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Drug Abuse

Limiting Opioids for Patients with Chronic Pain

By Jen Jenkins

Pain is one of the main reasons people go see their doctor. Although it was once overlooked or often dismissed, it is now a standard vital sign in a patient’s work-up. However, unlike other tests administered in a medical setting, pain is difficult to measure because among other factors, pain tolerance is highly individual. The United States has had a long and complex history with chronic pain management. In the 1990s, doctors were reproached for under-treating pain and were told that opioids, including OxyContin, could not only bring unmitigated relief to patients but do so in a safe way. Today, doctors are again being admonished but for a very different reason. Politicians and policy makers continue to publicly denounce what has been labeled as the “opioid crisis,” due in part to doctors over-prescribing medication, namely opioids.

A growing number of states are enacting measures to limit prescription opioids and the federal government has issued the first national guidelines to help reduce the use of these highly addictive medicines. Dr. Robert L. Wergin, chairman of the board of the American Academy of Family Physicians, said he doesn’t want to stop prescribing opioids altogether but that he can see why some doctors have gotten to that point. Dr. Wergin has taken professional and personal risks in prescribing opioids. Closely monitored by state and federal officials, he must go through an elaborate prescription checklist. He has also been threatened by addicts, desperate for pills. His patients now sign “pain management contracts” and must agree to random drug tests before receiving an opioid prescription. “You don’t want to become so jaded that you assume everyone in the E.R. is a drug-seeker,” Dr. Wergin said, but he has seen firsthand a growing number of overdoses and opioid-related deaths during his emergency room shifts.

Collectively, primary care physicians write the greatest volume of opioid prescriptions and these same doctors are now scrambling to find alternatives for their patients dealing with chronic pain. Prosecutors and medical review boards closely scrutinize physicians who prescribe controlled substances. Many medical associations now offer doctors training about chronic pain, urging the use of other remedies such as physical therapy, acupuncture, anti-inflammatories, antidepressants, or counseling before prescribing opioids. Unfortunately, alternatives are unrealistic for some patients for a variety of reasons: physical therapy may be too expensive; anti-inflammatories cannot be taken by those with a compromised liver.

Some state medical boards have recommended limiting the number of opioid doses per month while others have recommended limiting the strength of daily dose. Dr. Wergin is careful not to promise patients a prognosis of being “pain-free” and chooses instead to talk with them about setting realistic goals to manage their pain. Although opioids help to alleviate severe pain, they are highly addictive. The epidemic of overdoses and death is real and the responsibility of monitoring patients for potential abuse falls largely on prescribing doctors.

Take a moment to read the following New York Times article and learn more about Dr. Wergin and what he is doing for his patients.

Dangerous Risks of Using Opioids to Treat Pain

by Angela Sams

Have you ever been prescribed a painkiller to help with surgery recovery or maybe for back pain that just won’t go away? Even if not, it is likely that you know someone who has been on a painkiller medication at some time or another. That likelihood rose steadily between 1999 and 2010, as doctors began turning to a “quick fix” that will treat their patients in an aggressive manner. But, as patients cooperatively swallow their prescribed pills, it is important to consider the downsides of opioids on an individual and societal level.

A recent opinion article in the New York Times indicates that while there has been a “steady increase in the mortality rate of middle-aged white Americans since 1999,” this is not the case in other age and ethnic groups, or even with people in the same age group who live in other countries. Consider this disturbing statistic: “In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.” It is clear that opioid overdose is quickly becoming an epidemic, and a major shift in attitude is a key to the problem.

At one time, opioids were used mainly for pain caused by terminal illnesses or as a short-term fix for pain after surgery. However, during the 1990s, drug companies began marketing to doctors, encouraging them to “be proactive with pain and treat it aggressively.” Afraid of being seen as uncaring or reprimanded for not treating a patient’s pain to the best of their abilities, doctors fell for the marketing scheme and began prescribing powerful opioids such as OxyContin.

