It left him unable to sleep, put him in tears because he couldn’t play with his daughter and led him to “cave in” on himself. Treatment that included narcotics restored his quality of life, he said.
Jason White’s unrelenting pain radiating through his left side made him contemplate suicide.
Taking opioids helped him manage the pain, he said, and he’s now attending school.
Lisa Rasmussen’s shooting pain and joint aches left her unable to work, sleep or perform household tasks.
Taking Oxycontin and oxycodone eased her fibromyalgia symptoms, allowing her to get out of bed in the morning, she said.
“I wouldn’t be able to go shopping with my daughter. I wouldn’t be able to do anything,” she said. “It’s the quality of life that it gives you.”
Although all three patients credit heavy doses of narcotic painkillers for restoring the quality of their lives, they and others interviewed by the Gazette said they’ve had a hard time finding a doctor who will treat them or continue their prescriptions after Mercy Health System fired the doctor they had been seeing.
Paul Mannino, a family physician who worked at Mercy East Clinic in Janesville, was fired April 7 because he breached his physician agreement “by repeated violations of appropriate prescribing standards after numerous discussions and restrictions designed to conform your prescribing practices to accepted medical standards,” according to his termination letter.
Mannino contends that Mercy “basically doesn’t want physicians to utilize opioids in the management of our chronic pain.”
In a time when abuse of prescription painkillers is on the rise, the use of narcotics for pain management raises serious questions about the risks of addiction or the diversion of prescription drugs to recreational use.
Some doctors say their colleagues won’t prescribe opioids, fearing action by the federal Drug Enforcement Administration.
Mannino questions how hospital or clinic policies can trump a doctor’s ability to prescribe what he feels is necessary for patients. The fear of prescribing narcotics also could lead to the under treatment of pain.
Opioids are among the oldest and most effective analgesics, or painkillers. They include oxycodone, codeine, hydrocodone, morphine, methadone, tramadol and fentanyl. While they are the drugs of choice for cancer pain, controversy remains over their use for non-cancer patients, doctors say.
Although effective, opioids can be addictive and often are abused.
The oxycodone overdose death of a 13-year-old Milton Township boy in February made headlines around southern Wisconsin.
But area pain patients say they are the faces of responsible opioid use for the treatment of chronic pain. They say opioids have restored the quality of life they lost when other treatments didn’t ease their suffering.
“We’re just trying to raise more awareness. These patients traditionally have been shunned, minimized,” Mannino said. “I think they deserve respect and compassion.”
Mercy officials declined to discuss Mannino’s firing.
Gregory Love, an anesthesiologist and pain management physician at Mercy’s Pain Center, said he could not discuss Mercy’s prescribing policies for chronic pain patients.
“What I can say in principle is we make every effort to get a proper diagnosis, to prescribe enough medication to do the job to improve the quality of life and improving the goal of pain (relief) without undue risk of abuse or addiction, and then we monitor the patient to make sure that continues to be true,” Love said.
Some of Mannino’s patients told the Gazette they are having a hard time finding new doctors and continuing their prescriptions. They have been meeting—forming a sort of support group—in their efforts to continue their care.
Opie, 41, had his first episode of sciatica—pain that radiates along the path of the sciatic nerve—in 2003. He needed pain medication just to function, he said. He didn’t receive lasting relief from cortisone injections or acupuncture and admits he tried “other avenues that insurance doesn’t cover.”
Under Mannino, Opie’s prescriptions included Oxycontin, Percocet, generic Valium, amitriptyline, trazadone and Zoloft, and his doses increased as his tolerance grew over the years, he said.
He said he has not had a high from medication in years.
“The only thing it’s done is hit the pain and allow me to function,” he said.
An independent medical exam that his former employer requested found no signs of abuse or misuse of any of the drugs and indicated that he was functioning with relief, he said.
