Archive for the ‘Prevention of Drug Addiction’ Category

Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

The Drug Czar Praises Project Lazarus

On Wednesday, August 22, the Drug Czar came to town.

Mr. Gil Kerlikowske, the director of the ONDCP (Office of National Drug Control Policy) gave the keynote speech at the Project Lazarus Symposium held in Wilkesboro, NC.

Being a drug czar isn’t as much fun as it sounds like it might be. It means Mr. Kerlikowske works hard helping to create the drug control strategy for the nation. His agency advises the president regarding drug-control issues, and sets the tone for the nation’s approach to drug addiction and treatment. For more information see my blog of April 20th, 2011. At the Project Lazarus Symposium in Wilkesboro, Mr. Kerlikowske gave the keynote speech and elaborated on these topics.

The Drug Czar came to Wilkesboro because of the impressive program Project Lazarus. Project Lazarus is a grass-root, non-profit organization established in 2008 in response to the very high rates of opioid overdose deaths in Wilkes County. That county had one of the highest drug overdose death rates in the entire nation, but over the last four years, those rates have dropped dramatically. For more data about these rates and about Project Lazarus, go to their website at:  http://projectlazarus.org

The ONDCP has placed more emphasis on prevention and treatment, acknowledging that law enforcement efforts alone won’t fix our nations’ problems. During his keynote address, Mr. Kerlikowske praised Project Lazarus and said it should be used as a model for communities in other states facing the same problem of overdose deaths.

Project Lazarus’ founder and CEO, Fred Brason, gave an overview of the components of the program and most recent data. Then Mr. Kerlikowske spoke for about twenty minutes, explaining the ONDCP’s vision for drug control policy. Then came a roundtable discussion where parties from various agencies and organizations explained their role with the project.

I was invited to the roundtable because I am the medical director at Mountain Health Solutions, an opioid treatment program in North Wilkesboro that prescribes both buprenorphine and methadone to treat patients with opioid addiction. This OTP is now owned by CRC Health, but was started by Dr. Elizabeth Stanton nearly three years ago, in response to the need for medication- assisted treatment in Wilkes County. At first, her program prescribed only buprenorphine, but later she saw the need for methadone for those patients for whom buprenorphine didn’t work.

I started working there relatively recently. I’ve been amazed at the number of patients presenting for treatment for pain pill addiction, nearly all of whom live in this relatively small community. At present we have more than three hundred and fifty patients enrolled in treatment.

As part of Project Lazarus, all of our patients receive a prescription for (free) naloxone kit to prevent opioid overdose deaths. I was invited to the Project Lazarus Symposium because in my blog on March 28th, 2012, I described how a patient of our OTP clinic saved a relative’s life by using one of the kits.

At the roundtable, I said a few words about the effectiveness of medication-assisted treatment using buprenorphine and methadone, and then made a few comments about the overdose death that was prevented with the naloxone kit.

Next, during the roundtable discussion, representatives from many different organizations and locations across North Carolina described the role Project Lazarus plays in their missions. Representatives from such disparate populations as the Cherokee Nation and the military at Ft. Bragg described how they used Project Lazarus’ programs to keep patients safer. Several epidemiologists gave information about the lowered overdose death rates in Wilkes County. A local doctor explained how doctors have revised their prescribing of opioids in the Emergency Department. We also heard from several people connected with the Harm Reduction Coalition, and from the county’s sheriff.

Representatives from state organizations such as the Governor’s Institute on Substance Abuse, the North Carolina Medical Board, the NC Department of Health and Human Services, and the NC Division of Public Health, Injury and Prevention all explained how they worked with Project Lazarus. For example, a portion of Project Lazarus’ activity has been to encourage physicians to sign up for – and use – our states’ prescription monitoring program.

We heard about the Chronic Pain Initiative, a program developed with the help of Project Lazarus, which helps educate physicians about the best practices of opioid prescribing. Initially meant for Medicaid patients, the Chronic Pain Initiative is now available to help all patients.

This initiative helps reduce overdose deaths by providing physicians with, among other things, a toolkit for healthcare providers. It gives them everything from evidence-based information about safe opioid prescribing to a form that can be filled out to gain access to the NC CSRS. It contains worksheets, flow sheets, and addiction screening tools. It contains everything a doctor could want to keep patients on opioids as safe as is possible, while still making opioids available for patients who need them.

