Archive for the ‘cultural norms’ Category

Black Box Warning

black coffin



Last month the FDA (Food and Drug Administration) announced their decision to require black box warnings on opioid and benzodiazepine prescribing information. This warning will state that co-prescribing these two classes of medications increases the risks to patients of death, coma, sleepiness, and respiratory depression. The FDA also said they would require medication guides for patients, describing these risks.

Black box warnings are the strongest warnings issued by the FDA. These warnings are literally placed in a bold black box at the top of the prescribing, where the information is most noticeable.

I applaud the FDA’s action. I think FDA’s statement will make physicians and other providers think twice before blithely writing a benzodiazepine prescription for a patient already prescribed opioids. A black box means, “Take this seriously!”

Ten years ago, co-prescribing of opioids and benzodiazepines was commonplace for primary care physicians in my area. Earlier this year, our state medical board announced they would investigate the top prescribers of opioids and benzodiazepines together. Since then, I have noticed some prescribers appear to be backing away from the routine prescribing of benzodiazepines..

Most opioid treatment centers have policies in place to address benzodiazepine use, both licit and illicit. There are still a few OTPs who approve benzodiazepines to be prescribed for methadone or buprenorphine patients, but I think they are in the minority. Most opioid treatment program physicians feel that besides the dangers of sedation and overdose, there are few medical indications for long-term (more than three months) benzodiazepine prescriptions, and much better long-term treatments for anxiety disorders.

An article In the April 16th, 2016 issue of the American Journal of Public Health underlined how important it is to evaluate benzodiazepine prescribing in the U.S., particularly when prescribed along with opioids. [1]

The authors begin the article by stating that benzodiazepines were found to be involved in nearly a third of opioid overdose deaths in 2013. The authors wished to investigate nation trends in benzodiazepine prescribing and in fatal overdoses involving benzodiazepines.

The authors found the percentage of U.S. adults filling benzodiazepine prescriptions increased significantly over past years. They also found that among people who filled benzodiazepine prescriptions, the amount, defined as lorazepam equivalent doses, also increased significantly. Simultaneously, overdose deaths rates involving benzodiazepines rose nearly four-fold, though deaths appear to have plateaued since 2010.

Another study, this time in Canada, evaluated the risk of death in polysubstance users. In a prospective cohort study of IV drug users, done from 1996 through 2013, benzodiazepine use was more strongly associated with death than any other substance of abuse. [2

Many patients ask why they can’t take benzodiazepines while on methadone or buprenorphine. I tell them I’m mainly worried about the increased risk for overdose death, but I also tell them benzodiazepines are over-prescribed. Prescribing information suggests benzodiazepines are most beneficial when prescribed for no more than three or four weeks. Long-term prescribing of benzodiazepines is generally discouraged, due to serious side effects seen even in patients with no substance use disorders.

Benzodiazepines are associated with increased risk of auto accidents, increased risk of completed suicide, worsening of mood disorders like depression, increased risk of drug-induced dementia, and increased risk of daytime fatigue. Benzodiazepines are also associated with increased risk of cancer, falls, and pneumonia.

Although an association of benzodiazepines with these conditions doesn’t necessarily mean benzodiazepines cause these conditions, it’s a good reason to be conservative when prescribing benzodiazepines and other sedatives, pending further studies.

Sedative medications including benzos can make undiagnosed sleep apnea worse, even to the point of causing death. Obesity increases the risk of sleep apnea, and with more adults becoming obese, the risks of benzodiazepines in such patients may be overlooked.

As for my patients, many of whom are prescribed methadone or buprenorphine, the risk of drug interaction and overdose with the hypnotics usually outweighs all of the benefits, and I recommend that patients do not mix these two types of medications.

  1. Bachhuber et. al., “Increasing Benzodiazepine Prescription and Overdose Mortality in the Unites States, 1996-2013,” American Journal of Public Health, April 16, 2016.
  2. Walton et. al., “The Impact of Benzodiazepine Use on Mortality Among Polysubstance Users in Vancouver, Canada,” Public Health Rep., 2016 May-June;13(3)491-9.