When he called to schedule an appointment to get a refill after Mannino was fired, Opie said Mercy told him he would have to go outside Mercy’s system. He said he was cut off from his prescriptions, including the generic Valium that other doctors told him could cause seizures or death if the dosage is not gradually reduced.
Love said he could not comment on individual patients because of privacy laws, but he said Mercy has a triage process to properly take care of Mannino’s patients. He said he has never cut off a patient from medication when there are signs of dependence.
Mannino has filed a complaint with the state Department of Workforce Development claiming Mercy discriminated against him because he has bi-polar disorder and is retaliating against him for a previous suit. He said his peers didn’t face the same scrutiny, and when he tried to phase out pain management from his practice, Mercy wouldn’t allow him to do so.
“There was no way out for me,” he wrote in his complaint.
Mercy Vice President Barb Bortner declined to comment on anything related to Mannino because she said it is a personnel issue. But Mercy officials’ explanation of why they fired Mannino, according to their written response to his complaint, describes Mannino as a doctor who over-prescribed and didn’t consistently follow the system’s prescribing guidelines.
Mannino provided a copy of Mercy’s response to his complaint. He disputes Mercy’s allegations, saying none of the complaints has been substantiated.
Mercy’s response document indicates patient complaints about Mannino’s prescribing practices began to surface in 2003. The document outlines at least three cases in which a family member of one of Mannino’s patients contacted Mercy with concerns about the high doses of medication prescribed.
In one case, a father of a patient requested his son be put into detox because he said Mannino over-prescribed Oxycontin. In another case in January, a family member of a patient reported the patient received up to 300 pills a month and was in a comatose state every day.
In response to what Mercy saw as a “troubling pattern of over-prescribing medication,” Mercy set up specific procedures for Mannino, but Mercy said the doctor’s “disturbing behavior” didn’t stop.
Mannino said except for discussions in January, Mercy never brought to his attention the patient complaints from prior years.
Mannino served a two-week paid suspension in 2006 after he said three copies of prescriptions he wrote didn’t copy through the carbon to make duplicate copys and because he paid a patient in the parking lot for fixing his sister’s computer and gave a bag of sample insulin to the patient, who had no insurance.
According to Mercy’s documentation, Mannino was observed taking medications from the “shot room” and giving them to the man in the parking lot in exchange for electronic equipment.
Mannino said opioids aren’t the only option to treat pain, and he prescribed opioids often after other treatments failed to improve patients’ pain.
“They can say what they want about the use of opioids and pain management, but the documentation is right here, and it’s completely valid,” he said, referencing a folder full of medical journals. “The correct dose of opioids is the one that provides the patient help without causing significant side effects.”
Patients said Mannino was the only doctor they had who took the time—often an hour per appointment—to listen to them.
“He’s the only doctor that has given me any help so that I can function for the last seven to eight years,” Opie said.
Mannino started at Mercy 12 years ago and began seeing pain patients in about 2002, Mannino said. His own interest in chronic pain led him to get additional training and take on such patients. Between 60 and 70 of his hundreds of patients were chronic pain patients, he said.
Many of the chronic pain patients he treated were considered high maintenance, he said. Many of them had multiple ailments.
“I tended to get the patients that other doctors didn’t want, so I had some difficult patients,” he said. “I was taking the worst of the worst. Those people sometimes required large doses of opioids.”
Mannino contends he was never trying to get people high but only trying to get patients back near where they were before pain. Opioids should be used with other treatments, he said.
“The problem is by the time I see a patient, they’ve already done everything but the opioids, and they’re frustrated, and they don’t want to do any of that other stuff,” he said.
Mannino gave the Gazette a copy of Mercy’s guidelines for prescribing controlled substances for non-malignant chronic pain. The guidelines indicate daily doses in excess of 200 milligrams per day of morphine or equivalent are to be avoided.
Opioids have no ceiling doses, Mannino said, and some of his patients were on about 1,500 milligrams per day of morphine or equivalent.
“I felt if that’s what the patient needed, then it should be fine,” he said.