I’ve blogged about this program in the past. I knew there was more to Project Lazarus than distribution of naloxone rescue kits, but I didn’t know the full extent of the Projects activities in the state. At Wednesday’s program, I was impressed as professionals from organizations across the state explained how Project Lazarus helps them prevent, intervene, and treat opioid addiction, and reduce overdose deaths.

I was inspired with the depth of knowledge and commitment of all of these people, and by their collaborative spirit. People in all strata of the community cared enough about overdose deaths that they were trying to fix the problem before more lives are lost. These groups were cooperating, which is essential. Both Gil Kerlikowske and Fred Brason took pains to emphasize the importance of working together and not against each other.

In other words, naloxone kits aren’t enough to fix the epidemic of opioid overdose drug deaths. Law enforcement can’t arrest our way out of this problem. Prescription monitoring programs aren’t enough to stop all drug diversion. It takes the sustained efforts of people different segments of the community, working together, to get results. No one intervention is enough. That was the bottom line message I got from the Project Lazarus Symposium and the Drug Czar.

Check Out CASA’s New Free Publication

If you’ve never browsed CASA’s website, you need to do so. CASA, which stands for Center on Addiction and Substance Abuse, at Columbia University, has helpful information about addiction and its treatment that you can download for free. They have information about how to reduce the risk of addiction in teens (“The Importance of Family Dinners” series), information about the cost and impact of untreated addiction on society ( “Shoveling Up”), in formation about substance abuse and the U.S. prison population (“Behind Bars” series), and the availability of drugs on the internet (the “You’ve got Drugs” series). All of these contain useful and thought-provoking data.

This summer, they published a masterpiece: “Addiction Medicine: Closing the Gap between Science and Practice.” I’ve read most of this book, and admire the clarity and call to action it presents. This publication outlines all aspects of what is wrong with addiction treatment in the U.S., and how to fix it.

Every politician should read it. Every parent should read it. Physicians and treatment center personnel should read it. Anyone who is concerned about the extent of addiction and its poor treatment in the U.S. should read it.

CASA describes their key findings of the drawbacks of the U.S. system – or non-system – of addiction treatment. This nation is doing many things wrong, to the detriment of people afflicted with addiction, their families and their communities. Our mistakes are based on ignorance, misperceptions, and prejudice. All of these impede our ability to help our people with addiction. The CASA report clearly describes these factors, saying they all contributed to our present situation. We have declared a war on people who use drugs, not on drugs.

The CASA report describes how public opinion about addiction isn’t based on science. We now have science that proves addiction is a brain disease. We know that continued use of addicting substances alters the structure and function of the brain, affecting judgment and behavior about the continued use of drugs even when bad consequences occur. We know that at least half of the risk for developing addiction is determined by one’s genetic makeup. Yet surveys show that about a third of U.S. citizens still feel addiction is due to lack of willpower and self-control. Why are public attitudes so disconnected from science?

Addiction is a complicated diagnosis, existing as it does at the end of the continuum from occasional drug use to regular use to compulsive use. People often compare a drug user with a drug addict. They say that since the drug user was able to stop when he wanted that the drug addict should be able to stop when he wanted. This compares apples to oranges. If someone can comfortably stop using drugs when given a good enough reason to do so, this person isn’t an addict. They may be a drug abuser, a problem user, and at high risk for addiction, but they haven’t crossed the line into uncontrollable use.

The CASA report illuminates what addiction medicine physicians have been saying for years: addiction treatment and prevention isn’t treated by physicians and health professionals. Most addiction treatment is provided by counselors who, for the most part, aren’t required to have any medical training. Only six states require a bachelor’s degree to become an addiction counselor, and only one (Alabama, go figure) requires a master’s degree.

Even when physicians are involved in the treatment of addiction, most of us have very little, if any, training in medical school or residencies about addiction prevention or treatment. Ironically, most of our training focuses on treating the consequences of addiction.

In medical school and residency, I spent countless hours learning about the proper treatment of cirrhosis, gastritis, anemia, pancreatitis, dementia, and peripheral neuropathy from alcohol addiction. I had little if any training about how to treat alcohol addiction, and none about how to prevent it.

We know brief interventions by physicians during office visits can reduce problem drinking and are an effective way to prevent problems before they occur. Yet few physicians are trained to do this brief intervention. Even if they are trained, primary care physicians and physician extenders are being asked to do more and more at each visit with patients, and asked to do it with less and less time. Often, primary care providers aren’t paid to do brief interventions, and an opportunity for prevention is lost. Yet that same patient may consume hundreds of thousands of healthcare dollars during only one hospital admission for the consequences of with alcohol addiction.