Though opioids may relieve pain and help a patient recover more comfortably, evidence suggests that they should only be used for short-term treatment, not long-term treatment of nonmalignant pain.  There are also many downsides to taking such a medication. This type of painkiller is extremely addictive, may affect mental health, lead to unemployment, and cause poor health in general, to name a few risks. Ironically, using these drugs can also make a patient more sensitive to pain.

So what is the solution to this problem? Should people suffer in pain, rather than take the risks associated with opioid drugs? Actually, the answer may be as simple as taking an over-the-counter medication. In one study, researchers found that when Motrin and Tylenol were combined, they were actually more effective than opioids, not to mention safer. While opioids are still very readily available to patients who are in pain, small steps towards a solution have been taken. For example, the Food and Drug Administration issued a Risk Evaluation and Mitigation Strategy, ensuring that opioids now contain warning labels. The makers of these drugs must also give training and education that will help doctors prescribe them safely. Certainly, patient awareness is helpful, but only time will tell if physicians can turn this shift in attitude back around, and work towards other, safer solutions for pain management.

Beating Back Opioids – Now What?

WorkComp Central published a new report,“We’re Beating Back Opioids — Now What?” this past June, by Peter Rousmaniere in cooperation with CompPharma. It narrates a 20-year story and poses some provocative recommendations, noting that we are at a turning point in treating chronic pain though the statistics remain daunting. Every workday, some 5,000 workers sustain injuries which disable them for at least a week; on any given day in the U.S. 500,000 injured workers are treated for chronic pain. The majority of treatments includes opioids, and for individuals with chronic pain, care and wage replacement can reach $1,000,000 in cost per claim.

Per the study’s author: “This report does two things. First, it chronicles the two decade-long story of how opioid use greatly expanded in workers’ comp, then halted and began to retreat in the face of fierce criticism. Workers’ comp professionals can use this story to tell their friends about a war they still are fighting.”

Rousmanier also credits several organizations in the detection and reporting on trends and solutions. They include the California Workers’ Compensation Institute, CompPharma, the National Council for Compensation Insurance, Washington State, and the Workers’ Compensation Research Institute. Read more…

 

A Changing Landscape: America’s Opiate Epidemic

by Jen Jenkins, MCN Market Analyst

Many Americans have developed an expectation for something that on the surface appears harmless but in reality has proven rather dangerous: the quick fix. This expectation falls into a variety of categories but the dangers here tend to lurk around seemingly magical solutions that directly involve our health.

During the 1990’s there was a surge in pain medication being prescribed freely as an easy fix for chronic pain sufferers over the use of other types of rehabilitation. Prescribers were outspoken about their belief that these drugs were not addicting when used in these scenarios and pain medication was not only being freely prescribed but done so in enormous excess. Between 1999 and 2010 the US saw sales quadruple for opioids such as Percocet, Vicodin and OxyContin. These names probably sound familiar as they have readily become household names, yet we are only more recently being warned about the dangers of using these drugs.

On the other hand, heroin is widely known to be illegal and highly addictive. Fatal heroin overdoses in this country have almost tripled in the past three years, claiming the lives of more than 8,250 people per year. As horrifying as that is, it may not be all that surprising since the dangers of heroin are so well known.  In a shocking comparison, around double that number of people are dying every year from prescription opioid painkillers, which are molecularly similar to heroin. If that statistic is news to anyone it’s probably because overdoses due to prescription medications are far less scrutinized and rarely publicized. The victims of these overdoses are overwhelmingly white, financially well-off, and young; a very different demographic from what we have come to know in relation to other types of drug abuse.

This article in The New York Times provides a snapshot of the new heroin landscape and why it is more dangerous than ever before. Use of this addictive drug had been on decline since the 1980’s but was revitalized thanks to prescription opioid addicts who are more readily turning to heroin as a less expensive and more accessible alternative for a similar high. The article goes on to look at how this change of demographic has also brought about a new kind drug dealer, in particular highlighting the business practices of the group of traffickers dubbed “The Xalisco Boys.”

