Tuesday, November 22, 2011

Older ER Patients Less Likely to Get Pain Meds, Data Shows - Health News - Health.com

Elderly patients are less likely than middle-aged patients to receive pain medications in U.S. hospital emergency departments, even when they have severe pain.

That's the finding of researchers who analyzed data collected from U.S. emergency departments between 2003 and 2009.

Among patients with a primary complaint of pain, an analgesic (such as morphine, oxycodone or ibuprofen) was given to 49 percent of patients 75 and older, and 68 percent of patients aged 35 to 54.

An opioid (such as morphine or oxycodone) was given to about 35 percent of elderly patients and 49 percent of middle-aged patients, the investigators found.

Age-related differences in the use of pain medications remained even after the researchers adjusted for factors such as sex, race/ethnicity and pain severity. Elderly patients were nearly 20 percent less likely to receive an analgesic and 15 percent less likely to receive an opioid than middle-aged patients.

Even among those with severe pain, elderly patients were less likely to receive pain medications than middle-aged patients (67 percent versus 79 percent, respectively).

The study was published online ahead of print in the Annals of Emergency Medicine.

The reasons why elderly patients are less likely to receive pain medications aren't clear but doctors may be concerned about potential side effects in older patients, suggested lead author Dr. Timothy Platts-Mills, an assistant professor of emergency medicine at the University of North Carolina at Chapel Hill School of Medicine.

"To us, the gap we observe in pain management for older patients highlights the need to better understand how best to manage pain in older patients and understand the barriers to doing this. All patients, regardless of age, deserve to have relief from pain, especially when it is severe," he said in university news release.

Each year in the United States, patients 65 and older make more than 20 million visits to hospital emergency departments and nearly half of those visits are pain-related.


Navigating the Long Road to a Sjogren's Diagnosis - ABC News

Suffering for over six years with widespread, unidentifiable pain and fatigue is a test of patience. For me, the answer came years after seeing dozens of doctors shrug their shoulders at my condition or say I was in excellent health since I looked well.

After enduring endless exams, rounds of blood drawing, body and brain scans, all for no diagnosis at all, I was determined to get answers somewhere else and that's what landed me mid-country. I finally found my diagnosis in the Midwest, thousands of miles away from my home in Massachusetts.

This specialist asked me to describe everything of concern. Then he examined me and began to write his note. Every few sentences, he stopped, turned the computer screen in our direction, and asked me and my husband whether he had captured my problem accurately. We were amazed since no other specialist had ever double checked with us before. No other doctor outright explained my care as a team effort.

And then, a week later, the diagnosis: Sjogren's syndrome -- an often overlooked but serious autoimmune disorder.

Nearly 4 million Americans suffer from Sjogren's, and 90 percent of whom are women. As I looked through the symptoms for Sjogren's, I found myself identifying with most characteristics I saw on the list – symptoms like widespread muscle soreness, joint pain, brain fog that ways so extreme I had trouble sorting through the mail. I also felt fatigue so extreme that I felt like I got hit by a truck.

More importantly, my pain had a name. And a name meant I would finally get the right treatments.

But coming to the diagnosis required a Herculean effort.

My medical file was stacked high with referral notes and test results, which translated into months of pain unexplainable by doctors, and a growing sense of hopelessness that I would ever be diagnosed, or recover. Five rheumatologists, two neurologists, two immunologists, one infectious disease specialist, several endocrinologists, two psychiatrists, three integrative medicine doctors, two functional medicine doctors and multiple primary care physicians later, I was fed up playing the medical pinball machine.

"She looks well and in excellent health," one part of my file read. "Would benefit from stress reduction dealing with the natural effects of aging, a little tucking in around the edges."

But I knew I wasn't well.

Another part of my file read that I was "doctor shopping," a term used to describe pain pill addicted patients who are fishing for a diagnosis just to get prescribed more pills.

As a PhD clinical psychologist and board member of one of Massachusetts's leading medical systems, I am involved in broader discussions about how patients can better navigate the system more efficiently to get the right diagnosis and treatment faster.

I never thought of health care as a maze until I found myself on the opposite side of one of the top healthcare systems in the nation, this time as a patient suffering from progressively debilitating pain. That may have been one the greatest eye openers on medical system operations than board meetings could offer.