When I practiced in primary care, I often thought about how I never got to the root of the problem. I felt like I was slapping Band-Aids on gaping wounds. I would – literally – give patients with addiction strikingly absurd advice. “Please stop injecting heroin. You got that heart valve infection from injecting heroin and you need to quit.” I could see it was ineffective, but I didn’t know any better way at the time. I thought if there was a better way to treat patients, I’d have learned about it in my training.

Wrong. Instead, I learned about this vast body of scientific literature about addiction treatment by accident, when I worked at an addiction treatment center for a few days, covering for a doctor friend of mine.

In coming blogs, I’ll outline more of the points made by this timely publication. In the meantime, read it for yourself at  http://www.casacolumbia.org

Information from the ASAM Conference: the CDC

At the recent ASAM conference, Dr. Ileana Arias, Deputy Director for the Centers for Disease Control and Prevention, spoke at a plenary session, explaining the public health impact of our epidemic of prescription drug abuse and addiction. She did a great job explaining how bad the problem of opioid addiction has become in the U.S. She also had some great slides. The above slide shows how by 2008, poisonings overtook motor vehicle accidents as the number one cause of death in the U.S. Overwhelmingly, the poisonings were drugs, and the vast majority of these drug overdose deaths involved opioids. Dr. Arias explained the ice berg phenomenon, where for each person who dies from opioid overdose death, an estimated 118 are estimated to meet the diagnosis for opioid abuse and dependency. She presented information showing that the amount of prescription opioids sold quadrupled between 1999 and 2010.

Dr. Arias spoke at our conference to encourage us and to let us know the CDC was committed to help solve our nation’s prescription opioid addiction problem.

She outlined some of the measures the CDC is taking to help prevent opioid addiction and overdose deaths.  She explained the new lock-in programs now being used by some insurance companies, where the patient can have only one doctor and one pharmacy to prescribe and fill medications. The CDC is advocating for all states to have prescription monitoring programs, and for those state programs to be linked, so that a doctor can access medications filled in other states.

Dr. Arias mentioned the progress being made in Florida, where pill mills are being shut down. Unfortunately, some pill mills have moved to other states like Georgia, Texas, Louisiana, Ohio, and – my favorote state to criticize – Tennessee.

She also spoke of the success of medication take-back days, where people drop off old medication for appropriate disposal so that it doesn’t fall into the wrong hands, and she described many other actions the CDC has started.

This was all great information, familiar to those of us treating opioid addiction over the past five to ten years. I’m grateful the CDC has joined the effort to quelch this problem. Their resources and experience can help a great deal. I just wish all doctors in the country could hear her message.

The addiction medicine doctors had a chance to make comments and further suggestions to the CDC through Dr. Arias, and I was pleased to see how carefully she listened.

One of the suggestions I liked the best addressed the expense of maintaining state prescriptoin monitoring programs. Apparently these can cost around a million dollars a year to administer. One doctor said why not have the pharmaceutical companies that make and sell controlled substances pay or help pay for the monitoring programs? These companies are the main entities that have benefitted from the sales and diversion of their products; why not ask them to bear at least some of the cost for detecting the problems they cause? Genius, though it would be hard to mandate the pharmaceutical companies to do this.

One doctor suggested that law enforcement personnel be educated about the types of treatment available to opioid addicts, so they can stop being barriers toward effective treatments, namely medication-assisted treatments using buprenorphine and methadone.

Another doctor suggested the CDC promote the naloxone programs that provide kits to reverse fatal opioid overdoses. Why not help fund these projects and/or help create more? The Harm Reduction Coalition estimates there are around 155 naloxone programs in the U.S. Some are government-funded and some are privately funded, but around 10,000 fatal opioid overdoses have been reversed. Like Project Lazarus in North Carolina, many of these programs started at a grass roots level because citizens got involved.

Another doctor made the extremely common sense suggestion that the best way to allow more patients into suboxone treatment would be to allow doctors to treat more than one hundred patients at a time. At present, suboxone doctors are allowed to have no more than thirty patients on buprenorphine in their first year prescribing, and no more than one hundred after the first year. This would cost next to nothing for the government to implement, and expand treament dramatically.

One of our past ASAM presidents endorsed mandatory physician education as a requirement for maintaining medical license.