“This is an extreme case of where administration is setting policy in violation of patient’s rights to access care,” he said.
Love said patients might not know all the implications of taking high doses of pain medication.
One of the issues patients don’t understand, Love said, is the concept of opioid-induced hyperalgesia, which is an increased sensitivity to pain associated with the long-term use of opioids. Doctors still are trying to understand the phenomenon, Love said, but patients are at risk for hyperalgesia when they take more than 200 milligrams per day equivalent to morphine, he said.
The more medicine patients receive, the less it works, resulting in “dramatic and frightening” escalations in pain medicine with no real sedation or pain reduction, he said.
Half of all pain is subjective—no lab tests can show the pain, Love said.
“That’s why we get back to trust and verify,” he said.
Many patients don’t need much more than 60 milligrams per day, said June Dahl, director of the Wisconsin Pain Initiative, Alliance of State Pain Initiatives and a professor at UW-Madison’s School of Medicine and Public Health.
While some people need much more, she said when she finds “pretty hefty doses,” sometimes the patient hasn’t been well evaluated.
“I think sometimes if someone is a very good-hearted physician who doesn’t want to see people hurt, I think sometimes it’s easier to write a prescription than to do all the other things,” she said. “Chronic pain patients are often very needy, and the reimbursement isn’t there.”
The patient needs to be part of the treatment plan, she said, so the physician is aware of depression or anxiety problems and the patient’s lifestyle.
Opioids are not just a drug of last resort for pain; for many, they are the best drugs, said Jim Cleary, director of the palliative care program at University Hospital in Madison.
But prescribing narcotics clearly poses the risk of misuse. It’s a balance issue, he said.
When new drugs are approved, representatives of disease-related groups question why the drugs are only for cancer patients, he said. They wonder why the opioids can’t be used for others with significant pain, he said.
One of the problems is there’s no data as to how common prescription drugs are diverted to recreational use, he said.
Will Taylor, a federal Drug Enforcement Administration spokesman, confirmed there are no statistics to say how often prescription drugs are diverted, but he noted that prescription drug abuse causes more overdose deaths than heroin and cocaine combined.
A level of trust has to exist between the physician and patient, Cleary said.
“I often say to people, ‘Tell the truth; this is about trust,’” he said.
Doctors reduce the risk of diversion by having patients sign agreements saying they will use their drugs as prescribed, scheduling more frequent appointments, using random urine testing and doing a complete screening on patients, including their histories of drug use and addiction.
Local patients interviewed by the Gazette say they are not addicted but have become physically dependent on their prescriptions.
Some studies indicate that addiction is a result for 2 to 20 percent of patients, Cleary said.
Love said worldwide addiction literature shows patient addiction rates of between 12 and 14 percent.
Addiction is a disease characterized in part by craving for the mediation and seeking the drug despite the harm it does to the person, Dahl said.
If they’re taking a drug and not doing anything with their lives, then the drug is doing them harm, she said.
When assessing the effect of a drug, physicians need to look not only at what it does to the pain but what it does to the patient’s ability to function, she said. Is the patient getting back to work? Is the person getting tasks done around the house? Can the person interact with family and friends?
“Sometimes I’ve encountered folks who aren’t having any problems with the drug, then find they aren’t doing anything—(they’re) laying on the couch all day,” she said. “They may have pain relief, but the drug is just stopping them from doing anything meaningful with their lives. That’s not good pain management.”
“It gets kind of tricky in terms of are those people addicts? (It’s) a fine line.”
Even so, documentation shows that pain of all kinds still is inadequately treated, Dahl said.
“One of the issues that seems to be very up front is that pain does not seem to be adequately assessed,” she said.
Studies show patient pain may be well controlled in the hospital after surgery, but patients are in pain when they go home because there’s no continuity of care, she said.
Cleary said some doctors fear prescribing opioids because they believe the federal Drug Enforcement Administration is watching them.