Although low-profile and anti-violent, The Xalisco Boys are drug dealers to fear because they are going after their customers instead of the old standby of waiting for customers to come to them. They also rely on marketing instead of perpetuating street crime and have devised a system resembling pizza delivery for selling heroin across the United States. Interestingly, they even keep business hours between 7am and 7pm to instill a “safe” sort of atmosphere along with reliable delivery and balloons of heroin that have been properly dosed out by weight and potency. Free samples given out at methadone clinics, discount pricing, and free hits delivered to customers showing signs of quitting are cited all examples of their entrepreneurial take on drug sales.

So what do we do in this ever-changing landscape?  Do we look for resolution on the street or in our clinics and hospitals? Especially now that “street crime is no longer the clearest barometer of our drug problem; corpses are.”

When Does a Behavior Become a Disease?

There are plenty of behaviors which are bad for one’s health. Smoking and not getting enough exercise are two things which quickly come to mind. Binge eating. But are these disorders, or is it that their consequences can lead to disorders?

Is it that we create diseases to fit the profitable (and dangerous) cures? If binging is a disease, then so is anything done to excess. Recently binge eating, officially recognized as its own disorder in 2013 by the American Psychiatric Association, has received attention for a media campaign promoting the amphetamine Vyvanse to treat it. Retired tennis player Monica Seles has been hired by pharmaceutical company Shire as a paid spokesperson, appearing on talk shows from “Good Morning America” to “The Dr. Oz Show” to share her personal struggle with binge eating. And to plug Vyvanse.

One prominent eating-disorder specialist said that although Vyvanse showed promise, other treatments, like talk therapy, had more research behind them. And the use of Vyvanse is worrisome, with its classification by the federal government as having a high potential for abuse. In fact for decades, amphetamines, which suppress the appetite, were widely abused as a treatment for obesity.

“Once a pharmaceutical company gets permission to advertise for it, it can often become quite widely prescribed, and even tend to be overprescribed, and that’s a worry,” said Dr. B. Timothy Walsh, professor of psychiatry at the New York State Psychiatric Institute at Columbia University.

American Addiction Centers Goes Public

In October American Addition Centers, which runs 8 facilities in 6 states, went public. Currently valued at about $588 million, the company’s stock price has almost doubled since its IPO, from $15 to $28. In 2013 its revenue was $116 million, up from $28 million in 2011.

AAC’s IPO underwriters estimate there are 8,100 substance-abuse treatment enterprises across America, operating 16,700 clinics and centers. The market is estimated to be worth $35 billion.

This month’s Bloomberg Business has an in-depth story on AAC, “Addiction Treatment Goes Public: AAC’s Recovery-Center Empire” and its founder Michael Cartwright  as well as a look into the history of treatment centers in the U.S.

New federal and state laws are improving addicts’ treatment options. In 2008, Congress passed the Mental Health Parity and Addiction Equity Act, which requires health plans to provide the same dollar limits for mental-health benefits as for medical and surgical benefits. This is a step in the right direction, as are the additional beds AAC and others have added: while almost 23 million Americans suffer from addiction, only about 4.1 million receive treatment each year, according to 2013 data from the U.S. Substance Abuse and Mental Health Services Administration. Read more…

Fewer People Taking Prescription Narcotics —but Abuse Remains a Problem, Study Suggests

Last week pharmacy benefits manager Express Scripts released a study of 6.8 million Americans who had at least one prescription for an opioid filled between 2009 and 2013. The findings? One piece of good news and a lot of red flags related to a medication that was involved in 16,000 overdoses in 2012 alone.