One person compared the prescription opioid addiction to HIV infection in past years, and commended the CDC on its past efforts to reduce the stigma associated with having HIV. This person asked the CDC to make public service announcements to help reduce the stigma of addiction, and encourge people to get treatment.

Another doctor asked the CDC to produce public service announcements telling people to lock up their medications, to prevent medication diversion to a teen or other person for whom it was not prescribed. This doctor also said that patients need to know that not all pain conditions require prescription opioids. He recommended telling the general public the true risks of opioid addiction, which have been downplayed. In the past, pain medicine experts underestimated the incidence of addiction in patients prescribe opioids for chronic pain for more than three months.

The CDC representative, Dr. Arias, confirmed that the CDC already has plans to make PSAs about pain pills and pain pill addiction, much like their present (and very successful) anti-smoking television PSAs.

All great information, and now let’s get the word out to all physicians, and the public too.

New Opioids

I’ve blogged about states that have passed new laws addressing the prescribing of opioids, but the manufacturers of prescription opioids medications also have made changes to help reduce the potential for medication misuse. Of course, opioids will never be misuse-proof, but at least it’s a little harder to misuse some of the newer ones.

Oxecta is a new immediate-release brand of the drug oxycodone. It’s formulated so that it breaks into chunks when crushed, instead of a powder. When it’s mixed with water, it forms a gel so that it can’t be injected. This pill contains sodium laurel sulfate, a substance that irritates the nose if snorted.

Lazanda is a new delivery form of a very potent opioid, fentanyl. This brand is designed to be used as a nasal spray, which I would expect to be very addictive. The preparation itself has no anti-abuse features, but in order to distribute, dispense, prescribe, or be prescribed this medication, parties have to sign an agreement and be enrolled with the drug company. This extra scrutiny is hoped to deter diversion by distributor, pharmacy, doctor, or patient. Physicians must take a training program specific for this brand, and be enrolled with the drug company as a prescriber, or pharmacies can’t dispense to the patient.

Patients also need to complete a patient-prescriber agreement. Many people (like me) think doctors aren’t likely to jump through these extra hoops to prescribe this particular brand, when other brands of the same medication are already on the market, though not in the form of nasal spray.

Remoxy, another brand of oxycodone, hasn’t yet been FDA approved. Supposedly, it’s resistant to injection or snorting, and also has been formulated to be resistant to alcohol extraction.

Drug companies are now required by the FDA to have plans to evaluate and mitigate the risks associated with the opioid drugs they manufacture, particularly if they make sustained release or long-acting opioid preparations. This cooperation by drug manufacturers is a necessary part of turning the tide of opioid addiction in this country.

Last year, Purdue Pharma re-formulated OxyContin, making it more difficult to crush to snort or inject.  I noticed a sudden drop-off in patients entering treatment for pain pill addiction who said OxyContin was their drug of choice. During the years 2002 through 2007, nearly all of the opioid addicts I admitted to treatment said OxyContin was their preferred drug. It became obvious that the re-formulation made a big difference.

Addicts can and will still abuse these medications orally to get high, but the new formulations really do reduce abuse by making pills less likely to be snorted or injected.

National Prescription Drug Action Plan

Yesterday, government officials proclaimed the formation of collaborative plan to address this nation’s problem with prescription opioid abuse and addiction. Speakers included Mr. Gil Kerlikowske, the director of the ONDCP (Office of National Drug Control Policy), Dr. Howard Koh, from the department of Health and Human Services (DHHS), Dr. Margaret Hamburg from the Food and Drug Administration ( FDA), and Ms. Michele Leonhart, administrator of the Drug Enforcement Administration (DEA).

 Speakers recited pertinent statistics regarding the state of opioid addiction and abuse in the U.S.  It’s now the faster growing public health problem in our country. Around 28,000 citizens died from unintentional drug overdose in 2007, the latest year for which data is available.  More people in the U.S. now die of unintentional drug overdose than gunshot wounds. In seventeen states and Washington D.C., unintentional overdose deaths outnumber deaths from motor vehicle accidents.

 The plan has four main points. First, both patients and prescribers of controlled substances will be provided with better education about these potentially dangerous medications. The drug manufacturers will be asked to develop educational products for both patients and providers for education, which will be reviewed by the FDA before approved for release. The medications included will likely include sustained-release oxycodone, oxymorphone, hydromorphone, and methadone. Fentanyl patches will also be included. The ONDCP is seeking to introduce legislation that will change the Controlled Substances Act in order to make training mandatory for doctors who prescribe long-acting opioids.