More than 80 million people in the United States suffer from chronic pain, most of whom are women, according to the American Chronic Pain Association. And each year, nearly $100 billion is wasted due to reduced productivity, sick time and medical costs associated with chronic pain.

For the first time, these statistics made personal sense. I imagined that if I did not have the credentials or the backstage pass into the health care system -- if I was "the average patient" -- perhaps nothing could have navigated me through getting the right diagnosis and treatment for my pain.

I had been bounced from specialist to specialist in the greater Boston area where, despite my significant contacts were dismissed summarily to other specialists when my symptoms were confounding, and endured innumerable repetitions of paperwork, exams and lab protocols, many duplicating those done only days earlier.

I had experienced the emotional distress of a first-hand look at healthcare systems gone awry; even within the same healthcare system, clinicians had not consulted with each other, clinical record errors were passed on and further misconstrued, and countless dollars were unnecessarily expended.

Worse, no one seemed the least bit concerned. If I occasionally pointed out the lack or break in process, I was frequently met with a blank stare. It was almost as if no one cared, as if they themselves were not part owners of the process that was operating.

This problem persists in more places across the nation that just my neighborhood. Online patient chat boards echo the same story, and many chronic disease advocacy organizations, besides those dedicated to Sjogren's, spend entire meeting sessions dedicated to helping their members navigate a difficult to diagnose condition.

There's no cure or Sjogren's, but there are treatments to manage the symptoms. While it may be difficult for many of us, except for researchers, to curb the prevalence of chronic conditions like Sjogren's syndrome, there are certainly ways to reduce the personal cost burden and the frustration.

First, write a simple timeline of your problem connecting dates and symptoms. I tried to keep my timeline as concise and accurate as possible. Second, carry copies of your records with you for any visit. Despite electronic medical records, many doctors still aren't using them and, in any case, they usually can't see things across different healthcare systems. I owned my medical chart and it helped me understand my condition better throughout the process.

Third, persist. Don't discount your feelings if you think something is wrong. Experts are highly skilled and deserve the same respect given to you, but even they can't keep up with the flood of new discoveries being made. Be sure to put your most important questions first, in case the doctor and you run out of time.

Finally, for a perplexing or very serious problem, seek out a medical center of excellence, preferably one that explicitly advertises itself as putting patients first. The system in the Midwest had this motto written everywhere, and it actually turned out to be the way people treated each other.

Diagnosis of what can be a progressive disease is a bittersweet experience. I learned that being an expert did not automatically make me an informed patient. Until bigger changes are made among healthcare stakeholders and experts -- the implementation of electronic medical records, more emphasis on patient-provider communication – it's up to patients to find shortcuts in the maze, and share those pearls of wisdom with those of us who took the long way to better health.

Jessica Wolfe, MPH, PhD, has been an entrepreneur, behavioral researcher, and executive in healthcare, health sciences, and public health for over 30 years.


Friday, November 11, 2011

Hurt All Over - Diagnosis - Dr. Lisa Sanders - NYTimes.com

'Will you please see my sister?' the young woman asked Dr. David Podell, who was a friend of a friend and had a reputation as a kinder version of TV's Dr. Gregory House. People told her that Podell was a doctor who specialized in diagnosing odd diseases, and she hoped he might finally solve the puzzle of her older sister's mysterious illness.


Over the past 10 years, the patient — now 33 — became completely disabled by strange pains and odd episodes of weakness that no one could explain. The sister handed Podell a letter from the patient. "I am very desperate for help," she wrote, "and I am struggling every day all day without relief. I have heard you are the best, and if there is help out there, you are the one who will find it. . . . Please give me back my future."

Podell wasn't sure he could help but wanted to try. The patient, however, lived in Ohio, and Podell was in Middlebury, Conn. If she were going to travel, Podell told the sister, he wanted to make sure that he could do something for her. He would need copies of her medical records and recent test results, and he would need to talk with her before he saw her.

That weekend, Podell called the woman. Her voice was soft and high-pitched and sounded younger than her 33 years. She told him that her whole life had been one of near-constant pain. It became unbearable when she was pregnant and developed crippling back pain. Now, seven years after her daughter was born, her entire body ached almost all the time.


Her joints hurt, she told him. So did her muscles, even her skin. She was tired yet couldn't sleep. She had frequent migraine headaches. She had irritable bowel syndrome. She was severely depressed. She had fibromyalgia, anemia, endometriosis.

Recently she had episodes during which she would lose her strength on one side of her body. The first time it happened, it was just her left arm. She went to the emergency room, where a doctor was worried that she'd had a stroke. But a CT scan of her head was normal. Her strength returned within days. She had seen so many doctors, and no one knew what was wrong. Her voice broke on the phone. He could hear her sobbing quietly.


Podell is a rheumatologist — a specialist in diseases of the tissues that hold the body together — bones, muscles, tendons. He sees a lot of people who have pain all over their bodies. But he was worried about seeing this patient. "She'd put all her eggs in my basket," he told me. "And I didn't want to drop it." So in addition to having her doctor send him all the studies she had so far, he wanted her to get other tests — lots of tests. He was determined not to miss this diagnosis. "I went for the zebras," he said, meaning rare diseases, "because frankly, after all the doctors she's seen, I was pretty sure all the horses had already been looked at."


Podell has a list of unusual diseases that he considers in patients who have this kind of diffuse pain. The list includes hepatitis B and C; Lyme disease; Sjogren's syndrome (which affects the glands that produce tears and saliva); lupus and other diseases of the connective tissues; H.I.V.; thyroid disease; celiac disease (which affects the digestive system and is triggered by foods containing gluten).


The patient's doctor in Ohio sent records from the past two years. The patient had seen two pain specialists, a gastroenterologist and an allergist. She had been scoped, X-rayed and CT scanned. She'd been stuck for blood and pricked for allergies. Most of the tests were unrevealing. But two stood out: in 2009, two blood tests were performed for celiac disease, and both were positive.

Then results from tests that Podell ordered started to arrive. As before, most were unrevealing, with the sole exception of those testing for celiac disease, which were strongly positive. Podell was excited, but a blood test is not a diagnosis, he knew. False positives are not unusual, so generally a biopsy of the small intestine is recommended. The patient hadn't had one. In addition, the patient saw a gastroenterologist earlier that year, and he didn't even mention celiac in his note. Had it already been ruled out somehow?


Three weeks after they spoke on the phone, the patient came to Podell's office, accompanied by her mother and the sister who had made the arrangements. As they exchanged pleasantries, Podell quietly began his examination. The first thing he noticed was that the patient was much smaller than her sister and mother. She was only 4-foot-9. Otherwise she looked well. He listened carefully as the three women told him about the woman's years of pain.


While the patient undressed for the physical, Podell hurried to his office to read up on the ways celiac disease affects the body. He knew that short stature, abdominal pain and diarrhea were associated with the disease. What else? The list he found was long: neuropathic pain, headaches, psychiatric disorders, iron deficiency, vitamin D deficiency — she had all of these.

Podell examined the woman, and she was extremely tender; everywhere he touched was painful — especially her muscles and skin.

Podell then asked what might have been his most important question: Had she ever tried a gluten-free diet? If she had but hadn't improved, that would make celiac disease very unlikely. The patient said she had tried the diet. After the positive test two years earlier, she gave up pasta and bread for a month or so. But she didn't feel any better, so her doctor said to forget it. Podell smiled. She hadn't really been on a gluten-free diet. Even small amounts of gluten in, say, cereal or baked goods would make her sick. This was celiac disease. He would bet on it.


Celiac is an inherited disease of the small intestine that causes abdominal pain, diarrhea and an inability to absorb nutrients. When affected individuals are exposed to gluten — a very common protein found in cereals and grains — they develop antibodies that attack the lining of the small intestine. Once the absorptive lining is injured, the small intestine can't do its job of taking up nutrients from food. The undigested foods go on to cause abdominal pain, bloating and diarrhea. This patient had some of these digestive symptoms, but mostly she had pain — nerve pain, muscle pain, headaches, depression. These are also seen in patients with celiac disease. What causes these other symptoms isn't known.


Podell sent the patient to a nutritionist to learn the fundamentals of the celiac diet. She has been disciplined about eating gluten-free for nearly three months. She has more energy and less pain, and she's back at work — not quite full time, but she's getting there.

I asked Podell why the patient did so much better this time than she did two years ago, when celiac was suggested as a possibility. He said that maybe her doctors didn't really think she had celiac, and so she didn't think she had it either. "I was very enthusiastic about this diagnosis. And I thought she really had it. So maybe it was the nonscientific component — the salesmanship — that made her try and stay with it."

This case is a reminder of an important precept in medicine: a diagnosis isn't really final until it is embraced by both the patient and the doctor. That's the real art of diagnosis and an essential part of the cure.

Monday, November 07, 2011

Are Doctors Really to Blame for the ‘Overdose Epidemic’? | TIME Healthland

Forty people die each day from what Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention (CDC), calls an "epidemic" of prescription drug overdose. Frieden largely attributes the rise in overdose deaths, which have tripled since 1999, to overprescribing by doctors. But the reality is much more complicated.

At Tuesday's teleconference announcing the release of new CDC data on the problem, Frieden said, "In fact, now the burden of dangerous drugs is being created more by a few irresponsible doctors than by drug pushers on the street corners."

Such hyperbole is unlikely to lead to effective solutions for an extremely complex problem. Panics over addiction have always tended to focus relentlessly on supply, while failing to understand demand. In this case, unnecessary hysteria may also serve to reduce legitimate patients' access to needed pain treatment.

MORE: U.S. Aims to Reduce Overdose Deaths, But Will the New Plan Work?

Let's start with the facts: the vast majority of people who misuse prescription painkillers — 7 out of 10, according to drug czar Gil Kerlikowske — get them from family or friends, not directly from doctors. Secondly, most people addicted to these medications have used illegal drugs previously; they do not become addicted while being treated for pain.

A 2007 study of nearly 1,400 people addicted to OxyContin, who were treated at rehabs across the country, found that 78% had never been prescribed the drug themselves; the same percentage had been in rehab for a previous drug problem. Earlier data found that 80% of those addicted to OxyContin had previously used cocaine, a rate many times that seen in the general population.

That overlap is not likely to be attributed to pain patients who suddenly decide to try cocaine. The more probable explanation is that painkiller addiction is primarily affecting people with current or previous drug problems, not innocent patients being treated by pill-happy doctors.

Indeed, it is impossible for a doctor to "make someone" into an addict. Even if the doctor tied the person down and injected him or her daily with heroin or other strong opioids, only physical dependence could be created. That means the person would suffer withdrawal symptoms when the doctor stopped, but whether such victims genuinely became addicted would be determined by their own actions after that point.

MORE: Fueled by Growing Painkiller Use, Overdose Deaths and Child Poisonings Are on the Rise

If the research data is anything to go by, most people who use illegal drugs don't subsequently go looking for dealers or rob their grandmothers to get money to buy more. Of those who try heroin, more than 80% do not become junkies. Likewise, among adults who are legitimately prescribed opioid painkillers and who do not have past histories of drug problems, more than 97% don't develop new addictions.

Normal, healthy people given these drugs tend to find them unpleasantly numbing, not overwhelmingly attractive. Even among soldiers who served in Vietnam — 45% of whom tried opium or heroin while serving — just 1% developed ongoing heroin addictions that persisted after they came home.

Addiction doesn't just "happen": it requires people to choose repeatedly to use drugs to get high or to escape. By definition, this behavior must occur despite ongoing negative consequences; otherwise, it is not classified as addiction.

Moreover, although people with addiction often have genetic predispositions or exposures to traumatic experience that make drugs especially attractive to them, and although continued use itself can impair decision-making, they are not automatons with no free will. Their ability to choose not to take drugs may be reduced as they get hooked, but it's not eliminated: after all, no one shoots up in front of the cops.

MORE: Should an Overdose Antidote Be Made More Accessible?

The fact that addiction is not just about access to drugs is why talk of drug "epidemics" rarely changes their course. Supply-side efforts have had little effect on addiction rates. The exponential growth on such spending since Ronald Reagan declared war on drugs in the 1980s has no correlation whatsoever with rates of drug problems. The recent crackdown on prescription opioids began in the mid-2000s, with intense concern over OxyContin misuse — and yet overdose deaths continue to rise.

If we want to reduce opioid addiction, it might help to try to figure out why so many people feel the need to escape. And if we want to reduce opioid overdose, it might make sense to distribute the antidote, naloxone (Narcan), with prescriptions and make it available over the counter. Unlike efforts to restrict prescribing, this won't hamper appropriate pain care, and unlike rhetoric about epidemics and associated crackdowns on supply, there's actually a growing body of literature suggesting that Narcan saves lives.

Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland's Facebook page and on Twitter at @TIMEHealthland.


Sunday, November 06, 2011

Academy of Pain Medicine Announces Two-Day Course for Safe Prescribing for Your Primary Physician - PRNewswire

On the cusp of the recent Centers for Disease Control and Prevention (CDC) report about the growing death toll from prescription drug deaths, the physician leadership of the American Academy of Pain Medicine (AAPM) announced its plans to roll-out a new education initiative:  Safe Opioid Prescribing: Reversing the Trends.
Debuting as a two-day course that will be held in Palm Springs, CA, in February 2012, the Safe Opioid Prescribing program is based on clinical research and data in the field of pain medicine that has been effective in minimizing the risks and reducing the number of deaths associated with opioid prescribing for chronic pain by educating family physicians, internists and other primary care clinicians.
"We have been deeply concerned about the serious public health problem of unintentional overdose deaths from prescription medications.  The Safe Opioid Prescribing program is one way we are actively seeking to make a difference in this issue by sharing our expertise with other clinicians, who may not be as aware of the most relevant information in prescribing and the practice of pain medicine," President Perry G. Fine, MD said.
As the lead clinical experts in the specialty of pain, the physician leaders from the American Academy of Pain Medicine have dedicated countless hours to problem-solving on this issue, including:
  • Collaborating with the Office of National Drug Control Policy (ONDCP).
  • Working with Senator Jay Rockefeller (D-WV) and others to seek better pain care.
  • Providing clinical testimony to the Food and Drug Administration (FDA) around the Risk Evaluation and Mitigation Strategy (REMS) for long-acting and extended-release opioid drugs.
  • Collaborating with the Federal State Medical Boards (FSMB) to effect responsible prescribing patterns among all physicians of every specialty.
  • Accrediting a second edition of AAPM's Past President's Scott Fishman, MD's "Responsible Opioid Prescribing" publication, which has become an authoritative reference for safe prescribing.
  • Ongoing education to the medical community about the latest science and treatments for pain. The June 2011 issue of the Academy's journal, Pain Medicine published a series of manuscripts describing the complexities of the problem of safe prescribing, but also identified where significant progress has been made to curb and reverse this serious issue.
"We strongly believe that prescribers, policymakers, and our communities must work collaboratively to ensure all patients who need prescription medication have access to them but are safely and appropriately prescribed and consumed," Dr. Fine added.  
These efforts align perfectly with the recently released CDC report, which concludes "Improving the way prescription painkillers are prescribed can reduce the number of people who misuse, abuse or overdose from these powerful drugs, while making sure patients have access to safe, effective treatment."
The Academy's Safe Opioid Prescribing Program has the statistical base of proof that reversing the trends is indeed possible.  It is based on a successful pilot program that was launched in 2007 in Utah through the Utah Department of Health (UDOH), when a public awareness and provider educational program effectively reversed trends of unintentional drug deaths in the state. 
"After the first year of the 2007 campaign, the state experienced its largest decreases in prescription drug deaths since 1994," AAPM Board Member Lynn Webster, MD said, citing the UDOH findings. 
"These findings were remarkable," Webster said.  And, that is when he began building the foundation of what is now the AAPM's Safe Opioid Prescribing curriculum that uses the experts in pain and the science of prescribing to help inform clinicians and ultimately patients and their families how to safely prescribe, use pain medications and to find ways to reverse the trends of overdose, death and diversion."
"It's a well-known axiom: if you want the most trusted and reliable information, go to the most reliable resource," said Dr. Webster.  "We have invested so much time and energy researching and preparing to share our success and expertise with others for the good of society.  This is a program that every physician should plan to attend," Webster said.
More information about the Safe Opioid Prescribing: Reversing the Trends Course, as well as the other programs of the Academy will be posted on the AAPM website when available at www.painmed.org.  

CDC seeks data to help curb overdose deaths | Business Insurance

Those and other CDC recommendations accompanied a report concluding that U.S. deaths from prescription pain-killers more than tripled during the past 10 years, with more than 40 overdose deaths occurring daily.

The U.S. Centers for Disease Control and Prevention last week called for tapping workers compensation claims data and cracking down on "pill mills" to avoid an epidemic of prescription pain medication overdose deaths.

While some insurers, self-insured employers and state agencies already track prescription data to prevent abuse and misuse of prescription narcotics known as opioids, others could undertake such measures or refine their practices, said Christopher Jones, a health scientist for the CDC in Atlanta.