  • Nearly 60 % of patients taking the painkillers to treat long-term conditions were also being prescribed muscle relaxants or anti-anxiety drugs that could cause dangerous reactions.
  • Nearly one-third of patients were prescribed an opioid and a muscle relaxant in the same month, and around the same percentage were prescribed a muscle relaxant and an opioid at the same time.
  • About 8% of patients were taking all three types of drugs — a combination known as a “Houston cocktail,” which gives a heroinlike high — during the same period.
  • 27% were taking more than one opioid at a time, another hazardous combination.
  • Of the patients taking the mixtures, two-thirds were being prescribed the drugs by two or more doctors
  • Nearly 40% filled their prescriptions at more than one pharmacy.
  • Overall use of opioids had fallen, especially for people using them to treat short-term ailments.

“Not only are more people using these medications chronically, they are using them at higher doses than we would necessarily expect,” said Dr. Glen Stettin, a senior vice president at Express Scripts. “And they are using them in combinations for which there isn’t a lot of clinical justification.” Read more…

 

The Happiness Calculation for Smokers

How do you quantify happiness levels? The question has relates to a longstanding requirement — first codified under the Clinton administration — that every set of federal regulations with more than a $100 million effect on the economy needs an analysis to prevent the adoption of regulations with high costs and low benefits.

Now it is being applied to the government’s new tobacco regulations proposed this past April, specifically to a cost-benefit calculation which assumes that the benefits from reducing smoking — fewer early deaths and diseases of the lungs and heart — have to be discounted by 70 percent to offset the loss in pleasure that smokers suffer when they give up their habit.

Is this a problem? Well, yes, according to many, as the proposed regulations could water down the agency’s ability to regulate tobacco products. If the formula for assessing costs and benefits remains unchanged in the final version of the regulations, it could set a dangerous precedent that would constrain public-policy making for years to come.

“This is the single biggest obstacle facing the F.D.A. in executing the job Congress gave it,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, an advocacy group. “There’s no way the F.D.A. can do its job if this is applied.”

An F.D.A. spokeswoman, Jennifer Haliski, said that there was “still a great deal of uncertainty” surrounding the calculation, and that the agency was helping fund research to explore the issue. So far the Food and Drug Administration has received at least 69,000 public comments on the new regulations, some quite high profile. Earlier this month a group of economists, including one Nobel Prize winner, weighed in, asking that the calculation be changed before the ruling takes effect. Read more…

Opioid Deaths Drop in Florida as the State Cracks Down

Prior postings have decried deaths and abuse in prescribing of opiates. Florida was the poster child of abuse, with strip mall featuring “pain clinics” where patients from other states would fly into to receive bogus prescriptions.

The sheer number of prescriptions nationwide has helped drive abuse in the United States. In 2012, more than 259 million prescriptions for pain pills were dispensed, federal researchers said, enough for every American adult to get a bottle of them. For the past decade, more than 20,000 Americans have died each year from prescription pain pill overdose.

As this article and associated editorial demonstrate, change is possible. Florida and other states have made a good start in curbing abuse. Lives have been saved in the process. There is more to be done in curbing the misuse of opiates for chronic pain. Opioid painkillers are dangerously overprescribed, but Florida has shown how states can confront this problem.

Politicians’ Prescriptions for Marijuana Defy Doctors and Data

Brian L. Grant MD

This is a fascinating article on a number of levels. The comments by readers as well as the article are illuminating. I come to it as a person who came of age in the 70s, trained in psychiatry and reside in Washington State. I also have an interest in medical anthropology which among other issues looks at cross-cultural health care systems and beliefs. Finally, I have a strong interest in medical politics and economics which are major drivers of policy and practice in US Healthcare.