 Second, the national government will push the few remaining states that don’t have function prescription monitoring programs to put them in place, and to be able to share data with adjacent states.

 Third, the government will support more medication “take back” days in communities across the U.S. Citizens will be encouraged to bring old medication to community sites in order for proper disposal. Previous take back days have been very successful, with tons of pills collected and disposed. This will reduce the number of prescription opioid pills available for diversion. Surveys reveal that round 70% of the pills obtained by people misusing prescription medication for the first time are obtained from friends and family members, often without permission, from old prescription bottles.

 Fourth, state and federal agencies plan to crack down further on rogue doctors and clinics that are “pill mills.” This will require participation from state medical boards, law enforcement, and the DEA.

 At the end of this presentation, Karen Perry, founder of NOPE, told the story of her son, a bright young college student who died of an unintentional drug overdose. She described how his death affected her and his siblings. Her face was etched with the grief that can only come from such a profound loss

 The goal of this plan is to achieve a 15% reduction in prescription opioid misuse in this country by at within the next five years.

 I’m so pleased to see this announcement. Back in 2001, when I first started treating prescription opioid addiction, I was amazed at the numbers of people seeking treatment for this disorder. Studies since then have shown the situation has gotten much worse.

 There will be problems with this plan. Many doctors will not be happy they must have mandatory training in order to be able to prescribe some controlled substances (probably schedule II). Some will stand up on their hind legs and protest this new regulation, if it is passed by congress. But after seeing the prescribing habits of some of my brethren and sistren, it’s obvious we need this. We don’t get much education about appropriate prescribing of opioids, recognizing addiction, and referral for treatment. I’ve blogged before about this (see February 10th’s entry)

 I’ve been blathering on to anyone who will listen about the need for prescription monitoring plans (see prior blog entries for March 6, 8, and 31), so I’m delighted more attention is being paid to this. But I still worry about how states will communicate with each other. For example, my practice is close to South Carolina, yet that state has denied me access to their database. The only allow access to doctors licensed in South Carolina. I use the prescription monitoring program in my state both at the two Opioid Treatment Programs where I work and in my own office, where I see Suboxone patients. I’ve been using it since 2007.

I support the pill “take back” programs. While such events probably won’t do much for those with established addiction, they can help reduce the number of new users and experimental users. Remember, opioid overdose deaths don’t just happen to addicts. Youngsters experimenting with opioids can die from overdoses. In fact, new users dabbling with these pills, because they think they’re safer than “street” drugs, may be more likely to die because they don’t have any tolerance to opioids.

 We need good judgment and balance when shutting down pill mills. How can the DEA tell a pill mill from a legitimate pain treatment practice? I believe this is best done by other doctors. In this state, the medical board does investigations, which I feel is more appropriate than having investigations done by law enforcement. Law enforcement personnel just don’t have the training to tell the difference between appropriate care and careless prescribing with disregard for patients. Let other doctors do that. Granted, a few places will be so obvious that little investigation is needed.

 We don’t want the opioid pendulum to swing to the opposite side again, and become completely opioiphobic. These pain medications are addictive, but are also godsends in the right setting and used in the right way. Let’s take care not to throw out the good with the bad. The best people to set policy in this area are well-trained doctors who approach this issue with common sense and balance.

 Coming as late as it does in this epidemic, I could be negative and say the government has had an epiphany of the obvious. But I do know it takes time for all of these agencies to come together in a cooperative manner and form a plan of action. I’m just thankful that action is finally being taken.

Governor Scott’s Flamingo Express to Misery

Flamingo Express of Florida

All I could think was, “What can he be thinking???”

 I was reading an article about the governor of Florida and his bizarre decision to block the formation of a prescription monitoring program in his state. (1)

 Prescription monitoring programs are databases that contain lists of controlled substances a patient receives, the prescribing doctors, and the dispensing pharmacies. Usually, only approved physicians can get access to these databases. Prescription monitoring programs help prevent “doctor shopping,” which is the term describing the actions of a patient who goes from one doctor to another to get prescription pills, usually opioids, without telling the doctors about each other. Addicts do this to supply their ever-increasing tolerance for the drugs. Drug dealers do this to get pills to sell and make money.

 Forty-two states have approved the formation of prescription monitoring databases, and thirty-four states have operational databases. Florida was one of the last to approve the formation of such a program, in 2009, long after this recent wave of prescription pain pill addiction burned through the country. Now, the new Florida governor wants to cut this program out completely, before it even starts.