Judges Behaving Badly

aaaaaaaaaaaaStepping Stone memo from Judge Ginn (2)


Methadone and buprenorphine treatment for opioid use disorders saves lives. Over five decades, we’ve accumulated more studies to support this treatment than any other medication, device, or intervention that I can think of. And yet, opioid use disorder appears to be the only disease where medically untrained people dictate medical treatment. The above memo from a judge of the 24th District Court in North Carolina illustrates this all too well.

Let’s change that sentence in the middle of Judge Ginn’s memo: “Therefore, effective immediately, the use of insulin as a treatment for diabetes will no longer be allowed as a part of any probationary sentence in the 24th Judicial District.”

It wouldn’t make any sense, would it? People would wonder why a judge was involved in a patient’s medical care. They might even be tempted to believe a judge had no authority to dictate medical care.

I worked in Boone, North Carolina, when this memo was issued, and it caused a great deal of suffering for patients. These patients, contrary to the judge’s beliefs, were doing well on medication-assisted treatments. They were no longer injecting drugs or committing crimes to support their active addiction. Their involvement with criminal justice system almost always pre-dated their entry into treatment. Yet the judge proclaimed they must stop the very medications that were helping them become productive members of society again!

I wrote letters of advocacy and information, citing studies that support MAT. I encouraged patients, and told them to expect their lawyer to advocate for them on this issue. The patients said their lawyers often advised them just to do what would make the judge happy. Patients, understandably, were timid about pushing against a judge with so much power over their lives.

Ironically, many of the people Judge Ginn thought were doing well in his court were also our patients. It was widely known that probation officers’ drug tests didn’t detect methadone or buprenorphine at that time. Unless the offender told the truth about being in treatment on buprenorphine or methadone, the court never knew. I’d estimate that dozens of people successfully passed through Judge Ginn’s court while being treated with buprenorphine or methadone, without him ever knowing about it, due to inadequate drug testing. The people who told the truth were penalized by being told to quit life-saving medication.

I know Judge Ginn is now retired, but I suspect attitudes and beliefs of the judiciary in that area haven’t changed much.

One of the opioid treatment programs in the area tried to advocate for their patients, by seeking some sort of censure against Judge Ginn, but I don’t know what came from that.

The National Institute on Drug Abuse (NIDA) and Substance Abuse and Mental Health Services Administration (SAMHSA) both strongly recommend expanding opioid addiction treatment with medications to criminal justice participants. Congress just passed a bill that recommends spending money to treat opioid addiction in jails and prisons That bill pushes for people with opioid use disorder to get treatment instead of jail sentences. Experts everywhere advocate for expanding medication-assisted treatments to patients involved with the legal system, whether in jail, on parole, or on probation.

All of these actions are great. But Judge Ginn is an example of the many obstacles to implementation of the evidence-based treatments that experts recommend. Particularly in rural Appalachian areas, people in positions of power actively thwart life-saving medical treatments.

I don’t understand how judges can get away with such irresponsible actions. To me, it appears Judge Ginn practiced medicine without a license. If I somehow lost my medical license but continued to practice, I’d be committing a felony.

What if Judge Ginn commanded a patient stop buprenorphine or methadone, and the patient died in a relapse? Would Judge Ginn have any liability, civil or criminal?

I don’t know what can be done about judges like him, but don’t they have to answer to someone? Are they appointed, or elected? If elected, perhaps we need to start understanding judges’ positions on medical treatments before we vote for them.

You Can Find My Office Next to the Restroom

bathroom break

Warning: this is one of those fluffy entries, not much substances, lots of musings…

A few weeks ago, I ushered a new patient to my office for her initial history and physical. Once in my office, she looked around and said, “Wow, they don’t think much of you, do they?” At first I was puzzled, but then figured out she meant that my office is small and undesirably positioned right next to the patients’ restroom. It’s not furnished lavishly, only with the essentials: desk, exam table, and two chairs. I also have a file cabinet containing some species of records.

Perhaps in the business world, one’s value to a company is reflected in the lavishness of one’s office. It is not like that in the doctor world, or at least not in the doctor world I inhabit. I don’t think about the size of my office, the location, or the furnishings. As long as I have everything I need to do my job, I don’t care or even notice other amenities. But some of the patients notice.

