BECKLEY — Editor’s Note: During the next several weeks, The Register-Herald will be publishing stories related to the treatment of patients for various health conditions that cause them pain. There are a variety of approaches to pain management, and these stories will focus on the types of treatments that are available. Also, we will explore the issue of how drug addicts use the claim of pain to try and feed their habit by seeking pill prescriptions at pain clinics and other medical treatment facilities.
Question: “OK, my friend has access to some generic oxycodone and we want to freebase some. How many mgs should we do? thanks.”
Response: “I’m not even sure it’s possible to freebase oxycodone. Just crush it up and snort it. Start off with 15-20 mg your first time, then if that ain’t enough, do a little more.”
— Conversation posted online from a drug abuser’s forum
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On a pharmaceutical representative’s worst day in 2000, the industry joke was, “Well, at least you’re not the OxyContin rep.” Mark Radcliffe was that rep, a Purdue Pharma district sales manager, and while it wasn’t his only product to be responsible for, it was by far the most talked about.
OxyContin is the branded form of the highly addictive narcotic oxycodone, and while Purdue had built a controlled release mechanism within its formulation, leading the FDA to find it no more addictive than other Schedule II pain medications, the iron will of drug abusers found a way. Enterprising addicts attained their instant oxycodone high by crushing and snorting OxyContin, and Pandora’s bottle was officially opened.
Just after Americans began staring sheepishly at their Y2K stockpiles of water and canned peaches, FDA favor for the narcotic analgesic went to hell in a hand basket. Southern West Virginia took to the habit like white on stockpiled rice.
Radcliffe sits behind a desk after an open house ribbon-cutting on Carriage Drive in early December 2010, dressed in a T-shirt with a logo in the shape of a police badge on his chest, touting his new endeavor’s acronym HOPE (Hi-Tech Opioid Pharmacovigilance Expertise). He thinks back to what happened shortly after 2000 and how it brought him to being manager of a pain clinic he hopes “law-abiding citizens” will adopt as their source for pain resolution.
Having just opened his doors, he is saddened over the announcement of a once-prominent Fayette and Raleigh County doctor’s arrest for selling and sharing prescriptions she wrote for narcotics. Radcliffe believes it will only make matters worse for suffering patients seeking help.
“Her indictment will go through the medical community as ‘See, if you treat pain, you’ll go to prison,’” he says.
“I believed in what we did.”
Radcliffe describes his pharmaceutical days representing OxyContin before and after the FDA issued its strongest black box warnings to the product’s package insert to combat rampant abuse of the drug. Black boxes are prescription pariahs; physicians think long and hard about alternatives to prescribing medications with such amendments to their labeling. The resultant hardship is typically a decrease in a drug’s market share and subsequent profits.
“We promoted OxyContin for patients who were in pain. I saw physicians who were prosecuted because they believed the wrong patients.”
Radcliffe theorizes employing just the right element of policing will help his team members, Dr. John Pellegrini, a former OB/GYN, and Dr. James Blume, a trusted family practice and ER physician he describes as historically tough on drug-seekers, to believe the right patients.
He sits in a patient intake area behind a laptop, much as he would be if he were screening a patient prior to physician evaluation. This initial interview room incorporates the high-tech equivalents of scarecrows — a fingerprint machine as well as a microphone for recording the details of pain complaints.
The fingerprints aren’t fed into a database or processed, but “If you were selling drugs and came here, would you want your fingerprints recorded?” Radcliffe asks.
Perhaps residual from his pharmaceutical detailing days, he is a prolific reader of studies dissecting pain control and the pain problem in America, and he is, in particular, a defender of reformulated, branded OxyContin. To him, it is the classic tale of one bad apple spoiling the whole barrel for those he’s most passionate about — patients with documented pain issues unable to get legitimate prescriptions from local physicians fearful of prescribing.
“Think of an arthritis patients whose fingers are bound up and crooked,” he says. “Physicians here are so afraid of being prosecuted, they would avoid treating that patient’s pain.”
Radcliffe gives the example of a 48-year-old patient with degenerative disk disease who couldn’t find a physician to help her.
“She goes from ER to ER, each ordering expensive tests and giving her three to four days of Lortab, not giving her satisfactory pain relief.”
HOPE clinicians prescribed long-acting morphine with an additional prescription for breakthrough pain control.
“Now, in one visit, her pain is controlled,” he says, explaining each visit to the ER had cost the health care system $1,400 to $2,000.
“When a patient sits in front of a physician, that patient is either telling the truth or telling a lie.”
Radcliffe is confident in his ability to detect abusers as well as sellers. He has flown the OxyContin Express flights from Huntington himself, he says, to obtain information on abuse patterns. He states he’s found patients with true pain problems flying to different markets to procure needed medication because of local physicians shying away from the pain business.
Flights to and from the Florida pain clinics can also garner a drug seller his airfare and a guaranteed profit to boot selling pain pills from carte blanche prescribers on Mountain State streets.
Radcliffe discovered a passenger on one express flight who was well-dressed and well-spoken, but he also noticed a blaring red flag — needle or “track” marks on the passenger’s hands. It is the type of patient he maintains would have been screened out at HOPE as an addict and offered help or detected as a seller and prosecuted to the fullest extent of the law.
Radcliffe’s practice accepts cash and, while receiving patients by physician referral, also accepts those who choose to self-refer. Therein lies the rub that makes opponents’ hair stand on end. Is there room for fee-for-service transactions where controlled substances are concerned? The accusations are unsettling to him — products, he says, of oversimplified judging of a complex, multi-faceted problem.
“I don’t have insurance myself,” he reveals, explaining that while the clinic is undergoing the appropriate accreditation for insurance reimbursement, HOPE will always accept cash.
Regarding the ability to refer oneself, Radcliffe states in an e-mailed response: “Please note that although we get many physician referrals, we don’t require patients to get a physician referral in order to get an appointment with HOPE Clinic, but they must present diagnostic tests such as MRIs, CT Scans, X-rays and/or other lab tests that help document the evidence for the cause and severity of their chronic pain.”
The first full month of December, HOPE could hardly keep up with patient traffic, according to Radcliffe. One January day in particular, he saw exactly no law-abiding patients and was exasperated but undaunted by the number of drug-seekers he’d turned away.
The HOPE team identifies patients with substance abuse issues and cooperates with FMRS Health Systems to assist such abusers. FMRS officials confirmed, as of the end of December, that one patient identified as having a substance abuse problem was referred from HOPE into its recovery program, with another patient on the way.
For those who sell and whose drugs end up in local communities and schools, Radcliffe expresses zero tolerance.
“These druggies are causing horrible problems among legitimate patients. We will be a network of support for law-abiding patients, but a spider web of entanglement for criminals.”
— E-mail: firstname.lastname@example.org