 How big of a deal is this?

In the latest survey, 5.3 million people in the U.S. used prescription pain pills nonmedically over the past month. This means they used them in ways not intended, or for reasons not intended by the prescriber… for example, to get high. In the last year, 2.2 million people misused these prescription pain pills for the first time. Our young people are particularly at risk; between 2002 and 2009, the percentage of 12 to 17 years olds misusing prescription opioids rose from 4.1% to 4.8%. Not all of these people will become addicted, thankfully. Some will only experiment, and be able to stop before addiction develops. Many won’t be able to stop taking pills, and will progress into the misery of addiction. Others will die of drug overdoses. (2)

 Why pick on Florida?

Florida is infamous for its pain clinics. As a reporter for Time Magazine pointed out, there are more pain clinics in South Florida than there are McDonald’s franchises. In 2009, 98 of the top 100 prescribers of oxycodone in the nation were all located in Florida. Altogether, these doctors prescribed 19 million dosage units of oxycodone in 2009. Estimates of the numbers of pain clinics located in South Florida vary, but most sources say between 150 and 175. (3, 4) Many of these clinics are “pill mills,” where doctors freely prescribe controlled substances with little regard to usual prescribing standards and guidelines.

 Are all these clinics pill mills?

No. Some of the pain clinics are legitimate, and their doctors follow best practice guidelines, providing quality care to patients with pain. But careful monitoring and screening for adverse events, including the development of addiction, takes time. A conscientious doctor, trying  to do a good job, isn’t going to be able to see fifty pain patients in one day.

 I’ve talked to addicts who were previously patients at these pill mills. They describe how they were shuffled through rapidly, sometimes not even seeing the doctor. Some addicts say they were asked what pills they wanted, and quickly written that prescription, with little or no conversation beyond that. That was the extent of the visit. 

But Florida’s problem doesn’t stay in Florida. Appalachian states like Kentucky, West Virginia, and North Carolina all have addicts who buy these prescription pain pills after they’re transported out of Florida. The DEA sees so many pain pills being transported from Florida to Appalachian states that they call it the “Flamingo Express.” In one of the methadone clinics where I work, I’ve noticed a peculiar upswing in the reported use of Opana, a brand name for the drug oxymorphone. It’s not a drug I’ve seen prescribed much in NC. When I ask patients where the pills come from, many say, “Florida.”

 Governors of several states, including West Virginia and Kentucky, along with congressmen from New York and Rhode Island, have sent a letter to Florida’s Governor Scott, urging him to reconsider his decision to torpedo plans for a prescription monitoring program. Since the leading cause of death in West Virginians for those under the age of 45 is drug overdose, I can see why this governor is protesting Governor Scott’s poor decision. (4)

 It’s estimated that setting up a prescription monitoring program costs about one million dollars. The Florida Prescription Drug Monitoring Program Fund, Inc., a non-profit organization dedicated to raising money for the program, says on their website that they’ve already raised at least half of that from donations. Other states have received the Harold Rogers grant money, available from the federal government to set up these monitoring databases. This leads me to question the excuse of “budget cuts” as the reason for Governor Scott’s poor decision.

 I’ve also seen internet stories that mention the governor’s fear of invasion of privacy. This is a legitimate concern, but there are ways to safeguard the information in such a database, and laws that can regulate who has access. I’m no fan of the government peering into my business, but this database is essential, given the overwhelming numbers of people struggling with pain pill addiction. For a description of the ways in which the North Carolina prescription monitoring database has helped me help my patients, please see the preceding blog entry. It’s been a lifesaver.  

  1. http://articles.sun-sentinel.com/2011-03-05/news/fl-prescription-drug-forum-20110305_1_pill-mills-prescription-drug-monitoring-program-attorney-general-pam-bondi (accessed 3/6/11)
  2. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD.
  3. Thomas R. Collins, Invasion of the Pill Mills in South Florida, Time, Tuesday, Apr. 13, 2010,  Ft. Lauderdale, FL
  4.  http://manchin.senate.gov/public/index.cfm/press-releases?   ContentRecord_id=f62482b4-f6dd-4adc-8b49-1563d8fa605b&ContentType_id=ec9a1142-0ea4-4086-95b2-b1fc9cc47db5&Group_id=e3f09d56-daa7-43fd-aa8b-bd2aeb8d7777&MonthDisplay=2&YearDisplay=2011 (accessed 3/8/11)
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