I’ve had some patients ask how I can stand the smell. On intake days, with eight or so new patients in varying stages of opioid withdrawal, my office can sometimes take on a certain redolence from the restroom next door.

It doesn’t bother me. I became immune to bad odors in 1985, roughly when I started my clinical rotations in medical school. By the time I got to my residency program, any sense of smell I still had was burnt out during my two-month rotation through the emergency department. I’ve been exposed to massive burdens of every type of stench emitted from the human body. As a result, I reflexively start mouth-breathing in the presence of unpleasant smells. It’s automatic.

I’ve worked for five opioid treatment program companies, in fifteen separate facilities. In many of them, the doctor’s office was next to the restroom, but I’m sure that’s just coincidence.

The worst was in an old building shaped like a “U”, with the pharmacy in the center. My office was at one end of the “u” and directly across from…you guessed it…the patient bathroom. That wasn’t the worst thing, though. Unfortunately my office had an inch and a half gap between the floor and the wall, and it appeared to be a major thoroughfare for bug travel. It was not uncommon for a roach to emerge from the gap, waving antennae like he was a pageant queen.

I usually had my back to this area, so the patients would be the first to see the invader. Almost without exception, the male patients would jump to their feet and stomp the intruder into bug heaven. I would smile and say, “Thank you, my dragon slayer.” We would share a laugh and get back to business.

Why are the physicians’ offices less luxurious in the opioid treatment programs than the rest of the doctor world? I think for the same reason some OTPs are in run-down buildings in the worst part of town. The stigma against medication-assisted treatment makes it more difficult to get regular medical office space. For all I know, maybe only the buggiest places were rentable. It’s also possible that some opioid treatment programs don’t think it’s worth spending money for a nice facility.

Doctors’ offices at OTPs may tend to be shabby because doctors aren’t in the opioid treatment program every day. Obviously, the counselors who are there every day should get the nicest offices because they will be using them more hours per week. Often when the facilities are cramped for space, the program doctor has to share an office with one or more other people. I know where I work now, two or three other people work in my office when they need space. As a result, a variety of detritus comes and goes.

One day a patient asked, “Are those your shoes under the exam table?” I didn’t have to look up. I knew he meant the pair of espadrilles that appeared one day without any explanation. I said “No, I don’t know whose those are.” He looked at me oddly, as if that were a strange answer, so I told him, “That’s nothing; there are other random things. I just don’t ask anymore.” One day my office was filled with balloons, and on another day, with hot dog buns.

The shoes were gone a month or so later, as quietly as they had appeared.

At my other program, my office is so small that literally we have to ask the patient to leave the room so that we can wheel in the EKG machine, then come back in. It is very cramped, but what I really mind is the heat. This OTP is in the mountains, but as cold as it may be outside, it’s always summer in my office.

This office has no vents and no overhead lights. When I complained about the lack of proper lighting, the program manager brought in floor lamps. One gives a puny little light, and the other throws enough heat to keep French fries warm. I have to remember to dress for summer even in the middle of winter.

It would be easy to take shabby offices personally, but I don’t think that’s generally what is behind it. OTPs take a more utilitarian approach towards facilities than other branches of medicine. I think OTPs get so used to being the red-headed stepchild that they forget to take pride in their surroundings.

Having nice facilities may not feel like a high priority, but it should be. We need to provide space as nice as other medical offices. We provide an intensely important service, with literally decades of data to support what we do for patients. Maybe our surroundings should reflect the importance of what we do, and the significance of what we do.

Thank you Nurses!



This will be the first blog entry about how much I appreciate nurses at the opioid treatment programs I work with.

I’ve been remiss. Some of the best people I’ve ever met have been nurses at opioid treatment programs. Nearly without exception, they have been bright, caring, and compassionate.

At my OTP, we are temporarily short-staffed with nurses, so the stress they deal with is even more evident than usual. New nurses are being hired, so help is on the horizon, but right now, things are tense. Our nurses try to dose patients as quickly as possible without making any dosing errors.

Being a nurse at an opioid treatment program isn’t an easy job. I’ve overheard one imprudent program manager, several years ago, make an unfortunate comment that being a nurse at an OTP was easy, and that “anyone” could do it. He had no medical background, so he can be forgiven for his lack of knowledge.

