Friday, March 16, 2001

Doctor is tough on narcotic abuse

He monitors all patients' use of pain drugs such as OxyContin

By Kristina Goetz
The Cincinnati Enquirer

        In a state that has no current prescription tracking program, one Cincinnati physician is taking narcotics monitoring into his own hands.

        Dr. Neil Jobalia's strict monitoring of patients' pain medication goes well beyond national standards. Some authorities say it could be a model to help cut illegal use and abuse of OxyContin and other powerful painkillers starting at the physician's level.

        “Addicts are going to find a way to do what they're going to do whether OxyContin is out there or not,” says Dr. Jobalia, who treats 1,000 patients with chronic pain. “If they weren't abusing this, they'd abuse another drug.”

[photo] Dr. Neil Jobalia talks with patient Angela Schultz about her chronic back pain. She is treated with OxyContin.
(Brandi Stafford photo)
| ZOOM |
        The mindset and methods of physicians like Dr. Jobalia are catching the attention of law enforcement officials and other Greater Cincinnati doctors.

        Recent Tristate drug busts involving the illegal use of OxyContin, a time-release drug whose abuse has soared locally the past year, sparked a national debate over how to better catch and track prescription drug abusers.

        The 36-year-old Dr. Jobalia is among those who support initiating an Ohio tracking system like those in Kentucky and Indiana that monitor prescription use by patient, physician and pharmacy.

        While some Ohio lawmakers have expressed interest in creating such a system, no legislation has been introduced this session, and the logistics of how to run such a tracking program remain a question.

        Federal law enforcement officials learned in early February of an elaborate, illegal trafficking network crossing at least five states — including Ohio — that brings OxyContin in and out of Eastern Kentucky for illicit use.

        After so much attention on the illegal use of OxyContin, medical experts have started to worry about its availability.

        Some worry that patients may not take it, fearing addiction, and that physicians may prescribe less of it because of increased scrutiny. They're also concerned that pharmacies won't carry it for fear of increased robberies.

        Dr. Jobalia's program is an effort to protect his patients, himself, and, he says, the availability of the drug that is so crucial in treating patients with chronic pain.

How it works
        Dr. Jobalia, an anesthesiologist who specializes in pain management, has offices in Drake Center and Fort Hamilton Hospital. He implemented his monitoring program in 1999 when he began a solo practice.

        The program goes far beyond national standards set by both the American Pain Society and the American Academy of Pain Medicine.

        Dr. Jobalia treats all kinds of pain, both chronic and acute. He treats back pain for which there is no surgical option, post-surgical pain, chest pain, head pain, cancer pain.

        The monitoring begins during a patient's initial visit.

        Like some other pain management physicians in the Tristate, Dr. Jobalia requires patients to sign a medication contract and agree to fill all prescriptions at one pharmacy.

        But he requires all patients to take random drug tests, which start with the initial visit. Not all physicians test every patient.

        To further make sure patients are taking their medications correctly, Dr. Jobalia insists that they bring their pill bottles to every visit for pill counts.

        If another drug shows up in the patient's urine screen, or he misses two appointments in a row, he's out of Dr. Jobalia's program.

        If the patient violates any of the contract's provisions for any reason, he is dismissed, no questions, no excuses. Dr. Jobalia has dismissed 72 patients since April 2000 for contract violations.

        “You don't know what your patients are doing with your prescriptions,” the physician says. “This, at least, gives me some insight.”

        Beyond that, Dr. Jobalia has developed working relationships with law enforcement officials and pharmacists.

        In his contracts, patients agree that any deception used to obtain prescriptions can be reported to authorities.

        Agent Bob Mortimer of the Drug Abuse Resistance Task Force, which serves 16 Hamilton County communities, says cooperation of physicians like Dr. Jobalia is crucial.

National opiod monitoring standards:
    The American Academy of Pain Medicine and the American Pain Society agree that opioids — like OxyContin — are effective in treating chronic pain.
    Their standards for monitoring patients on the powerful drugs include a suggested medical agreement outlining conditions for usage. The agreement should include:
    • A signature of informed consent.
    • Patients using only one source to obtain all opioids/sedatives.
    • An explanation that the medication should be used according to the directions only. That includes no early refills under any circumstances.

Dr. Neil Jobalia's standards:
    Dr. Neil Jobalia, a Cincinnati pain management specialist, has a no-tolerance monitoring system that is tougher than most nationwide. Patients must sign a contract under which they agree to:
    • Obtain all controlled substance prescriptions from his Pain Treatment Center only.
    • Use only one pharmacy.
   • Take the medication only as directed.
    • Submit urine samples at any time directed, without prior notice. Tests that reveal any pain medications not prescribed by a Pain Treatment Center physician or illegal drugs will be dismissed.
    • Bring all medication to every visit for pill counts.
    • Keep scheduled appointments or possibly face dismissal.
    • Give 72 hours' notice for any medication refill. No refills are given at night, on weekends or on holidays.
        Since it popped up on the illicit market about a year ago, Tristate police have confiscated more than 13,000 doses of OxyContin. Last year, of 140 arrests by the Cincinnati Police Division's Pharmaceutical Diversion Squad for illegal possession or trafficking in pharmaceuticals, 32 were for OxyContin.

