Prescription drug abuse
Kate Alfano, CMS contributing writer
State effort focuses on safe use, storage and disposal
Aaron started using prescription opioids when he was in high school. From an upper-middle-class family, his parents described him as a typical teenager; light-hearted and full of energy, he was athletic and loved to wrestle. He went to a so-called “pharming” party where students raid their home medicine cabinets, bring any prescription drugs they can find, mix them up in a bowl, pick one or two, and chase them with a beer.
“That’s considered fun, a reasonable thing to do and reasonably safe because the kids think, ‘they’re just prescription medications. How dangerous can pills be?’” said Rob Valuck, PhD, president of the Colorado Prescription Drug Abuse Task Force and coordinating center director of the Colorado Consortium for Prescription Drug Abuse Prevention.
Without major incident from that first experience, Aaron continued his nonmedical use: trying one or two of his parents’ Vicodin, then one or two more; getting more from friends; and gradually falling into a downward spiral. Tolerance led to increased use, then to dependence, and ultimately addiction.
As his addiction became stronger, Aaron started to scam doctors for opioid medications. In an interview with authorities, he estimated that he visited between 40 and 50 doctors over an 18-month period and went to about an equal number of pharmacies to stay beneath the radar. He said most doctors would give him at least an initial prescription for Vicodin. When he developed a tolerance he progressed to OxyContin.
Aaron eventually started using Oxy- Contin at very high doses, often mixed it with Xanax and alcohol, and overdosed at age 21. He had a difficult stay in the ICU: two myocardial infarctions, seizures, a staph infection and pneumonia, on top of extreme withdrawal symptoms. Doctors prepared Aaron’s parents for his death, which appeared imminent and very likely. Surprisingly, he regained consciousness and eventually recovered well enough to be discharged home. But the overdose left him paralyzed and unable to speak.
“The worst consequence is death,” his mother said in a video about this real patient case for the Medicine Abuse Project. “Other consequences are, like Aaron, trapped in your own body alive but unable to communicate in the way that you would hope that you could. You also lose all of your hopes and dreams and everything you wanted to accomplish in your life.”
The growing epidemic
Prescription drug abuse and misuse is serious problem in Colorado and around the United States. In 2010, more than 38,000 people died from a drug overdose in the United States – one every 14 minutes, Valuck said. Nearly 60 percent of those deaths involved prescription drugs and, of those, 75 percent were opioid painkillers. In Colorado, the number of drug overdose deaths range from 250-500 per year; in 2010 it was just over 300.
The rates of misuse and overdose death are highest among men, persons ages 20-64, non-Hispanic whites, and those in poor and rural areas. “That said, this cuts across all strata demographically – age group, gender, race, ethnicity, diagnoses; it’s a problem all over the place,” Valuck said.
And while the public typically hears statistics on overdose deaths, Aaron’s story demonstrates that death isn’t the only outcome. In 2011, for every opioid overdose death, there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who met the medical criteria for abuse or dependence, and 825 selfadmitted nonmedical users.
“What’s gotten our attention in Colorado is that we’re high in the ranking in self-reported nonmedical use of prescription pain relievers among anyone age 12 or older,” Valuck said. “It’s nonmedical use that puts people at very high risk for becoming addicted and having those problems. That’s led us to do something about it.”
A small percentage of providers prescribe the majority of controlled substances. In Oregon, 8.1 percent prescribed 79 percent of these drugs, which Valuck said is typical, especially considering some specialties’ scope of work. “Many doctors prescribe few; some doctors don’t prescribe them ever. It’s really variable and we know that this isn’t an indictment on doctors or one type of doctor.”
However, providers who do prescribe these medications frequently inherently see more higher risk patients and are more likely to have patients who are doctor shopping for opioids. “It’s not necessarily your fault; it’s just the territory,” Valuck said. “You’re working with highly addictive stuff and people who become addicted. That’s where 63 percent of the overdose deaths come, among the 20 percent of prescribers who prescribe the most.”
One of the answers is to try to develop a coordinated response among the many stakeholders. “We could attack this problem at any place in the distribution chain, from manufacturers to the medical system to pharmacies to insurers and payers to patients and the public. Everyone needs education about this,” Valuck said.
As for physicians, he has six recommendations for what an individual can do to help mitigate the prescription drug abuse epidemic.
- Take continuing education courses and seek out additional training.
- Find and follow guidelines for safe opioid prescribing, whichever they are.
- Be willing to prescribe less, whether that’s smaller quantities or other alternatives, and see patients more often.
- Check the prescription drug monitoring program (PDMP) more often.
- Educate patients on the importance of safe storage and disposal of unused medications.
- Talk with colleagues, family, friends and neighbors about the issue and tell them stories about affected patients.
In regard to the PDMP, a bill was signed into law in late May that requires physicians to register for a PDMP account (but not mandate they use it) so they have access when they need it, allows for delegated access of up to three delegates per provider, provides unsolicited reports of potential doctor or pharmacy shoppers, gives the Colorado Department of Public Health and Environment access to the system for public health surveillance, and creates an advisory board to guide implementation and future directions.
Outside of the bill is action by the Colorado Board of Pharmacy to enhance the PDMP system: allow for daily reporting of dispensing data by pharmacies, interface enhancements, batch querying and reporting, and fewer clicks and attestations.
“Over the next six to nine months, we (through the Colorado Consortium for Prescription Drug Abuse Prevention) will be doing a significant amount of public awareness and provider education on safe use, safe storage and safe disposal as a starting point, and we’ll try to work upstream over the next several years about alternatives and doing a lot of things better.”