A note about this project: This story is part of an ongoing collaboration between InvestigateWest, an independent nonprofit newsroom covering the Pacific Northwest,  and  public broadcast station KCTS 9. An accompanying documentary airs Jan. 30 at 9 p.m. to be followed by a half-hour in-studio discussion. Second of two parts.

Washington State has made an aggressive attempt to crack down on the prescription drug epidemic by passing strict new rules governing pain management. But even those may not be enough to stanch the flood of deaths from prescription opiates in this state.

The passage of a new law, regarded as one of the toughest in the nation, makes Washington the first state to require dosing limits for doctors and others who prescribe these medicines. The law, RCW 2876, went into effect January 2, but those who have watched the epidemic spiral out of control still see significant challenges ahead.

Among the first is the dearth of pain specialists in the state. Under the new law, doctors and other prescribers with patients who need more than 120 mg a day must seek a second opinion from a pain specialist. But there are few of those professionals to go around.

Medicaid is already struggling to comply with the new law. Despite having thousands of patients currently over the threshold limit, the agency can only get one or two evaluated by a pain specialist a month, said Dr. Jeff Thompson, medical director of the state’s Medicaid program.

“Access is an issue,” said Dr. Gary Franklin, medical director of the state’s Department of Labor & Industries, adding that telemedicine consultation programs and other efforts to increase capacity are helping, but still don’t fill the need.  

The new law makes Dr. Merle Janes of Valley Rehab & Emergency in Spokane angry. He said legitimate pain patients and doctors who prescribe for them are paying the price for the policy changes designed to nab addicts. People in real pain can’t get adequate relief, he says.

“It’s been a disaster for all these people,” Janes said.

Dr. David Tauben, a clinical associate professor and director of medical education in pain management at the University of Washington, agreed that not enough doctors are treating pain well.

“But this problem was happening well before the new law,” Tauben said. He’s optimistic that the new law will actually encourage more doctors to take on pain patients because they will have guidelines to follow to help keep them from running afoul of disciplinary agencies. The guidelines should remove ambiguity and help doctors communicate better with patients about the goals and limitations of pain treatment, he said.

Lax oversight

Another obstacle to the success of the state’s new pain policy is the continuing lax oversight of prescribing habits.

“What we’re doing now is not working,” said Dr. Rosemary Orr, anesthesiologist at Children’s Hospital and Medical Center in Seattle. Orr lost her own son to an OxyContin overdose. She said she’s still amazed at the amount of pain medication she sees prescribed in her own profession.

A key limitation of the new law: While it gives state regulators a reason to discipline doctors, the statute does not require the state to check whether doctors or other medical professionals are breaking it.

That’s in contrast to the U.S. Drug Enforcement Administration, which monitors whether medical professionals with narcotic permits are following its rules. The new state program also falls short of Washington’s Medicaid program, which routinely tracks how much narcotic medication doctors hand out. Instead, the system set up by the new law relies on complaints from patients or medical professionals to trigger investigations.

As a result, the Medical Quality Assurance Commission, which investigates doctors and other healthcare professionals, can’t say how much of a problem excessive prescribing is for Washington doctors, dentists, advanced nurse practitioners, physicians assistants, and other providers licensed to prescribe these powerful medications.

An InvestigateWest review of recent cases against medical professionals found only a handful over a three-month period. The majority of those disciplinary actions involve medical workers who are addicted themselves. A few, however, had been disciplined for excessive prescribing.

In July, for example, the Department of Health issued a statement of charges against an Everett osteopath for prescribing excessive amounts of pain medication to a dozen patients. Documents describe a pattern of prescribing to patients known to be at high risk for drug abuse. The doctor allowed his license to expire in September.

The state’s actions came after the doctor’s offices had been raided the previous year by DEA agents, an action that resulted in charges related to financial transactions the DEA indicated could be used to hide drug trafficking activity.

Doctors and others disciplined for drug-related issues are usually given chances to go into rehab, get additional training, or pay fines. In 2009, however, Spokane-area doctor Keith L. Hindman, went to prison for health care fraud and prescribing controlled substances for non-medical purposes.

The DEA, in contrast to the state, does carry out surprise inspections. The agency has shut down the top five prescribers in the state over the last several years, including a clinic in Vancouver that operated as a so-called “pill mill.” When the clinic shut down, many of its addicted patients flooded local ERs.

In August, the federal agency broke up an eight-member prescription drug ring operating between Washington and Alaska. Members were charged with conspiring to possess with intent to distribute the drugs, as well as money laundering. 

For his part, Thompson of Medicaid sent a letter last summer to the top 20 doctors prescribing opiates to Medicaid patients, alerting them that they’d been flagged for the volume of their prescribing.

“That doesn’t mean they are good or bad doctors,” he said. “There is no definition. However, it does say, it’s worth looking at why they are so high.”

Prescription monitoring programs

One reason there has been little oversight of prescribing habits in Washington is that until this year there hasn’t been a systematic way to track the information.

Washington has been slow to adopt a statewide prescription monitoring program that would enter all patient prescriptions in one shared database. The state Legislature created such a program in 2007, but pulled its funding the next year. It never got up and running.

Currently, 35 other states have such programs in place, and the information has led to a reduction in prescription fraud as well as provided a way to identify doctors who have excessive prescribing habits.

The lack of such a program here frustrated Chris Johnson, policy director for the Washington Attorney General’s office. “We know from the war on meth that tracking sale of precursor drugs had helped curb the problem,” he said. “We figured the same approach could help stem the wave of prescription drug abuse.”

Johnson was part of a group that has now helped secure temporary funding to mount a prescription-monitoring program in Washington. But the program will be exhausted by June, he said. And even this program has limitations. Prescribers are not required to consult the new database before writing a prescription. Participation is voluntary.

In Kentucky, where it is also voluntary, only about 20 percent of doctors used it, said Franklin. Iowa is contemplating moving to a mandatory system because only 10 to 12 percent of its providers currently participate in the state’s prescription-monitoring program. New York is also considering legislation to require practitioners to use its reporting system.