Balance, Pain

Reducing opioid diversion; Thinking outside the box!


The ongoing discussion on Prescription Drug Abuse has drawn me back to the recent JAMA Commentary, “Curtailing Diversion and Abuse of Opioid Analgesics Without Jeopardizing Pain Treatment” by Volkow and McLellan (JAMA 305; 13). Dr Volkow is Director of the National Institute for Drug Abuse and Dr McLellan, an addiction specialist at the University of Pennsylvania.

One paragraph strikes me as being of great importance:

“These recommendations for better education and harmonization of pain management should improve pain management and reduce diversion of opioid analgesics. This is an important and practical starting point. It is possible to reduce opioid abuse and diversion while preserving proper patient care, but a comprehensive effort will also require control of nonmedical sources of diversion (ie, stolen medications, illegal prescriptions, illegal pharmacies), clearer guidelines for disposal of unused opioid medications, and incentives for pharmaceutical firms to develop abuse-resistant formulations to prevent diversion.”

Let me comment on 1) the control of nonmedical sources of diversion and 2) the disposal of unused opioids.

Several years ago, my colleagues, Dave Joranson and Aaron Gilson, asked the DEA for information on the amounts of opioids that had been stolen from the supply chain (JPSM, 2005; 30(4)).  The results were staggering for the 22 states for which they provided data: From 2000 to 2003, there were 12,894 incidents of theft, primarily from pharmacies, of millions and millions of dosages of opioid analgesics, before they were prescribed and reached the hands of patients.  In another irony, it appears that the amounts stolen plus the amounts pharmacies buy to re-stock what was stolen would both be reported as “consumed.”  So it is possible that so-called “opioid consumption data” may contain a kind of inflation factor that allows illicit diversion to be counted as medical use of opioid analgesics (e.g. USA Oxycodone data  http://www.painpolicy.wisc.edu/internat/AMRO/USA/united_states_americaopioids.pdf).  I would also put the “pill mills” that have nothing to do with pain control into this category.  Having more accurate data is essential to addressing the problem.

Volkow and McLennan go on to state that “access to unused left-over medications has been reported as the main source for diversion among youth.”  And these are not just long acting opioids; “after excluding alcohol and tobacco, the prevalence of hydrocodone abuse is second only to marijuana abuse.”   Addressing this issue requires both addressing the supply side and the disposal side.

I recently asked a group of physicians from different areas of practice, what was an appropriate quantity of opioids to prescribe after a procedure for instance, removal of wisdom teeth in a middle aged man (me, 12 months ago).  A consensus?  Not really but it was agreed that it is probably a common practice to ensure that enough is prescribed so as to reduce return calls to the practice and to covering colleagues after hours.  Yes the conclusion of a non random focus group but if it is even partly true, it is not really a rational approach given the problem with unused opioids. For my wisdom teeth, I was prescribed thirty 5 mg tablets of oxycodone.  What if I was allowed to partially fill this, 15 tablets initially with the ability to get another 15 tablets after three to four days? If I only fill the initial 15 tablets I have reduced significantly the number of unused pills in the system without jeopardizing pain control. Can I do this now in Wisconsin?  Not now. Partial filling is only available for patients who have a terminal illness. We need to think outside the box with relation to reducing this problem.

Thinking outside of the box is also important in terms of disposable.  It is ironic that the closed distribution system to keep controlled drugs safe also means that, legally, patients and families have not been able to return unused opioid analgesics to the system. This is beginning to change through Take-Back programs that now receive tons of drugs, the most common in a previous Dane County collection being the short acting opioids.  Too many of us have opioids sitting in medicine cabinets around the country, clearly creating a situation where they may be abused, misused or in fact taken accidentally.

Saturday April 30th, 2011 is the second National Prescription Drug Take Back Day in the US. It is not just for opioids but is an opportunity for people to make an active decision to remove these from  http://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html. Too many of us have opioids sitting in medicine cabinets around the country, clearly creating a situation where they may be abused, misused or in fact taken accidentally.

As we work to ensure people have adequate access to opioids, we all, including the patients for whom we prescribe, need to play a responsible role in reducing the risk of diversion, abuse and misuse of these medications, “among the most effective medications for pain management (including noncancer pain).”

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide

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