Not every RN or LPN can manage to do this job well; it takes a special heart.

First of all, the state of North Carolina disagrees that “anyone” can do the job of a nurse at an OTP. They insist you have a nursing degree, so there’s that.

Secondly, medical professionals of all types have jobs where mistakes can be deadly. The ordinary human errors that cause problems in other work environments can kill in our line of work. That’s a special kind of stress. We accept that stress as part of the price of working as a medical professional, and we also accept that other people can never understand what that feels like.

Over a decade ago, I knew a nurse who made a dosing error by mis-reading the physician’s induction order for a patient on methadone. She gave a somewhat higher dose than was ordered by the physician on day two and day three. The patient died on day three. Of course the family was devastated, and a lawsuit ensued, settling for an undisclosed amount. But that nurse will never be the same. She left the OTP and I don’t know if she’s still working as a nurse or not. But that illustrates what a nursing error at an opioid treatment program can mean.

Out of all we do at OTPs, the most critical moment of care happens when the nurse hands over the patient’s daily dose of medication. The patient must be quickly assessed for impairment by the nurse, and the correct dose of medication given. This must be done perfectly, day after day, patient after patient. Any mistakes made at this point can undo the rest of treatment.

Any time perfection is expected of you at your job…that’s stress. And just like nurses in all medical settings, they are also being asked to work faster and faster, to be ever more efficient.

I’m not saying the counselors don’t also have high-stress jobs. Lord knows they do. But their errors don’t have the same ability to kill someone.

Thirdly, the amount of documentation and record-keeping demanded from nurses at the opioid treatment program is mind-blowing. These documents are intermittently inspected by the state’s department of health and human services, by the DEA, by the state opioid treatment authority, by CARF, etc. Someone is always looking over their shoulder, because they are working with strong opioid medications.

I’ve seen many nurses who couldn’t cut it in the OTP. It’s fast-paced and exacting, and often they deal with difficult people. Sometimes patients get angry at the restrictions of the opioid treatment program, many of which are mandated by state and federal organizations. Patients often direct their anger at the nurses. I’m often amazed at their ability not to take these outbursts personally. I’m afraid I might harbor resentment, but they seem to start over every day.

This is not a glamorous field of nursing. On the totem pole of medical specialties, addiction medicine and especially opioid treatment programs are the part of the pole that’s underground. When these dedicated professionals tell their friends and families about the work they are doing, they are sometimes chided for not doing something more mainstream. Or their family thinks their job consists of “shooting up them addicts with methamphetamine,” as one nurse told me.

Of course, we in the addiction treatment field know these nursing professionals are likely helping more people at the opioid treatment program than they would at any office or hospital setting.

It takes strong character to do a difficult job well, especially when you don’t get a lot of praise from nurse peers who know little about this niche area of medicine

So today I am honoring the nurses who work at opioid treatment programs. Thank you for the work you do. You are appreciated.



Non-drug Ways to Help Insomnia


Insomnia is defined as a sleep disorder which makes it difficult to get to sleep or stay asleep. Insomnia can come & go for periods of time, or can be a chronic problem. Not sleeping well can make us less able to handle the stresses of the next day, and can severely affect the quality of our lives.

Insomnia afflicts many patients in recovery, including those on medication assisted treatment with buprenorphine and methadone. Insomnia can occur for many reasons: the brain may be adjusting to life without the chemical ups & downs of addicted life, or because the patient had insomnia even before the addiction started. Physical health problems (chronic pain, thyroid disease, and menopause to name but a few) can cause insomnia or make it worse, as can mental illnesses like anxiety and mood disorders.

Active addiction can destroy normal sleep-wake cycles. Addictive chemicals disrupt the structure and function of the brain, and often people in active addiction become accustomed to passing out rather than falling asleep. It can be difficult to re-learn how to get to sleep naturally.

Many U.S. citizens, and not only addicts, have become “chemical copers.” We have the idea that every problem can and should be fixed with medication. But with insomnia, sleep hygiene is the best first option, and medication can be used if sleep hygiene doesn’t work.

