“Overdoses involving prescription painkillers are at epidemic levels and now kill more Americans than heroin and cocaine combined. States, health insurers, health care providers and individuals have critical roles to play in the national effort to stop this epidemic of overdoses while we protect patients who need prescriptions to control pain. ”
Thomas Frieden, M.D., M.P.H., CDC Director 1/11/2011
I was going to use the term “rebalancing” to address the issue of opioid access in the USA, but I am not sure there has even been balance. The CDC report, “Prescription Painkiller Overdoses in the US” released yesterday confirms the lack of balance in the US. The CDC director states it well: Stop the deaths from opioids, while ensuring appropriate medical care.
The Cancer Pain Initiative here in Wisconsin grew out of the imbalance in opioid access for patients with cancer. The Pain and Policy Studies Group was created to improve the legislation and regulations that were impeding accessing to opioids, to quote the CDC Director, for those “patients who need prescriptions to control pain.” Restricting the number of pills a patient can get in a 30 day period, allowing only 10 days of tablets on a prescription, or saying that opioids are a treatment of last resort can have dramatic impacts on patients with cancer and other life limiting (or serious) illnesses. And yes access to opioids has improved for patients with life limiting illnesses in the palliative care area, but still has a way to go.
But at the same time, there has been a large movement to make opioids available for non cancer pain. Some say pharma has been behind this. Yes in part, but also from groups like the Joint Commission that has said we need as a profession, to ensure pain relief as part of US Healthcare. Medical groups have agreed that opioids are useful in “carefully selected” patients, but no one is defining who these carefully selected patients are.
To achieve balance, we can do the many things listed by the CDC “What can be done”, but just as the strength of the evidence for the use of opioids in chronic non-cancer pain is questioned, what is the strength of the evidence for these recommendations. Do opioid agreements make a difference and are they ethical? Does random urine testing reduce the risk of misuse, diversion or abuse? If I mandate these into law. will cancer patients be required to sign a “contract” that may increase their perception that they should not be taking medications that may greatly relieve their suffering.
I am greatly concerned about the epidemic of opioid deaths. I am concerned for those who are dying and I am concerned for the potential ramification on the “balance” that may impede appropriate and necessary palliative care. What happens in the US has a huge impact around the world, and the USA’s “War on Drugs” has contributed to poor opioid access for “patients who need prescriptions to control pain” in most other parts of the world.
What do we need? A better understanding of the problem. There is nothing in this week’s report that changes the statistics that Methadone is the leading drug associated with opioids deaths. And these deaths are most common in white middle aged men living in rural communities. And the report quotes from the 2010 National Survey on Drug Use and Health, a report that shows that there has been no increase in the percentage of people misusing opioids (Table 2.3). Maybe is not an increase in the misuse and abuse? Do physicians lack the appropriate knowledge and skills to use these medications? This particularly applies to methadone, a leading cause of opioid deaths (see Fibs, Lies and Statistics: Do you understand the US prescription Opioid Crisis?)
An opportunity exists to establish balance through sensible dialogue with a number of key groups, the White House, DEA, CDC and Civil Society. Let’s seize that opportunity!
A footnote: nonmedical use of opioids in these reports is defined as use without a prescription of the individual’s own or simply for the experience or feeling the drugs caused. Using the vicodan that is in the bathroom cupboard from a family members tooth extraction for a sprain ankle is misuse. Offering a friend a vicodan for a severe headache is misuse. It does not necessarily represent “the start of chronic misuse.”
Source of Prescription Drugs
- Past year nonmedical users of psychotherapeutic drugs are asked how they obtained the drugs they most recently used nonmedically. Rates averaged across 2009 and 2010 show that over one half of the nonmedical users of pain relievers, tranquilizers, stimulants, and sedatives aged 12 or older got the prescription drugs they most recently used “from a friend or relative for free.” In a follow-up question, three quarters or more of these respondents indicated that their friend or relative had obtained the drugs from one doctor.
- Among persons aged 12 or older in 2009-2010 who used pain relievers nonmedically in the past 12 months, 55.0 percent got the pain relievers they most recently used from a friend or relative for free. Another 11.4 percent bought them from a friend or relative (which was significantly higher than the 8.9 percent from 2007-2008), and 4.8 percent took them from a friend or relative without asking. More than one in six (17.3 percent) indicated that they got the drugs they most recently used through a prescription from one doctor, while about 1 in 20 users (4.4 percent) got pain relievers from a drug dealer or other stranger, and 0.4 percent bought them on the Internet. These percentages were similar to those reported in 2007-2008.
- Among persons aged 12 or older in 2009-2010 who used pain relievers nonmedically and indicated that they obtained the drugs from a friend or relative for free, the individuals reported that in 79.4 percent of the instances that the friend or relative obtained the drugs from just one doctor. Only 2.3 percent reported that the friend or relative had bought the drugs from a drug dealer or other stranger.