Abuse of legal narcotic painkillers is on the rise in Vermont, but clinicians often prescribe such drugs for chronic pain.
The Boston University School of Medicine held a training this past weekend in Burlington to provide Vermont's doctors with tools to make these difficult decisions.
Earlier this year, Gov. Peter Shumlin drew national attention by devoting his entire State of the State speech to Vermont's battle with opioid addiction.
While Shumlin referenced "a full blown heroin crisis," addiction to prescription drugs is just as prevalent.
The BU project is called SCOPE of Pain - that's Safe and Competent Opioid Prescribing Education.
The training provided doctors with the opportunity to ask questions and share experiences around prescribing opioids.
Dr. Daniel P. Alford, associate professor of medicine at BU, was the course director. He says he tells physicians to always assume a patient is telling the truth about their pain level.
"We should believe people when they say they have pain 100 percent of the time," said Alford. "There's no risk in doing that, but there is a risk if you don't believe someone who really does have pain."
That doesn't mean he will necessarily prescribe opioids. He says he looks at risk factors for addiction such as previous drug use, nicotine dependence, legal history and mental health background when making that decision.
He acknowledges plenty of patients with chronic pain have one or more of these risk factors, but the key is monitoring those patients closely.
"Make sure you talk to the patient about their risk. Then you monitor them a little more carefully because you're worried about that risk," said Alford.
Several clinicians had questions about drug disposal. In the past, patients who wished to get rid of excess prescription drugs safely had limited options.
Nancy Coffey is the Diversion Program Manager with the New England division of the Drug Enforcement Administration. She says the DEA has just come out with new regulations that will make disposal easier.
She says the rules are still in flux, but patients will have new avenues to return drugs, such as approved pharmacies and doctors offices. Coffey says the DEA is moving away from the traditional "drug take back days."
"DEA right now is stepping away from our twice a year take-back programs," said Coffey. "That may not be permanent, but we want to give these new regulations a chance to take hold and have people come up with their own systems to do it."
The DEA hopes that allowing patients more ways of drug disposal will help to avoid diversion, or using prescription drugs recreationally.
Sometimes that's a relative finding painkillers in a medicine cabinet, but also includes those who sell excess drugs, or engage in what's called "doctor shopping" in an attempt to obtain multiple prescriptions.
Opioid addiction can intersect with illegal activities, but there is some tension when it comes to the involvement of law enforcement.
Thomas Mozzer of the Vermont State Police's Drug Diversion unit says only 10 to 15 percent of reports come from prescribing physicians, and police would like to hear from clinicians more.
"It would be nice if they do have questions or concerns, that they at least call us," said Mozzer. "And we work together on what the solution is going to be."
But Dr. Alford says that while police and the medical community both want the same thing, it's rare that he comes across a case so extreme that he feels comfortable calling police.
"Thank goodness, as far as I know no state has mandated reporting," said Alford. "And that's good, because it really is the unusual case where you are so convinced that this person is dealing drugs with your prescription. Usually it's much less clear."
He encourages physicians with high risk patients to consider alternative treatments for chronic pain.