Sleep hygiene, which sounds it means washing behind your ears at bedtime, really refers to habits that help us get satisfactory sleep. Most are common sense ideas, and they can really make a big difference. Here are some of these ideas:

1. Go to bed at the same time and wake at the same time every day, even on weekends.
If it’s at all possible, don’t go to bed later or sleep later on weekend days. Get your body into the habit of keeping a regular sleep/wake cycle. You will fall asleep more easily with a fixed bed time.
Besides making your feel better because you’ll get more regular sleep, this practice has other benefits. For example, people with migraine and tension headaches have fewer pain episodes with regular sleep/wake times. Keeping regular sleeping hours is also highly recommended for patients with bipolar disorder, as it can help with mood swings.

2. Avoid caffeine late in the day. For some people, drinking caffeine in the late afternoon can affect them up to six hours later. To be sure, cut off caffeine at least eight hours before you want to sleep. Caffeine doesn’t affect everyone to this degree, but unless you know for sure, try to limit late-day caffeine. If you consume energy drinks, consider cutting back or stopping them.

3. Make sure your bed is comfortable and your room as free from distractions as possible. Pets and rowdy bed partners may need to sleep in other areas. Make sure the room temperature is conducive to sleep and there’s no noise or light that may interrupt sleep. Keeping the television on for background noise isn’t a good idea and can prevent you from getting to the deeper levels of sleep.

4. Don’t set your alarm for earlier than you need to. Many of us like to do this so we can hit snooze a few times. However, the most beneficial sleep, REM sleep, comes at the end of the night, and we are depriving ourselves of REM sleep by hitting the snooze button a few times before getting out of bed for good.

5. Have a bedtime ritual. Have things you do each night before going to bed that relax you and put you in a mindset to sleep. This could be a series of ablutions like brushing your teeth, flossing, or taking a warm bath. Other people may prefer doing prayer or meditation to quiet the mind, or reading.

6. Don’t nap during the day to catch up on sleep. More than anything else, napping will keep you from sleeping at night.

This is a tough one for me, since napping has long been one of my hobbies. Because I think of a good nap as one of life’s great joys, on some days I’m willing to risk not being able to get to sleep at night and take the nap anyway.

7. Don’t use alcohol to help you sleep. While alcohol does cause faster sleep onset, it also shortens the sleep cycle, causing us to wake earlier, and robs us of the important REM sleep. Over long term, alcohol can greatly interfere with your sleep cycle.

8. Only use your bed for sleep. OK, for sex too. But don’t live in your bed so that you become accustomed to eating, watching television, and working on the computer in bed. Your mind should associate bed with sleep, and not these waking activities.

9. Exercise each day. More than most other suggestions, this one can help you more than you expect. Even a small amount of exercise can have surprisingly good benefits. Don’t exercise too close to bedtime, since exercise can have a stimulating effect.

Sometimes people in early recovery find they want to sleep more than usual. This can be part of your physical recovery, and I think it’s best to listen to your body and allow yourself extra sleep time without feeling guilty. However, some mood disorders also make people want to “take to the bed” during times of stress and negative emotion. This latter situation may need medication if it continues or interferes with your life.

The State of Denial (Tennessee) gets Another Chance

aaaprejudice and ignorance

If you read my blog, you know Tennessee is a frequent target of my ire. I’ve been aghast and distressed at Tennessee’s refusal to allow an opioid treatment program to open in the Eastern part of that state. Hopefully, that’s about to change.

Now a new opioid treatment program has applied for a certificate of need with Tennessee’s Department of Mental Health and Substance Abuse Services, asking for permission to locate a methadone clinic in Eastern Tennessee. Sources say this is the eleventh attempt to locate an opioid treatment program that prescribes methadone in that part of Tennessee. In 2002, approval was given but then withdrawn due to a technicality.

Even if the certificate of need is approved, this company faces stiff opposition from the modern-day equivalent of villagers with pitchforks, demanding that no treatment center be located near them. This is the ugly face of modern day NIMBYism, and it violates the American with Disabilities Act, a topic of a past blog. (See November 14, 2012) It’s illegal, and past federal court rulings have sent a clear message to towns that violated the ADA in this way, with high six-figure fines.

