Doctors struggle with concerns over painkillers

When Myrtle Beach doctors were sentenced in 2004 for improperly prescribing narcotic painkillers, Dr. John Nicholson pasted the news article to his then-Rock Hill exam-room wall.

Nicholson, now an attending physician in physical medicine and rehabilitation at Roper Rehabilitation Hospital, said when patients asked him why he wouldn't prescribe the opiates they requested, he pointed to the story.

"I really like you, but I'm not going to do 24 years in prison for you," Nicholson told his patients.

Myrtle Beach staff at the Comprehensive Care and Pain Management Center received federal charges after police, pharmacists and doctors raised alarm over the amount of drugs such as OxyContin prescribed at the center.

Changes in pain-management philosophy have led to an increase in the amount of pain medication sold nationally since the mid-1990s.

However, local doctors specializing in pain management see a growing number of patients whose primary care doctors won't prescribe any painkiller considered a Schedule II drug. (Schedule II drugs are controlled substances with acceptable medical uses, yet have a high potential for abuse and are illegal to possess without a prescription.)

Doctors may not prescribe these painkillers fearing scrutiny from the Drug Enforcement Administration and the Department of Health and Environmental Control or because federal regulations require clinicians to police their patients.

At Roper, Nicholson tries to discover the source of the pain and squelch it. Sometimes painkillers considered Schedule II controlled substances are prescribed.

"It is a last resort," Nicholson said, "and it requires a stringent agreement between patient and physician as far as how those medications will be used."

Cathy Therrell, director of Roper Rehabilitation Hospital, said that when she became a nurse in 1978, doctors prescribed a minimal amount of pain medication because they feared the potential for addiction.

"The philosophy now is to try to let patients have what they need," Therrell said.

In a short-term illness, pain medications may help patients participate in their rehabilitation. The high-powered medicines also are doled out to people who suffer chronic pain.

Today, doctors realize that just a small portion of patients become addicted to such drugs. Some patients might misuse the pills and that's where doctors can get into trouble.

When Dr. Marc Dubick, of Roper St. Francis' Pain Management Center, prescribes potentially habit-forming medications, his patients are warned to care for their prescriptions.

"If someone loses it or it gets stolen, they are out of luck," Dubick said. "People who really need it to function don't lose it."

Refusing to rewrite prescriptions is part of how Dubick says he is responsible to himself and his patients.

"I'm definitely concerned with DHEC and the DEA looking over my shoulder," he said.

Every physician can write prescriptions for potent pain medications, but a lot choose not to, Dubick said. Several patients come in because their primary care doctor chooses not to write them.

"It puts a burden on patients and specialists who are trying to take care of these folks," he said.

As long as doctors document their reasons for writing such prescriptions, they shouldn't fear scrutiny, he said.

Since high-profile cases of imprisoned doctors have made news, Nicholson said, he has been no less careful in prescribing Schedule II medications, but he does make patients sign agreements saying they will use the medicines properly. Patients have to come in monthly for ongoing treatment because no refills are allowed.

The contracts and policing of the drugs' use through random drug testing and pill counting are required in prescribing the medications.

That's something that Dr. Jason Rosenberg would rather do without.

Rosenberg, medical director of Nextstep Pain Management at Waccamaw Community Hospital, in Murrells Inlet, focuses on spinal-cord stimulators and other procedures.

"I'd rather diagnose and treat the problem appropriately and avoid the medicines," he said.

Dr. Angus Baker, medical director for the Hospice of Charleston who prescribes pain medication for his dying patients, feels less a target than doctors who treat chronic pain.

"Chronic pain is a tough problem," Baker said. "And we all hope that the 10 percent who might misuse a drug won't keep the other 90 percent from getting the drugs they need or get doctors locked up."

Reach Jessica Johnson at 745-5860 or jjohnson@postand courier.com.