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Originally published on February 2, 2016
According to the Centers for Disease Control, drug overdose is now the most common cause of injury death in the United States. How can providers help to stem this deadly tide?
So let's get something straight. Opioids are valuable drugs. They provide pain relief to people who are suffering, some of them can reduce inflammation in people with autoimmune problems and, although they were not designed for the purpose (maybe), they can also provide psychological comfort to folks who are stressed out from pain or chronic conditions.
Unfortunately, abuse of these drugs has become a national epidemic. The Centers for Disease Control and Prevention (CDC) reported last year that 46 people in the United States die every day from an overdose of painkillers. In Illinois, where I live, prescription painkillers were linked to 206 of the 999 drug overdose deaths in 2012. The Kaiser Family Foundation reports that 56 percent of Americans' lives have been touched in some way by abuse of painkillers.
The problem is getting worse. Again, to use Illinois as an example, prescriptions for opioids rose 26 percent from 2008 to 2014. Nationally, in 2012, 259 million prescriptions for opioids were written — enough, as the CDC states, for every American adult to have a bottle of them.
It is, as it always is, an uneven plague. The CDC says that the worst problem is in the South, especially in Alabama, Tennessee and West Virginia. I know from other sources that there is a huge problem in Kentucky as well. The differences are striking: CDC data indicate that almost 22 times as many prescriptions for oxymorphone were written in Tennessee as in Minnesota. The lowest rate of prescriptions per person are in California, Hawaii, Minnesota, New Jersey and New York. The highest are the aforementioned states, plus Oklahoma.
There's another unsavory aspect to this: There is a direct line — you could even say a direct path — from opioid abuse to heroin use. Why? Because in many locations, heroin is a lot cheaper than pharmaceutical opioids, and you don't need a prescription.
Not that a prescription is hard to come by. I have written about rogue prescribers before, so I need not go over old ground, but there are physicians in this country who would write anyone a scrip for anything for $50. And they do.
But it's more complicated than that. The CDC also reports that 55 percent of all persons who abuse prescription painkillers get them from friends or relatives; only 17.3 percent obtained them through a physician's prescription. Others were stolen, purchased privately or obtained by other means.
Last year, speaking at a forum in West Virginia about this issue, President Barack Obama said, "It touches everybody — from celebrities to college students, to soccer moms, to inner city kids. White, black, Hispanic, young, old, rich, poor, urban, suburban, men and women. It can happen to a coal miner; it can happen to a construction worker; a cop who is taking a painkiller for a work-related injury. It could happen to the doctor who writes him the prescription."
And we all know about that.
Senate Committee on Health, Education, Labor, and Pensions (also known, charmingly, as the HELP Committee) held hearings addressing the issue. Congress is investigating whether it should give Medicare and private Medicare insurers the power to monitor for signs of painkiller overprescription and/or abuse.
This is not necessarily a witch hunt; as Cynthia Reilly, director of the Prescription Drug Abuse Project of the Pew Charitable Trusts, explains, many overdoses are accidental. "Oftentimes," she says, "prescribers don't know that their patients are visiting multiple prescribers. Patients may not know when a prescription is duplicative or addictive in a way that is potentially harmful."
I've been there. When I was a young college student, I contracted strep throat. One physician prescribed codeine and another one prescribed Benadryl. I have never been that out of it in my entire life. I didn't know what planet I was on.
Back to the federal front. The CDC has established several components for fighting the epidemic. The first is to enhance and maximize the impact of prescription drug monitoring programs, or PDMPs, which track prescribing patterns and often can identify rogue prescribers and detect doctor-shopping. The second is to improve community or health system intervention programs through use of everything from pharmacy benefit managers to implementation of prior authorization and guidelines. The third is to evaluate state laws and regulations to determine their effectiveness. The fourth is "rapid-response projects," which create fast action to address emerging crises or take advantage of new opportunities.
Furthermore, in 2012, the CDC began collecting data on prescriptions of controlled substances through the Prescription Behavior Surveillance System, largely on the basis of data from PDMPs. Although all the CDC can really do is report the information, at least it gives us some sense of where the worst problems are.
I would add that e-prescribing, because it provides a history of prescription practices and other footprints, is enormously useful.
As is true with most health policy issues, this one falls largely into the states' laps, and they are all over the map on the issue.
