The Veterans Health Administration launched a campaign called "Pain is the fifth vital sign." The agency told its doctors to ask patients to describe their pain on a scale from 0 to 10. Later, the Joint Commission, which accredits health-care organizations, issued guidelines requiring hospitals and nursing homes to regularly measure patients' pain.
During the same period, pharmaceutical companies aggressively marketed opiate painkillers such as OxyContin.
In a typical 10-hour shift, Holmes sees about 25 patients. Between two and four are so-called "drug seekers." Some want anti-anxiety medications like Xanax. Most want opiate painkillers.
Many drug seekers say they're allergic to all non-narcotic painkillers, Holmes said. They ask for a specific drug, like Lortab or Vicodin. They exaggerate symptoms of pain. They relax on the bed, chatting on a cell phone, and then writhe when the nurse walks in.
Holmes can't measure his patients' pain with a thermometer or stethoscope.
When someone complains of excruciating abdominal pain, Holmes must rule out any possible emergencies, even if he suspects they're faking. He must order expensive tests. A CT scan costs $5,000. He and his patient could wait hours to get the results.
With doctors stretched thin, some doctors think writing prescriptions is the easy way out, Holmes and others say.
Dr. Carol Foster, a Charleston neurologist specializing in headaches, calls it "express lane" medicine. She practiced in Arizona for 25 years before she returned to her native West Virginia nearly two years ago. She was stunned by the state's prescription drug abuse problem.
"I was so excited about coming home. And within a month of coming home I thought, 'oh my lands, it's a war zone,'" said Foster, who works at Charleston Area Medical Center's Neurological Services. "I don't have any other words than a medical war zone."
She can't believe how many medications some patients take: Painkillers, anti-anxiety medications, sleeping pills, muscle relaxants.
"I can't imagine swallowing that many pills a day," she said.
Pain pills can make headaches worse, she said.
"Giving pain pills to headache patients is like giving Oreos to diabetics," she said. "They feel better for a few minutes and then they get sicker."
Foster works to determine the cause of her patients' headaches. She encourages behavioral changes, like eating a healthy diet and exercising.
"People are just medicating pain without figuring out why" they hurt, Foster said.
Foster works as an on-call neurologist for the emergency room at night. Like Holmes, she sees drug-seekers of all ages.
"The thing that breaks my heart is the grannies," she said.
Some live with grandchildren who abuse or sell their pills, she said.
Many hospitals survey patients and tie some doctors' salaries to "patient satisfaction scores," Holmes said.
"So if I don't prescribe a patient a medication that they want and they were the patient that gets the survey, " he explained, "they're going to say that I'm a terrible doctor, that we're a terrible hospital, that they didn't get good care."
Physicians need to learn more about the nature of addiction, said Dr. Louis Baxter, president of the American Society of Addiction Medicine.
"Pain pills do not cause addiction," Baxter said.
Research shows that many factors can increase risk for addiction, including genetics and a person's family environment.
Doctors who prescribe pain medications should pay more attention to patients' predisposition to addiction with substance-abuse screenings, Baxter said. "If physicians start to pay more attention to a person's susceptibility, then right there you can begin to be more careful about to whom you are writing prescriptions."
Drug monitoring program could do more
Both doctors and police in West Virginia say that certain policies have helped cut down on "doctor shopping," where patients visit multiple providers for prescriptions.
The state Board of Pharmacy runs a database where doctors can check where their patients have been filling prescriptions. The system has limitations:
* Doctors don't have to check it before writing prescriptions. About 81 percent of doctors surveyed say they do, but only 18 percent do it every time they write a prescription, according to an article Moss co-authored last year for the West Virginia Medical Journal.
* The system isn't linked to surrounding states' databases, though there is talk of doing so.
* By law, police and the state medical and pharmacy boards can only access data during an open investigation. A new report from the state Legislative Auditor's office recommends that lawmakers change this so that investigators can "red flag" unusual prescription practices and potential doctor shopping.
"People who are bent on abusing drugs are very clever, and as hard as we try, they're going to always find a way to get around the system," said Moss, who is a kidney doctor and palliative care specialist.
He remembers one patient who came in complaining of kidney stones. "She had blood in her urine. I gave her a prescription."
A nurse noticed that the woman didn't have a Band-aid on her finger before she slipped into the restroom for her urine sample. When she emerged, she did.
She had cut her finger to let it bleed it into the cup.
"Somewhere along the line, she learned what she should do," Moss said. "She fooled me."
Coming Sunday in the Gazette-Mail: Why are pill mills so hard to shut down?
Reach Alison Knezevich at alis...@wvvgazette.com or 304-348-1240.
This series was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of the USC Annenberg School for Communication & Journalism.