I’m surprised anyone wants to put a new clinic in Tennessee, given its recently passed anti-evidence-based regulations on methadone clinics, but I’m pleased. Eastern Tennessee probably has more untreated opioids addicts per acre than anywhere else in the nation. Tennessee has the 13th highest opioid overdose deaths per capita, compared to all other states, and is ranked number two in the kilogram of opioids prescribed per capita. [1]

Yet it has only a small number of opioid treatment programs. The nearest methadone clinic to Eastern Tennessee is located in Knoxville, and in bordering states. These states treat the opioid addicts Tennessee is neglecting. The certificate of need submitted by the petitioning opioid treatment program says that around one thousand opioid addicts are now traveling one or two hundred miles round trip each day for treatment. You know there are thousands more getting no treatment at all.

The state will make a decision about the certificate of need request this summer. Of course, any educated interpretation of data would conclude that the certificate of need should be approved forthwith. As I said, you can’t throw a rock in Eastern Tennessee without hitting an opioid addict. But so many people don’t know anything about the benefits of methadone.

Lack of knowledge about methadone does not prevent people in positions of authority from taking a strong stance against it. For example, this is a quote in the Johnson City Press from Roger Nave, committee chairman of the public safety committee of the county where Johnson City is located: “We have top-class medical facilities in this area to deal with any problem that our citizens have. The addicts do need help and support, but methadone is not the answer to their problems.”

Does Mr. Nave actually know any facts about methadone?? Does Mr. Nave know that the treatment of opioid addiction with methadone is one of the most strongly evidence-based medical treatments in all of medicine? Does he know that we have over forty years’ of studies that show the treatment of opioid addiction with methadone reduces overdose death rates and suicide rates? Does he know it improves employment rates and dramatically reduces crime rates? Does he know addicts treated with methadone have better physical and mental health? Does he know that for each dollar spent on methadone treatment, taxpayers save four dollars, mostly in reduced incarceration costs? Does he know that methadone treatment of opioid addiction significantly reduces the incidence of HIV in intravenous opioid addicts? [2,3,4]

Eastern Tennessee now has Suboxone providers, and these doctors have likely saved hundreds of lives. Buprenorphine is a great medication, and I prefer prescribing it rather than methadone because of its better safety record. It works on the same principle as methadone: both are long-acting opioids that can be dosed once daily to keep opioid addicts from having withdrawal or craving, thus freeing them to focus on changing their lives.

But buprenorphine is not strong enough for all opioid addicts. It doesn’t work for all opioid addicts. In fact, no treatment works for all opioid addicts, even medication-assisted treatment with buprenorphine and methadone. Some are too sick for these medications, and some aren’t sick enough.

Suboxone programs are too expensive for many addicts. Yesterday I called three programs in Tennessee to get an idea of their prices. A month’s worth of treatment is around $400, including doctors’ visits, group and individual counseling, and drug tests. The medication is not included in this cost, and can cost an additional $240 to $900 per month, depending on the dose of medication. Opioid addicts without health insurance can’t afford that kind of treatment. Methadone programs usually cost $9-$11 per day, and addicts can pay as they go.

At least one big Suboxone program in Johnson City doesn’t do maintenance treatment, but only a few months of detox, despite more studies showing greater benefit with longer treatment. Some addicts are forced to come off Suboxone before they are ready, a recipe for relapse.

Suboxone is a valuable option for opioid addicts, but let’s make all forms of evidence-based treatment available for opioid addicts. Why not let addiction specialist doctors decide which treatment is appropriate, rather than government officials without any medical training?

With so many untreated opioid addicts in Eastern Tennessee, all forms of evidence-based treatments need to be available. At present, health officials in Tennessee push patients into medication –free treatments. These can work, if patients are given long enough treatment and if they can afford it. In my experience, inpatient programs in Eastern Tennessee seem to keep patients for two or three weeks, instead of two or three months. This is understandable, since Medicaid isn’t known for generous reimbursement, and private insurance rarely pays for longer treatments. Patients with no insurance at all are often asked to bring money up front to pay for treatment. Asking an addict to bring a few thousand dollars with them to start inpatient treatment doesn’t work, for obvious reasons. Even treated patients are sent back home to the same living situation, and relapse quickly. Using inpatient detox alone for five to seven days has always given relapse rates of 92%, with most relapsing within the first week.