Although it is voluntary, every state has some kind of PDMP, but whether it has teeth depends on the state. Some are up and running and effective; others are sort of, well, there; and some are being created. There is a host of problems with these programs — the pharmaceutical companies are less than enchanted with them, the physicians don't want the hassle of checking the database before prescribing, there's expense involved, and there has been little evaluation of their effectiveness. Nonetheless, there is a psychological concept called the Hawthorne effect, which states that you behave differently if you think someone is watching you. Any port in a storm.
Some states have gone much further to stem the epidemic of addiction and death. New York state, with Attorney General Eric Schneiderman taking the lead, has made the drug naloxone, which counters the effects of opioid overdose, available to every law enforcement officer in the state. These police and other public safety officers are also being trained in how to administer the drug. So far, the program, known as the Community Overdose Program, has saved more than 100 lives. Schneiderman's office has also achieved much more transparency in the marketing of OxyContin, especially in terms of providers who may be prescribing it inappropriately. In addition, his office has jawboned pharmaceutical manufacturers into keeping the price of naloxone low. New York state also requires that all prescribers check the state PDMP before prescribing opioid painkillers. This has resulted in a 75 percent drop in patients who are seeing multiple physicians to obtain large amounts of these drugs.
A staff member in Schneiderman's office says the attorney general believes that "this is a public health issue that requires all providers to address the overprescribing of opioids. Any provider who handles patients who have pain must be aware of the various ways to treat pain and the limited evidence the CDC points out to support prescribing opioids on a long-term basis, especially given risks of addiction."
The state of Maryland also has been a leader in the field. Leana Wen, M.D., the Baltimore city health commissioner, told a Congressional hearing in December of last year that she has declared an opioid overdose public health emergency and has issued a standing order that pharmacists can provide naloxone without a prescription to any person trained in its use. As she told me in an interview, "From our standpoint, there are three pillars to saving lives: First, getting naloxone into the hands of everyone who has the opportunity to save a life, which includes not only first responders, but also friends and family. Second, providers must be judicious in prescribing opioids. Third, the public must be educated about opioid addiction."
The Baltimore City Health Department so far has trained more than 7,000 people in the use of naloxone, as Wen says, "In jails, public housing, bus shelters, street corners and markets." The department also has worked to prevent deaths from heroin laced with fentanyl, which killed 39 people in Baltimore in a three-month period last year. That happy product is apparently coming from China and is appearing in many urban areas.
There are those who say that it doesn't matter what happens to addicts. It matters to me; I spent years counseling Vietnam War veterans who came back with addictions. People end up in that situation for many reasons and I, for one, will not judge them. I just don't think addiction should be a death sentence. We spend a lot of time yammering about how all life is sacred; we should walk the walk.
This issue is starting to have legs, as it were, and many other states are initiating their own efforts. The North Carolina Harm Reduction Coalition is making naloxone, along with condoms and clean syringes, available to people who are at risk. There has been a 50 percent reduction in heroin overdose deaths as a result. Surrounding counties and neighboring states are starting to emulate this model.
The state of West Virginia has sued pharmaceutical drug distributors whom it says looked the other way when it came to high-volume purchasers and prescribers of opioids. Blue Cross Blue Shield of Massachusetts has launched a comprehensive opioid safety management program that includes prohibiting opioid purchases by mail, limits on the amount of drugs allowed per patient per day, and outlier reports on individual and group medical practices.
Florida has increased regulation of pain clinics — some of which are nothing more than pill mills — and has prevented physicians from dispensing painkillers from their offices. As of 2012, there has been a 50 percent decrease in overdose deaths from oxycodone in that state.
Tennessee requires all prescribers to check the PDMP database before writing a prescription for painkillers, and has seen a 36 percent drop in doctor-shopping. Colorado has developed a comprehensive plan that includes stronger surveillance of prescribing practices, public education, expanded access to naloxone and "increasing the voice of those who are affected by the epidemic," in the words of Robert Valuck, Ph.D., professor of clinical pharmacy at the University of Colorado, testifying before Congress in December.
So there's a lot being done, sometimes very creatively. But in the end, this problem begins with providers. Most prescription drugs are made available by the health care system, so it is our responsibility to see that they are used appropriately. Is that always possible? Of course not. Many rogue prescribers do not have hospital privileges and are, therefore, out of the reach of hospital or health system medical or nursing staffs. Some state and county medical and nursing societies are very serious about addressing the problem; others, not so much. Some state boards exercise excellent oversight; others don't.
We can't rely on other entities in this case. The buck stops with health care providers. The CDC offers this guidance:
Our health care system did not start this, although it has played a major role in it. But we can help to end it. Let's do so.
Copyright © 2016 by Emily Friedman.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. Her website is EmilyFriedman.com.
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