The LA Times ran a very interesting story a few days ago about deaths from overdose of narcotic pain medications. I strongly encourage readers of this blog to read the story, which discusses the issue from the perspectives of doctors, patients, and family members.
The story reports that a small number of Southern-California doctors wrote prescriptions that have killed a large number of patients. Over the past five years, 17% of the deaths related to prescription-drug overdose–298 people—were linked to only 0.1% of the area’s doctors. I was not surprised by the findings in the article, as I have read stories from other parts of the US reporting similar statistics.
There is a simple reason for the skewed numbers. Prescribing opioids for chronic pain is associated with risk of death by overdose. More and more doctors are avoiding that risk by refusing to treat chronic pain with opioid pain medication. That means that the few doctors who are willing to prescribe such medications are linked to a higher number of deaths from those medications.
Are the doctors who prescribe narcotic pain medications ‘bad doctors?’ Some doctors would claim that they are. I have described the doctors in a group called PROP, or Physicians for Responsible Opioid Prescribing, who take the position that almost all opioid treatment of chronic pain is inappropriate. I understand the point made by those physicians. Treating chronic pain using opioids carries significant risks. Complications, including death, are common. But I have met a number of patients who suffer from severe pain who take issue with doctors who tell them that they are better off without opioid pain medications. And I’ve noticed myself, from my own rare occasional injury, that it is one thing to talk about the proper treatment for someone else’s pain, and another thing when one’s self, or one’s loved one, suffers from pain.
The skewed numbers also demonstrate the problem with online doctor rating systems that report on the complication rate for one doctor vs. another. Across the spectrum of patients in need of surgery, for example, are healthier patients …
A couple weeks ago the manufacturer of Suboxone, Reckitt-Benckiser, filed a Citizens Petition with the FDA, announcing a voluntary recall of one of the company’s signature products, Suboxone Tablets. Suboxone was sold in tablet form for almost ten years, and the patent ran out on Suboxone Tablets last year. A couple years ago the same company began making Suboxone Film; a rapidly-dissolving form of the medication that comes with each dose individually packaged.
Suboxone is used to treat opioid dependence, and the medication has been a vital, albeit expensive, tool for saving the lives of patients addicted to narcotic pain medications or heroin.
Last week I expressed anger at the company for their actions. Uninsured patients treated for opioid dependence pay a high cost for the medication that helps keep them safe, and have been looking forward to a generic form of the medication for years. It appeared to me that Reckitt Benckiser was trying to tarnish the tablets, perhaps to reduce insurance or Medicaid coverage of the tablets when they inevitably (?) hit the market.
I have carefully read through the entire Citizens Petition, and I now have a better understanding of what, exactly, was accomplished by that action by the manufacturer of Suboxone. It turn out that I underestimated the people at Reckitt-Benckiser.
The Citizens Petition explains that Reckitt-Benckiser (RB) hired an independent group, RADARS (Researched Abuse, Diversion, and Addiction-Related Surveillance), to investigate the exposure of small children to Suboxone tabs and Suboxone Film. The results of the RADARS findings are spelled out in detail in the Petition.
RADARS showed an increase in exposure to Suboxone Tabs over the past ten years. They also show an increased rate of exposure, i.e. number of exposures, divided by the number of tabs prescribed. Reckitt-Benckiser wrote that they instituted REMS over the past few years to counter that increase. What are REMS, you ask?
From the FDA site: The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to ensure that the benefits of a drug …
I subscribe to Google news alerts for the phrase ‘overdose deaths.’ Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.
Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.
I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.
In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts. On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even …
As I’ve mentioned, I receive several e-mails each day asking questions about opioid dependence. There are a number of confusing opinions, attitudes, and regulations that ultimately get in the way access to treatment. And with opioid dependence, access to treatment can mean the difference between life and death.
One area of confusion relates to the use of methadone to treat opioid dependence. Methadone is a potent, low-cost pain medication. While a month’s prescription for Oxycontin may retail for $400, $500, or much more, a prescription for a similar amount and potency of methadone costs less than twenty dollars.
