Archive for the ‘pill counts’ Category

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. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w

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.

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Dosing Methadone for Pain versus Addiction

Using methadone for pain is different from using methadone for addiction.

It’s illegal in the United States for a doctor to prescribe methadone for the purposes of treating addiction, unless she is working at an appropriately licensed Opioid Treatment Center. Some doctors don’t know this, and have had grumpy DEA agents pay them a visit. However, it is legal for a doctor to prescribe methadone for pain, as long as she has an appropriate DEA license.

Methadone is prescribed differently when treating pain than when treating addiction. This is because each dose of methadone has an analgesic (anti-pain) effect of about six hours. However, methadone’s opioid blocking effect lasts for twenty-four hours or more. This is why methadone for pain should be dosed multiple times per day, but methadone for addiction can be given once per day.

The dose of methadone often varies, too, depending on the disease being treated. Doses of methadone 10 to 20mg, dosed three to four times per day, are adequate to treat pain for many patients. When treating addiction, studies have shown that patients do better when the doses are high enough to block other opioids. Usually, this occurs at doses 80 – 120mg per day, given as one dose. The patient doesn’t become sleepy or sedated at this dose because the dose is raised gradually, allowing time for tolerance to build to the sedating effect.

Some patients prefer to stay at a low methadone dose, so they can still feel intoxication from illicit opioids like heroin or oxycodone. For example, one patient told me he liked keeping his dose around 60mg, which was high enough to stave off the worst of his withdrawal symptoms. But it was also low enough to allow him to feel high from an injection of heroin in the evenings. He resisted going up on his dose as recommended by his treatment team.

Doctors have to be very careful prescribing methadone for pain. The very characteristic of the drug that makes it effective to treat addiction, its long duration of action, also makes it dangerous to prescribe. Too many patients, experimenting with methadone for the purpose of getting high, die of a drug overdose. Tolerance to the euphoric effect of methadone develops more quickly than the tolerance to the sedative effects. People consume a fatal dose before feeling high.

Over the last decade, the incidence of overdose deaths from methadone rose sharply. Most of these deaths were from people taking methadone pills, dispensed from local pharmacies, and prescribed by doctors who were treating patients for pain. Along the way, many milligrams were diverted to the black market, with disastrous results. Some methadone was diverted from opioid treatment centers, but appears to be a fraction of the total.

Given the overdose potential of methadone, it should be used cautiously when prescribed by physicians for pain. Soon, doctors may be required to take a training course before they can prescribe the long-acting opioids. This training will educate doctors on how to recognize if a patient is developing the complication of addiction, and to identify evidence of drug diversion.

Film Review: Suboxone

I had a chance to get more information about the new Suboxone film. I’ve decided I like it. It looks like one of those Listerine breath strips, and dissolves like one, too. When placed under the tongue, it dissolves faster than the tablets, but the taste is apparently about the same. The drug company’s representative brought me an inert (no active drug) film that’s supposed to taste exactly like the real thing. It was orange-flavored and bitterly sweet. While not terrible, it wasn’t tasty. But it was bearable. It dissolved very quickly, an advantage over the tablets.

I was concerned that my patients on 4mg or 12mg couldn’t use these films, as I heard they couldn’t be cut. But the drug company rep said the drug was evenly distributed on the film. Though the company’s official position was the film shouldn’t be cut into halves or fourths, it would probably work.  But she also reminded me that the drug company also says that about the tablets, but my patients use half-tabs frequently with no ill effects.

I don’t see any way the film can be snorted, though some creative and intelligent addict will probably find a way.

The films are contained in individual sealed pouches. Each pouch from the same box has the same number on it, meaning it would be very difficult to “fake” a pill (film) count if the doctor asked a patient to return to the pharmacy to make sure the appropriate amount of medication remains. If films from another box are substituted to make the count right, they will have different numbers. Very clever of the drug company. Oh, and the rep said the film would cost the same as the Suboxone tablet.

The film is available in pharmacies willing to stock it. If you are on Suboxone and want to try the film, be sure to ask your pharmacy to order it a few days before you think you will want to fill a prescription, to make sure they’ll have it.

I hope this delivery form is easier for patients and harder to divert or snort.