Many Vermont opiate addicts say their habit started with a legitimate prescription from a doctor. Others first bought pills stolen from someone else's medicine cabinet.
As Vermont combats opiate addiction, the state board that oversees doctors has issued a new policy on how to prescribe opioid painkillers, such as oxycodone.
The Board of Medical Practice in April adopted a new set of guidelines for physicians prescribing the highly addictive and easy-to-abuse drugs to people who suffer from long-term pain.
The new 17-page policy replaces a three-page policy adopted in 2006. The new version is a modification of a federal model policy. It begins by noting there is a lack of evidence on the effectiveness and safety of long-term opioid therapy.
"Despite that lack of evidence, opioids are widely used to treat chronic pain," the policy says, acknowledging that bad outcomes associated with misuse and diversion of opioids have increased dramatically since the prior federal policy was issued in 2004.
"It's hard to be involved in the practice of medicine in any way these days and not think about this as one of the number one challenges," said David Herlihy, executive director of the Board of Medical Practice.
The new Vermont policy, compared to the old version, puts more emphasis on assessing a patient's risk for addiction and describes ways to monitor whether patients take the drugs correctly, including pill counts and drug tests.
The policy recommends a range of measures from assessing a person's mood, work, relationships and physical activity before prescribing opiates to creating a plan to end opioid treatment as soon as possible. Many of the sections are extrapolations of the old policy.
However, the policy states outright that doctors should not fear disciplinary action from prescribing opioids. Many physicians agree opioids have a place in managing pain.
The number of prescriptions of opiate pain medications declined in Vermont over the past four years. There were 422,000 prescriptions of opioid antagonists in fiscal year 2010 and 393,026 in FY2013, although the number spiked to 450,000 in FY2011, according to the state health department.
The Vermont Board of Medical Practice not only creates policy, but investigates allegations of doctor misconduct. In recent years, there have been consistently more cases involving improper prescribing, according to Herlihy.
The policy is a guideline, and is intended to help doctors, not trip them up, Herlihy said.
Over the past 30 years, philosophies about treatment of chronic pain have shifted, doctors say. Whereas in the 1980s and ‘90s several factors, including a push by pharmaceutical companies, led to a surge in use of opioids to treat pain, the pendulum has now begun to swing back.
"Opioid analgesics are not the only means to treat pain," said Dr. Carlos Pino, medical director of the Center for Pain Management at Fletcher Allen Health Care in Burlington.
The goals of pain treatment include "reasonably attainable improvement in pain and function," the new policy says, whereas the prior policy speaks about "pain relief."
"The idea that it may not be a gain if you have a reduction in pain but the person can no longer function in life" is no longer so popular, Herlihy said.
At his pain management clinic, Pino works with Vermonters from across the state and New York. Alternative treatments to opioids include physical therapy and simple anti-inflammatory medications, he said. The most common type of chronic pain is back or neck pain, Pino said.
Pino serves on a committee at Fletcher Allen that is trying to make it easier for doctors to comply with rules about opiate prescription. There are not standard practices across hospitals or across the state, he said.
Standardization will create ways to hold doctors accountable, conduct audits and also ensure patients get the best care, he said.
"I think most doctors are overwhelmed with regulations," Pino said.
Since the 2006 policy was created, Vermont has implemented the Vermont Prescription Monitoring System as another tool to help cut prescription drug abuse. The system requires doctors to log when they prescribe controlled substances so other doctors and pharmacists can check for double-dipping. Doctors say the system helps, although it has shortcomings, such as not including out-of-state patients.
"(Doctors) want to believe their patients but with these meds, what time and experience has shown and what's reflected in our policy is that you need to use universal precautions," Herlihy said.
Meanwhile, a 2013 law requires the Department of Health to develop regulations about treating chronic pain with controlled substances, a category of drugs regulated by the federal government.
The health department rules will incorporate some best practices of the board's policy, according to Health Commissioner Harry Chen.
A draft of the rules will be released in the next few months and will go through the state government rulemaking process, Chen said.
The extensive rules around prescription of opiates make some doctors hesitate to prescribe them, Pino said. But because roughly a quarter of Americans at some point in their life will experience chronic pain, the state needs more professionals, whether they are doctors, physical therapists or acupuncturists, who are comfortable treating pain.
"I think there's maybe be a difficulty finding doctors who may be wanting to deal with patients with chronic pain which doesn't necessarily mean opioids," he said.
Pino also emphasized that the so-called "opiate addiction crisis" is not the fault of doctors, but rather a separate issue that needs more resources.
"It's an issue of addiction, not an issue of pain management," he said.