        “We make more arrests and better arrests” because of information from health-care specialists, Agent Mortimer says. “They're able to give us specifics that we might (otherwise) really have to dig to get. I think they're an absolute asset to any of our investigations.”

        Linda Berting, a registered nurse at the Pain Care Institute in Montgomery, said physicians there also have a good working relationship with police. The institute follows some of the same guidelines Dr. Jobalia does, including requiring patients to obtain medication from one physician and one pharmacy.

        “We are probably equally as tough,” she said. “We just go about it differently.”

Method catching on
        Dr. Jobalia's method seems to be catching on with doctors other than pain management specialists.

        Scott Slivka, an orthopedic surgeon in West Chester, treats many people with chronic pain. He plans to implement a similar system.

        “I was searching for some guidelines that tell patients up front what will and will not be tolerated,” Dr. Slivka says. “You want something that's upfront, that they've read and you know they understood.

        “I like the strictness of (Dr. Jobalia's) rules. I think you need that. It gives you something, as a physician, to stand on.”

        Dr. Michael Ashburn, president of the American Pain Society and a pain specialist at the University of Utah, says the illegal use and sale of OxyContin has brought the issue of prescription drug abuse to the forefront.

        Monitoring programs, he says, are very important. The pain center he runs uses one.

        “We are not quite as Draconian as (Dr. Jobalia), but there are more similarities than differences,” he says. “Appropriate measures must be taken for what God intended them (prescriptions) to be used for and not illicit use.”

What patients think
        Dr. Jobalia uses a multi-faceted approach to pain management that can include physical therapy and massage, as well as the use of painkillers.

        He learned about the use of long-acting pain medications like OxyContin while he was doing his residency in anesthesiology at the University of Cincinnati. But he didn't realize the importance of monitoring until he started his own practice.

        He knows that some patients may not like the rules he imposes, but all abide by them.

        Dr. Troy Jones, 27, of Dent , takes OxyContin for severe migraines. He sometimes gets three debilitating headaches a day. The drug, he says, allows him to work as a veterinarian.

        “I don't think it's intrusive,” Dr. Jones says of the policy. “Just like any drug out there, it has the potential for abuse.”

        Stephen Myers doesn't agree with Dr. Jobalia's tests, but has taken three of them. It's worth it, the 45-year-old Hamilton man says, to get the medication he needs to ease his chronic back pain. A degenerative condition has left him with disks that are wearing away.

        Both patients say OxyContin, though it doesn't take the pain completely away, gives them a level, consistent kind of relief that lasts for hours.

        “You want that smooth ride I'm talking about,” Mr. Myers says. “You don't want an hour of absolutely no pain and then seven hours of looking at the clock.'

        Dr. Jobalia ranks among the top 10 Ohio anesthesiologists who prescribe the most OxyContin. Purdue Pharma L.C., the Stamford, Conn., company that makes the drug, confirmed his ranking.

        The company refused to identify other top-prescribing physicians in the state or in Greater Cincinnati, saying revealing any such detailed information would be against company policy.

        Dr. Jobalia serves on the speak ing bureau of three pharmaceutical companies, including Purdue Pharma. He gave seven local lectures during 1999 and 2000 on the general topic of pain management — not specifically about OxyContin, Purdue Pharma officials say.

Why drug screening?
        Monitoring isn't about a lack of trust. It's about providing a rigid structure that those on prescription narcotics need and making sure the drug is not diverted.

        “I do trust my patients,” Dr. Jobalia says. “I give everybody the benefit of the doubt. (But) the bottom line is they need to be honest with me.”

        At first, Dr. Jobalia didn't perform drug screens on every patient consistently, but soon learned he couldn't tell for sure who was telling the truth. But drug screens don't lie.

        For example, a patient brought in an armful of documentation of the 30 surgeries she had had over her lifetime, filled out all the forms and swore she was taking one prescription from one physician.

        Only a drug test told the doctor she was lying.

        Dr. Jobalia has learned there are some patients who will never be able to follow the rules and that others are capable of manipulation. These people are not suitable for narcotic pain medication. But with the monitoring policy, he is able to focus on those who are.

Statewide systems
        In Kentucky and Indiana, physicians and law enforcement officials use statewide electronic systems to help stop illegal drug use. In Ohio, there is no such system, although there has been some interest in creating one.

        State Rep. Greg Jolivette, R-Hamilton, says the state could benefit from a system that allows physicians to check a patient's history before he is prescribed a drug. A statewide system could increase patients' quality of care.

        “I (also) think it has the potential of saving the state money, especially in the Medicaid cases,” says Rep. Jolivette, chairman of the House Health and Family Services committee.

        Until a statewide Ohio system is put in place, Dr. Jobalia will continue enforcing his own policy.

        “I'm sure there are people who slip through this, but not for long,” he says.

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