A survey of Wisconsin physicians that assessed their knowledge and attitudes toward opioid analgesic use found most physicians thought it lawful and acceptable medical practice to prescribe opioids for chronic cancer pain. But only half held that view if the pain was not related to cancer, according to the study published in the Journal of Pain in 2006.
About two-thirds of the about 222 respondents were not concerned about being investigated for their opioid prescribing practices, but some admitted that fear of investigation led them to lower the dose prescribed, limit the number of refills or prescribe a lesser-controlled opioid.
The physicians held many misconceptions about prescribing opioids, the survey found.
“Such views, coupled with a lack of knowledge about laws and regulations governing the prescribing of controlled substances, may result in inadequate prescribing of opioids with resultant inadequate management of pain,” according to the study.
Cleary acknowledged the stories of some physicians who have poor professional practice that results in criminal charges.
According to the Drug Enforcement Administration, less than 0.01 percent of physicians in the United States lose their controlled substance registrations based on a Drug Enforcement Administration investigation of improper prescribing.
When appropriate medical doses are used and patients are seen regularly, the risk of diversion can be reduced, Cleary said. For example, he has a number of patients for whom he writes weekly prescriptions.
Demetra Ashley is the diversion program manager for the Drug Enforcement Administration’s Chicago field office. Her program has diversion investigators in five states, but if something comes to their attention, it’s “generally particularly egregious.”
Physicians shouldn’t fear investigators, Ashley said.
“I know physicians want to be very careful, want to operate within federal and state laws, but … I don’t feel there should be a fear for a physician to prescribe to their patient for a legitimate need,” she said.
Dahl said it’s much more than the fear of federal drug officials.
“I think there’s just a lot of lack of knowledge because we just don’t do a very effective job of teaching people,” she said.
“Often they (physicians) really haven’t had the education to know exactly what to do.”
Dahl and her colleagues have been developing curriculum on pain management for medical residents.
“I think a big factor is a lot of responsibility falls on the family physician. The data I have say these people have seven to 10 minutes with each patient,” she said. “That’s not enough time to work on a chronic pain problem.”
Finding family physicians who will even treat pain patients can be a challenge, Mannino’s former patients say.
Rasmussen, the fibromyalgia patient, has struggled to find a new doctor. Mercy gave her a list of three doctors who were accepting new patients, but the first doctor she saw told her he wasn’t comfortable treating her because she was on opioids.
She has found another family doctor through family members.
Opie, the patient who is now off opioids, has since received injection treatments in Madison. But when those didn’t work, he said he was told the clinic could do nothing else for him. He’s been seeing a new family physician in Beloit—outside of the Mercy system—who has talked with Opie about referring him to a pain clinic in Milwaukee.
Opie believes that might be his last resort, he said, so he’s still trying to find a doctor in the area who will treat him in case Milwaukee turns him down.
“Now it almost seems like I’m doctor shopping,” he admitted. “That’s not the case.”
He thinks doctors may fear putting him back on narcotics because he has been off of them.
“I will always say it’s (opioids) the one and only thing that I’ve been through that has managed my pain,” he said.
Mercy’s Pain Center in Janesville is an outpatient, referral-only treatment center that sees 500 to 600 patients a month, said Gregory Love, an anesthesiologist and pain management physician at the pain center. When a patient is referred, the center starts with an intake process, which verifies and reviews the patient’s type of pain, he said.
Then a treatment plan is developed, and it is frequently multimodal, he said.
“No one modality takes precedence over others,” he said. “Yes, we use controlled substances. We use them in amounts that are generally believed to be appropriate or reasonable for a particular condition.”
Treatments also include interventional care, injection therapy, procedures to reduce the need for depending on narcotics only or when everything else has failed, acupuncture and chiropractics, he said.
Love also pointed to new technology that allows a pump to dribble pain medication into the spine 24 hours a day. The pump reduces drowsiness, tolerance and addiction potential and reduces costs after two years when the equipment—at $8,000 to $10,000—breaks even, he said.