Tennessee state officials have a chance to save lives, if only they can put aside their personal biases and look at the science supporting medication-assisted treatments. It’s the right thing to do. It’s a bargain, too. Patients are mostly self-pay, so it doesn’t cost taxpayers anything. Even from a purely economic view, methadone treatment would save taxpayers money.

If you support medical treatment of opioid addiction with evidence-based therapies, please write to the state and let them know. If you are an addict who has been helped by methadone, send a letter to the below address. If you are a family member who has seen the benefits of methadone treatment in your loved one, tell the people in government. This is the time to act. Don’t let this opportunity to slip by. Send your letter to:

Tennessee Health Services and Development Agency
Melanie M. Hill, Executive Director
Frost Building, 3rd Floor
161 Rosa L. Parks Boulevard
Nashville, TN 37243

3.California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295

Officially an Epidemic


It’s official. Prescription drug abuse in the U.S. is now called an epidemic by the Centers for Disease Control and Prevention. In November, CDC officials released a new report of prescription drug addiction.

It’s really interesting reading.

The CDC points out that prescription opioid overdose deaths now outnumber heroin and cocaine overdose deaths combined and prescription opioids were involved in 74% of all prescription drug overdose deaths.

The breakdown of their data by state is particularly interesting. The states with the highest rates of opioid overdose deaths are, in descending order: New Mexico, with a rate of 27 deaths per 100,000 people, then West Virginia, Nevada, Utah, Alaska, Kentucky, Rhode Island, Florida, Oklahoma, and Ohio. Tennessee missed the top ten, but was still 13th highest in overdose deaths, with a rate of 14.8. North Carolina’s rate was 12.9 per 100,000 people, which put North Carolina 24th out of 50 for prescription overdose deaths. That’s too high, but much improved since 2005, when North Carolina was in the top five states for prescription opioid overdose deaths. The lowest opioid overdose death rate was seen in Nebraska, with 5.5 deaths per 100,000 people.

The CDC also analyzed information about the amount of opioids prescribed in each state. They measured kilograms of opioid pain relievers prescribed per 10,000 people in each state. The state with the highest rate had over three times the rate of the state with the lowest rate. It’s no surprise that Florida had the highest amount, at 12.6 kilograms per every 10,000. Illinois had the lowest amount, at 3.7 kilograms per 10,000 people.

The big surprise: Tennessee has the second highest amount of opioids prescribed, adjusted by population. (OK, they tied for second place with Oregon). Yep. Tennessee, the state that refuses to allow more opioid treatment centers to be built within its borders, has 11.8 kilograms of opioids prescribed per every 10,000 people.  But since I want to devote an entire blog entry to Tennessee’s backward outlook on addiction and its treatment, I’ll defer further comments about that state.

Sales of prescription opioid quadrupled from 1999 to 2010. According to the CDC, enough opioids were sold last year to provide a month of hydrocodone, dosed 5mg every four hours, for each adult in the U.S.

The CDC estimates that for every prescription overdose death, there are at least 130 more people who are addicted or abuse these medications, and 825 who are “nonmedical users” of opioids. (I’m still not sure how nonmedical users differ from abusers. To me, if it’s nonmedical, that’s abuse.) Not all of the 825 are addicted or will become addicted – but they are certainly at risk.

Just like what was found in other studies, people who abuse opioids are most likely to get them for free from a friend or relative. So if you are giving pain pills to your friends or family members, you are part of this large problem.

In 2008, 36,450 people died from prescription overdose deaths. That was nearly equal to the number of people who died in auto accidents, at 39,973. In fact, in seventeen states, the number of overdose deaths did exceed auto accident deaths.

The CDC authors conclude that the prescription opioid addiction isn’t getting any better, and in measurable ways, it’s worsened, with some states worse than others. The worst areas, not surprisingly, have higher rates of opioid prescribing that can’t be explained by differences in the population. To me, this means doctors in some states are overprescribing, or at least aren’t taking proper precautions when they do prescribe opioids.

In my next blog entry, I’ll explain how people and organizations in North Carolina have been working hard to deal with the prescription pain pill addiction problem. Based on information from the CDC, it appears my state has made some major progress, at least compared to one of our neighboring states.