Besides treating pain, methadone is used to treat addiction to opioids through highly-regulated programs. Laws allowing for these ‘methadone maintenance clinics’ were enacted in the early 1970’s, to counter the surge in heroin use that began in the late 1960’s . The clinics were located mainly in inner cities, where most of the intravenous heroin addicts were located at that time.
Over the past ten years several corporations have purchased, consolidated, and refurbished methadone clinics, moving them to suburbs and rural areas to match the dramatic increase in addiction to heroin and other opioids in those areas.
Yesterday I received the following e-mail:
Hi Dr. Junig,
Please let me first say – Suboxone SAVED MY LIFE. I was down and out until 2 years ago, when I began using Suboxone. Now, having completed all the pre-req’s for medical school with nothing less than straight A’s, I find myself on track to apply to medical school.
But here’s the problem. I’m still taking Suboxone and have no desire to stop. I will quit if absolutely necessary, but I’m wondering if you’ve heard anything new regarding the legalities of health care providers taking buprenorphine.
I would love to enter a field like psychiatry or family medicine, as these are the doc’s I’ve grown fond of over the past two years. I haven’t told my doctors of my med school plans, as I fear that they will block my attempts to apply/matriculate. Do you have any insight on the subject? Do you know of any patients who have gone on to medical school?
MD to be
I have received a number of similar messages over the past few years. Just today I received an e-mail from a person who wants to become a CNA. I have been asked the same question by people wanting to work as truck drivers, nurses, and police officers, among other professions.
I saw a patient from up north earlier today, and we talked about the economy in his part of Wisconsin and in the Michigan Upper Peninsula. From what he had to say, things are the ‘same old same old;’ i.e. jobs are few and far-between. Seems as if it has been that way for a long time now. And it’s hard to imagine any industry doing well enough in the current economy to make a dramatic change up there.
One change that HAS become apparent over the past year is the increased availability of heroin, now easily found in small towns throughout the upper Midwest.
I’ve seen the same trend closer to my practice, where heroin use has grown from a Milwaukee phenomenon to just another high school temptation. Along with the use of heroin comes something not as often associated with high school; intravenous drug abuse, or IVDA. And a troubling comment pops up more and more during my discussions with people actively addicted to opioids: “Now that O-C’s are abuse-proof, we gotta’ use heroin.”
Like many people with opioid dependence, I did not progress to a severity of illness where I decided that I needed addiction treatment. It would have been less burdensome for my family, of course, had I come to such a realization. But I needed stronger ‘encouragement,’ in the form of life falling apart and having nowhere to turn, except treatment.
The nature of opioid dependence leads the addict to cling to the illusion of power, believing that if he tries one more time— just a little bit harder, or perhaps using some special technique—he will find the will power to taper off drugs on his own, and then avoid them forever.
Of course any person addicted to pain pills desperate enough to walk into a psychiatrist’s office has tried to stopping dozens of times, if not more. That doesn’t prevent cold feet at the prospect of surrendering to the treatment of some doctor, and patients often scramble to reverse the actions set in motion by spouses, parents, and other family members. ‘I really think I can do it this time,’ they say. I’ll cut back by a tiny amount every few days, and THIS time I’ll REALLY stick to the schedule!’
I’ve described the gray area between appropriate treatment of chronic pain using opioid medications, versus deliberate or accidental over-prescribing of narcotics for patients who don’t need them. In many cases, the decision whether the prescribing is justified depends on who is making the determination.
There are clearly physicians who act too aggressively at increasing dosages of narcotics, and there are clearly patients who are too careless in their use of addictive medications. At the same time, there are a number of patients who suffer from severe pain, who are unable to find a physician who will prescribe opioid pain medication– medication that if managed properly could relieve that pain.
And then there are cases that remind me of the famous quote from Justice Potter Stewart, in a 1968 Supreme Court case involving pornography: “I know it when I see it.” Such was the thought that came to me as I read the news story about a physician and his wife, whose prescribing of opioid pain medications has been linked to at least 68 deaths: