I have just returned from a two week visit to India which including participating in the 19th meeting of the Indian Association of Palliative Care.  It was great to meet old friends and colleagues, and to establish new friendships. I am honored to become one of three international members of the IAPC to serve on the IAPC board.

While talking about opioid consumption in India, I used footage of the documentary Freedom from Pain to bring home the issues (the first 6 minutes of the movie are about India (more later as well).

Let me share with you some facts about India in general

• Population: 1.21 billion (2011 census)
• More people live in India than USA, Indonesia, Brazil, Pakistan and Bangladesh combined
• India will overtake China as most populous nation by 2030.
• 17% of the world’s population

And some numbers as they relate to Palliative care

• 782,565 Cancer Deaths in 2009
• Opioid consumption  (in 2009)
•       morphine equivalents 239 kg (47% morphine)
•       morphine equivalents per person:  0.199 mg/person
•       morphine equivalents per cancer death: 305 mg/death (cf Germany 108,380 mg/death)
• Number of Palliative Care services in India: 700
• Number of Palliative Care services in the State of Kerala: 500
• Estimated 2% of population having some access to palliative care.

India is the world’s leading licit (legal) producer of opium (the latex obtained from the opium poppy plants), accounting for over 90% of global production. Poppy straw is another source of opioids.

Cost of 10 mg IR morphine tablet: 3.5 rupees (7 US cents)

Cost of 10 mg IR q4h for 3 days. 63 rupees (U$1.26)

Cost of 25 mcg/hr patch: 335 rupees ($S6.70)

The Morphine Manifesto calls for access to Immediate Release morphine prior to access to more expensive long acting opioids. It is a result of original collaborations with Pallium India, the International Association of Hospice and Palliative Care and the Pain and Policy Studies Group.

Radley Balko: The New Panic Over Prescription Painkillers.

That, in essence, is the principle of balance, and for decades it has been the guiding principle of the UW Pain & Policy Studies Group (PPSG).  But that is not the impression reporter John Fauber and the Milwaukee Journal Sentinel perpetrated with his Feb. 19 story.

The principle of balance recognizes the needs of patients in pain but also acknowledges the very real risks of dependence and abuse that such medications can pose – especially when they are prescribed irresponsibly.  The UW School of Medicine and Public Health office that provides continuing professional education in health care offered a course, “Responsible Opioid Prescribing,” that is based on a book of the same name.  Mr. Fauber took aim at the book and the course in an attempt to damage their credibility.  But he left out important information and presented a highly distorted picture of the issue.

The UW School of Medicine and Public Health is the home of both the PPSG and the Office of Continuing Professional Development that sponsored the course, which aims to educate prescribers on the appropriate use of opioid medications. Those interested in this issue should read the January 2012 report of the Wisconsin State Council on Alcohol and other Drug Abuse.  The report, compiled by a broad array of organizations that are addressing the problem of drug abuse in this state, points out that decades of data show that doctors have under-prescribed opiates for pain, and that such medications “offer tremendous benefits for patients when prescribed appropriately and used as prescribed.”  The report also notes that ensuring patient access to these medications must be balanced with strategies for reducing the risk associated with these medications. To see the full report, click here:  http://scaoda.state.wi.us/docs/prevandspfsig/FINAL01032012CSWReport.pdf

That has been and continues to be the view of the UW Pain & Policy Studies Group and the goal of “Responsible Opioid Prescribing,” which relies on model guidelines for the appropriate use of these medications.  The book was reviewed by a group of physicians and others experienced in pain management and is the best available guide to careful and thoughtful use of these medications.

Biased reporting not only hurts those unfairly targeted; it also compromises the public discussion of a very important public-health issue, and creates a dangerous environment that may set back the cause of effective pain treatment for thousands of patients.  We hope that Mr. Fauber’s writings do not undo years of work aimed at improving care and reducing human suffering.

I have seen this before in many places.  China in the mid 90s when a military hospital was not using readily available IR Morphine because “pharma” indicated the new standard was SR morphine.  Romania, where with the approval of new drug availability laws, Pharma moved in very quickly to promote various forms of longer acting opioids.  And here was Raj seeing it in India.

In email exchanges with the PPSG and Eric Krakauer at Harvard, Raj outlined what he considered the unethical nature of this process. Very early on, we involved Lilliana De Lima of the International Association of Hospice and Palliative Care.  IAHPC’s Essential Drugs List for Palliative Care includes a statement that countries should ensure the access of IR morphine before ensuring the availability of the longer acting morphine.

The result of this work?

The Morphine Manifesto! 

Have a look, sign your name in support and let’s make the 2012 World Cancer Day a day of action for improved opioid access throughout the world. Promote, share, tweep, like and whatever else you do with your social media tools.

Thanks to Raj for taking the lead on this and Rakesh, a volunteer with Pallium India, for all his excellent work on the website.

Spread the word!!!!

“ProPublica fumbles painkiller story; Seattle Times scores touchdown”

ProPublica leads attack on painkillers by misusing statistics; But Seattle Times investigation uncovers really shocking numbers. 

Coming up to Superbowl, US football analogies are getting thicker.  But this blog headline is certainly attracting attention in pain circles.  Rebecca Goldin PhD and Cindy Merrick, a doctoral student working with her, have reviewed the statistics of the Prescription Opioid Crisis in a STATS blog.  STATS is a non-profit, non-partisan Statistical Assessment Service whose goals are to “correct the scientific misinformation in the media and in public policy resulting from bad science, politics, or a simple lack of information or knowledge; and to act as a resource for journalists and policy makers on major scientific issues and controversies.”

The Painpolicy blog as been challenged as to how we can question the CDC.  Dr Goldin, a mathematician who has no ties with pharmaceutical companies, does indeed question the CDC with its own data.

“ProPublica quotes the CDC’s director, Dr. Thomas Frieden saying, “Right now, the system is awash in opioids, dangerous drugs that got people hooked and keep them hooked.” But neither ProPublica or, for that matter, Dr. Frieden report what the actual CDC’s data says.

This STATS analysis is really worth a read. Yes we have a problem but lets look at the data carefully.   A careful analysis will allow a public health approach to the problem. The authors conclude:

As reported by the MMWR, the tripling of overdose deaths in this time period, from 1999-2008, tracks closely with the period of nearly quadrupled growth of OPR sales. By 2008, the annual overdose death rate from just prescription drugs had quadrupled from 1999. By 2009, the abuse treatment rate was nearly six times that of 1999.  On the other hand, the NSDUH found in 2008 that among people who used opioids for nonmedical purposes, only about 3 percent are dependent a year later.

Unfortunately, this sad, messy, uncomfortable problem is the new addiction reality – and we need the media to reflect this lest more harm be done by crackdown on physicians and pain treatment than good. In this, the Seattle Times series has made a truly vital contribution.”

The full STATS blog is available at
http://www.stats.org/stories/2012/attack_painkillers_misusing_statistics_jan31_12.html

Poisoning is now Dane County’s number one cause of injury death, surpassing motor vehicle crashes. 85% of these poisoning deaths are caused by misuse or abuse of prescription, over-the-counter or illicit drugs. Of particular concern are opiate pain medications: they represent a significant proportion of deaths and non-fatal poisonings, can be overprescribed and can lead to dependence and abuse. This is true in many other communities around the United States.

While there is much to be done in Dane County, it was opportunity for the launch of a new report, “Reducing Wisconsin’s Prescription Drug Abuse: A Call to Action.”  This report from the State Council on Alcohol and Other Drug Abuse had 32 recommendations, which are shared below.

One of the most reassuring things I heard yesterday from both city, country and state presenters.  We need to ensure that those who need opioids for pain control have access.  A great example of balance.

Fostering Health Youth

• 1. Support communities to foster healthy youth

Community Engagement and Education.

• 2. Launch a public outreach and education campaign
• 3. Support community coalitions as the vehicle through which communities will successfully prevent and reduce prescription drug diversion, abuse and overdose deaths.

Health Care Policy and Practice

• 4. Mandate education and training for health care professionals.
• 5. Ensure that chronic pain sufferers have safe and consistent access to care
• 6. Establish standard prescribing practices for urgent care and emergency departments.
• 7. Develop standard screening methodologies for drug-test- ing labs to use in detecting the pres- ence of drugs to include all commonly misused opioids, benzodiazepines, psychostimulants, and related agents, and assure that drug-testing method- ologies used in clinical settings and in post-mortem settings (including the State Crime Lab system) are aligned in order to generate the most consistent and useful data.
• 8. Develop a standard set of treatment protocols for Opioid Treatment Programs (OTPs).
• 9. Establish guidelines to reduce the diversion of prescription drugs by those who handle prescription medications in the course of their daily work.
• 10. Equip healthcare providers and first responders to recognize and manage overdoses.
• 11. The Wisconsin Dental Association and Wisconsin Dental Examining Board should endorse and implement the findings of the Tufts Health Care Institute Program on Opioid Risk Management and the School of Dental Medicine, Tufts University.

Prescription Medication Distribution

• 12. Convene a work group to develop recommendations to increase security measures in the dispensing of prescriptions for controlled substance.
• 13. Implement a system to ensure that, for controlled substance prescriptions, patients are identified in a manner similar to photo identification as required to obtain pseudoephedrine.
• 14. Support a system that increases security and traceability of controlled substances from manufacturer to patient.

Prescription Medication Disposal

• 15. Establish a coordinat- ed statewide system for providing se- cure, convenient disposal of consumer medications from households.
• 16. Integrate medication collection with the Wisconsin Drug Repository.
• 17. Create an infrastructure for the destruction of drugs in compliance with state and federal environmental regulations.
• 18. Identify the causes for prescription drug waste and implement proactive solutions.
• 19. Identify a sustainable means for funding collection and disposal in cooperation with key stakeholders including pharmaceutical producers, local governments, law enforcement, waste management companies, health care providers, pharmacies and consumers.
• 20. Establish a system for effective disposal of consumer medications in all care programs and facilities which complies with state and federal waste management laws.
• 21. Establish regulations that would permit registered nurses employed by home health agencies and hospices to transport unused medications, including controlled substances, to designated drug drop-off and disposal facilities, so that when patient medications are no longer needed, such nurses are allowed by law to assist in their safe destruction.

Law Enforcement and Criminal Justice

• 22. Build bridges between law enforcement and community-based prevention efforts.
• 23. Make drugged driving a priority issue
• 24. Support Drug Courts

Surveillance System

• 25. Design and implement an electronic Prescription Drug Monitoring Program.
• 26. Develop a community early warning and monitoring system that tracks use and problem indicators at the local level.
• 27. Develop a community monitoring and early warning system that tracks overdoses at the local level.
• 28. Improve consistency in reporting drug use and abuse across the state.

Early intervention, Treatment & Recovery Across Lifespan

• 29. Establish guidelines to screen for substance use in all health care settings.
• 30. Promote and support evidence-based screening and early intervention for mental health and substance abuse.
• 31. Integrate high quality medication management and psychosocial interventions for substance use disorders so that both are available to consumers as their conditions indicate.
• 32. Make addiction treatment and recovery support services available both on a stand- alone basis and on an integrated basis with primary health care services, as well as in other relevant community settings.

The Working Group is be commended on what I would consider a rational public health approach to this current problem we are facing in the US. Exactly what my colleagues were calling for in 2006 in their paper,  A public Health Approach to Prescription Opioid abuse and Diversion.