protect human life; it also impliedly recognizes these victims need rehabilitative help instead of criminal sentences.
As demonstrated in this paper, there is no “quick fix” for this crisis, but we must act to counter the terrors associated with prescription drug abuse. We must make prompt, but incremental change to correct flaws in the current system. Most importantly, we must require a sea change in the perception of this medication. We must continue to acknowledge the power painkillers have to relief suffering, and respect the dangers associated with their misuse. All practitioners should become familiar with appropriate prescribing practices and the signs of drug-seeking behavior. Patients and the public must become versed in the signs of addiction, and openly communicate with their doctors. As a society, we must alter the dialogue and make wholesale change, including educational initiatives, limiting access to certain drugs, tracking pills, punishing bad actors, and providing opportunities for rehabilitation. We can, and must, weave together a variety of solutions to strengthen the current system. New York is often at the forefront of innovation and change, there is no reason we cannot aim these powers at combating a present, and very real danger to our citizens.