Washington State is one where medical marijuana (cannabis) is legal and recreational marijuana will be legal in July with a rigorous permitting and taxation system. In observing the medical marijuana “industry” and practice in Washington, what has been clear is that it is a parallel system whereby anyone can obtain a prescription for medical marijuana and that a tiny minority have the sorts of diagnoses such as glaucoma, terminal pain, cancer, and the like that were invoked to justify medical marijuana in the first place. Furthermore, given the wide array of symptoms that may be “helped” by medical marijuana, most of which are subjective, such as pain and anxiety – there is not a person reading this post who could not receive authorization if they so choose. The dispensaries that provide pot use nice euphemisms such as “medicine” to describe cannabis, and “donations” as what one pays to receive their medicine. Whether one can obtain marijuana while declining a donation is not clear.

So in my view, medical marijuana at least in principle, if not in practice, is by and large a sham. It makes liars out of decent people who want to get high, have a good time, harm nobody in most cases, and perhaps relieve some real symptoms. Similarly, it promotes disingenuous behavior on the part of practitioners who prescribe it, some of whom are true believers, but all of whom are paid good money to write a script often based upon one visit with someone they will never see again.

Therefore, with reasonable reservations and concerns, one should be pleased to see marijuana become legal for recreational use. Like alcohol, which was touted during prohibition as having medicinal value as a way to access whiskey and other drinks  and more, read here and here), marijuana as a medical substance has by and large been a back door to access by those who want to smoke it for its mood altering attributes.

There are many similarities between alcohol and marijuana. Both are substances that can alter one’s thinking and are psychoactive. Both can be sources of enjoyment and conviviality and both can and do cause harm. One is by and large legal and the other not and therein lies the problem. If we as a society wish to ban all substances and behaviors with potential for harm, the list would be long, not end with alcohol, and would certainly start with tobacco and include excessive caloric consumption and other quite legal and common substances. Unlike alcohol, or increasingly prescribed opiates, marijuana has little propensity for physical addiction and tolerance.

Relatively speaking, the end organ damage and aggressive behaviors that excess or chronic use of alcohol induce significantly outweigh the degree of harm seen in typical marijuana users. The numbers of those who use alcohol abusively with resulting damage to themselves or others is significant. Since marijuana use is generally defined as abuse per se, studies looking at actual damage from the use of marijuana need to focus on objective rather than regulatory criteria. Is marijuana harmless? Of course not. Dosages are imprecise as one smokes something with inconsistent intake and varying amounts of active THC. “Edibles” can be misused or accidentally fall into the hands of children. One can simply lack balance and overuse marijuana in lieu of more productive and useful activities, just as could happen with alcohol consumption. And the impact of smoking marijuana is of unknown concern as at least one study suggests that lung damage from typical use is not an issue.

Neither cannabis nor alcohol belong in the hands or mouths of children and make no mistake – increased access to either creates some collateral damage that non-use would avoid, just like opiates or the 70 MPH speed limit on the highways.

Interesting systemic questions include: What is the role of the health care system in deciding that it owns a portion of the human experience, or that something is a medical issue rather than a component of general life? What are the economics of the system and the impact of a substance like marijuana that can be easily grown and distributed outside of the pharmaceutical industry with no inherent barriers to entry other than access to sun or artificial light, soil, fertilizer, water and seed stock? Could there be an element of those in power wanting to maintain control of an income stream, resulting in criminalization, and restrictive regulations along with false or distorted claims of harm to control distribution and access?

Finally, what damage has flowed from criminality of cannabis? How many have died as a result of criminal and gang drug traffic? How many harmless individuals have been prosecuted and jailed for use or distribution of marijuana? How many of the judges, prosecutors, and jurors sitting in judgment on these defendants can with a straight face deny their own use of cannabis in their own lives at some point? What can we learn from countries like Holland where cannabis has long been legal?

We are about to embark on an experiment in Washington state, already started in Colorado, with legal recreational marijuana. The ultimate results remain to be seen. Whatever one’s personal views on legalization of cannabis, facts and data should inform both personal and government decisions on the policies and use of cannabis and other products. Unfortunately the subject is often polarized by advocates and opponents.