"We want to make sure that it's a concerted effort for all the companies out there, whether they are health insurers, pharmacy benefit managers...or workers comp claims programs," Mr. Jones said. "Because, one, they can save money, but it also can save lives."

The growing issue of prescription painkiller abuse is the subject of Business Insurance's newly launched workers comp channel solution arc at www.businessinsurance.com.

Other federal and state efforts, meanwhile, are focusing on arresting pill mill operators.

The law enforcement efforts have been particularly focused in Florida, although other states are not immune from pill mill operations.

Pill mills tend to be storefront operations, often operated by "rogue doctors" who "are in fact drug dealers," and Florida is "ground zero" in the fight against them, the U.S. Drug Enforcement Agency said in a June statement.

Florida's pill mills "are now the primary source of drug diversion in the Eastern United States," according to a statement from the state attorney general's office.

"Florida leads the nation in diverted prescription drugs, resulting in seven Floridians dying every day and countless others throughout the nation," according to the attorney general's office. "Our state has become the destination for distributors and abusers through the proliferation of pill mills."

Observers say Florida became a pill mill haven because of the state's history of lax prescription drug enforcement, which officials are working to change.

One operation spearheaded by the DEA against illegal drug dispensaries in Florida was dubbed "Pill Mill Nation." It coordinated the efforts of federal and state agencies including the Florida Department of Financial Services' Division of Workers' Compensation, to help monitor any insurance billing.

But the pill mills typically require payments in cash, sources said.

Because of that and other reasons, it's likely that workers comp claims payers have not substantially contributed to their revenue, state and federal sources said. And it is possible that workers comp claimants who have become addicted to opioids through treatment provided for their workplace injuries may find their way to pill mills.

However, studies to determine the extent of such behavior have not been conducted, the sources added.

"I am not aware of any data specifically tracking patients who were at one time in a workers comp program subsequently receiving their prescriptions from pill mills," the CDC's Mr. Jones said. "Certainly, we know people who are suffering with addiction to prescription painkillers may seek drugs at a pill mill."

According to last week's CDC report, "prescription painkiller sales per person were more than three times higher in the highest state, Florida, than in the lowest state, Illinois."

But Florida is not the only state grappling with the problem.

A health care fraud team for Ohio's Bureau of Workers' Compensation has been investigating and prosecuting doctors operating pill mills, although the mills are not the only problem, a bureau spokeswoman said.

Ohio's bureau also has publicized its recent prosecutions of claimants for "deception to obtain a dangerous drug," or visiting several doctors to fill the same prescription.

In one among several such cases, an Ohio claimant pleaded guilty after investigators found that he provided his adult granddaughter with narcotics prescribed by his workers comp doctor. The granddaughter sold his Opana for $50 per pill and his Percocet for $12 per pill on the street and split the profit with the claimant, according to the bureau.

To stem the use of prescription pain medication nationwide, the CDC wants state health and insurance regulators to encourage "use (of) prescription drug monitoring programs, public insurance programs and workers compensation data to identify improper prescribing of painkillers."

In its "Vital Signs" report, the CDC also encouraged state regulators to adopt and enforce laws that prohibit pill mills and doctor shopping. It also encouraged licensing boards to "take action against inappropriate prescribing."

In total, opioid pain relievers were involved in 14,800 U.S. deaths in 2008, or 73.8% of the all prescription drug overdose deaths, the CDC reported.

"The take-home point—and this is why we are calling on insurers and others to take action—is to improve how the drugs are prescribed," Mr. Jones said. "And certainly insurers have influence on how practitioners practice. They have reimbursement mechanisms, they have claims review processes; and we think that they can help positively impact the ways prescribers are using these drugs, which in turn helps make sure that patients that need these drugs can get them, but it also reduces the number of people that are abusing them and dying," he said.


Tuesday, November 01, 2011

More Deaths From Opioids Than Cocaine, Heroin Combined - Medscape

The number of overdose deaths from opioid prescription pain relievers (OPRs) in the United States has reached epidemic proportions and is now greater than fatalities from heroin and cocaine combined, according to a new report released by the Centers for Disease Control and Prevention (CDC).

According to CDC director Thomas Frieden, MD, MPH, 1 out of every 20 adults in the United States — 12 million individuals — has a history of inappropriate narcotic use, a problem that largely stems from inappropriate prescribing.

Data from the Drug Enforcement Administration shows sales of OPRs to pharmacies and healthcare providers have increased by more than 300% since 1999.

According to the report, enough prescription painkillers were prescribed in 2010 to medicate every American adult around the clock for a month. Although most of these pills were prescribed, many were diverted and ended up being abused.

"The burden of dangerous drugs is being created more by a few irresponsible doctors than drug pushers on street corners," Dr. Frieden told reporters attending a press briefing.

Fastest-Growing Drug Problem

The issue of prescription opioid abuse has been front and center for some time and garnered particular attention in April 2011 when the Drug Enforcement Administration (DEA) announced a comprehensive action plan to stem the United States' national drug epidemic.

Among other initiatives, the federal plan called for pharmaceutical companies to pay for targeted educational initiatives for prescribers and included support for the expansion of state-based prescription drug monitoring programs and support for law enforcement efforts that reduce the prevalence of "pill mills" and doctor shopping.

"Prescription drug abuse is our nation's fastest-growing drug problem... and the facts as outlined are truly devastating," said Gil Kerlikowske, director of National Drug Control Policy.

Kerlikowske added that state laws and policies can make a major difference to curbing the prescription drug problem in the United States. So far, 48 of 50 states have implemented state-based monitoring programs designed to reduce medication diversion and doctor shopping.

In addition, the Department of Justice has conducted a series of takedowns of rogue pain clinics operating as "pill mills."

The Obama Administration has also signed into law the Secure and Responsible Drug Disposal Act, which will allow states and local communities to collect and safely dispose of unwanted prescription drugs and support the DEA's efforts to collect unneeded or expired prescription drugs.

Wide Variation in Mortality Rates

To better understand the scope of the problem, the CDC analyzed rates of fatal OPR overdoses, nonmedical use, sales, and treatment admissions.

The investigators found that in 2008 drug overdoses in the United States caused 36,450 deaths. Of the 20,044 prescription drug overdose deaths, OPRs were involved in 14,800 (73.8%) — more than 3 times the rate in 1999.

Sales of OPRs quadrupled between 1999 and 2010, and the researchers found that nearly half a million emergency department visits in 2009 were due to misuse or abuse of prescription painkillers.

Further, death rates varied 5-fold by state. For instance, they ranged from a high of 27 deaths per 100,000 population in New Mexico to a low of 5.5 deaths per 100,000 in Nebraska.

Perhaps not surprisingly, the study also showed that states with lower death rates had lower rates of nonmedical use of OPRs and OPR sales.

With a rate of prescription opioid sales of 12.6 kg per 10,000 population, Florida had the highest rate of OPR sales. Illinois had the lowest rate of OPR sales, at 3.7 kg per 10,000 population.

The CDC estimates that nonmedical used of prescription painkillers costs health insurers up to $72.5 billion annually in direct healthcare costs.

Treatment of Last Resort

According to Dr. Frieden, opioids should be used only when all other treatments fail. It is possible, he said, to provide patients with adequate pain relief without necessarily resorting to narcotics. Such strategies range from addressing mood disorders to prescribing physical therapy for pain relief.

"There are many things that can be done to increase patients' comfort and functionality without risking a lifetime of addiction," he said.

In cases where narcotics are necessary, he added, physicians should prescribe only the quantity of pain medications needed based on the expected length of pain.

"For example," said Dr. Frieden, "if someone comes in with acute pain, 3 days rather than 30 days [of OPR] should be the standard."

He noted that many hospital emergency departments around the country are rethinking their use of long-acting narcotics, recognizing that perhaps the clinician who provides the patient's ongoing care is the best source for these types of highly addictive medications.

Patient education is also critical, said Dr. Frieden, and it is important for them to understand the risks of opioids and how to use, store, and dispose of them safely.

"Nonmedical use of prescription pain killers costs the healthcare system an estimated $70 billion a year, but there are measures that can be taken, particularly by states, where we have a huge variation in the rate of prescriptions and the rate of prescription overdose and overdose deaths.

"Through better monitoring and by taking appropriate action for patients and providers that are using these medications inappropriately; by cracking down on pill mills and doctor shopping and doctors who are prescribing inappropriately and by promoting good medical practice...it is possible to make a big difference and reduce this epidemic to controllable levels," said Dr. Frieden.