by Richard Thompson, MD
EK Health Services' Chief Medical Officer
Last month I addressed some aggressive approaches that physicians and the medical community could do to control the use and abuse of opioid pain relievers (OPR). This month, recognizing that educating doctors about the appropriate use of OPRs is not lessening this problem, we are starting to see alternative state and federal activity to control this problem.
On November 1, 2011 the CDC (Centers for Disease Control and Prevention) published an early release of their analysis of the epidemic use and abuse of prescription OPR in the U.S. in its Morbidity and Mortality Weekly Report (MMWR).
This class of drugs includes Oxycontin®, Vicodin®, Lortab®, Norco®, Dilaudid®, and methadone among many others. These drugs are impressively addictive and frequently diverted to friends, family or sold on the street. The CDC report reviewed the rates of fatal OPR overdoses, non-medical uses, sales, and related treatment admissions from 1999 - 2008. The MMWR is the sentinel reporting format for the CDC and is considered the gold standard for evaluation and recommendations for public health policy in the United States.
In summary, the deaths from OPRs in the U.S. have nearly quadrupled over the past decade. In 2008 there were 14,800 OPR-related deaths and a substantial increase in OPR sales, substance abuse treatment center admissions, and the non-medical use of OPRs. Broken down, this means 40 people die every day in the U.S. from prescription drug abuse and overdose. There is every reason to believe these numbers are continuing to increase since 2008.
Many of us in the workers’ compensation arena are well-aware of the increasing use of controlled substances for chronic pain. Although we seldom see the deaths, we certainly see the non-medical use of controlled substances, the emergency room visits for prescription drugs, and the low-function, non-productive states these drugs so often produce. We see utilization review doctors increasingly demanding improved function and objective evidence of improvement before approving powerful, addicting drugs for the treatment of pain.
Many of us have concern that the workers’ compensation system may be a large source of drugs that work their way into our society. But, as long as treating doctors’ remain naïve, but compliant, to the intimidating, manipulating, bullying behavior of drug-seeking, drug addicted pain patients, we will continue to see the many tragic faces of prescription drug abuse.
All carriers, workers’ compensation and indemnity plans, are alarmed at the staggering cost of these OPRs and their all-too-frequent link with muscle relaxants, anti-anxiety agents, sleeping medications, anti-depressants, and day-time stimulants.
Per CDC, wide variation among states in the prescribing of OPRs is directly related to the amount of OPR – related deaths and non-medical use. Clearly, the states that prescribe the most OPRs have the most problems. While there have been recent crackdowns on “pill mills” around the country there are more aggressive things that can be done by the legislature and the medical community to control the use and abuse of OPR:
Following are several examples of what state and federal activity is emerging:
1. The state of Washington has the strictest regulations for OPR prescribing. In tougher rules beginning in July, 2011 prescribers will have to evaluate and treat chronic pain patients by specific protocols including pain contracts, urine drug testing, written treatment plans, and general doctors will have to consult with pain specialists if the amount of OPR medication reaches a dosage threshold.
2. The state of Ohio, since June 2011, began mandating that physicians at pain clinics complete 20 hours of pain medicine continuing medical education every 2 years. Pain clinics must register with the state medical board, comply with patient-tracking requirements, and agree to random inspections.
3. The state of Florida, although out-of-control with the OPR epidemic, has recently introduced requirements similar to Ohio, but clearly they will need to do much more.
4. The Obama administration is supporting federal legislation to make DEA authorization to prescribe OPRs contingent on completing opioid prescribing education. However, the CDC, the AMA, and the federal government seem to be bogged down with trying to balance patient access to appropriate pain care with the need to reduce diversion, misuse and excessive dosing.
5. Encourage all states to develop their own PDMP. Such programs are now available in 36 states and the number is increasing. You can follow this at the Web site of the National Association of State Controlled Substance Authorities – www.nascsa.org.
6. PDMPs and insurance claims information can identify and address inappropriate physician prescribing and inappropriate patient use. Per CDC, based on this information, state laws need to be enacted, enforced, and rigorously evaluated. We are not seeing this yet!
To view the recent CDC/MMWR article and obtain additional information go to http://www.cdc.gov/vitalsigns.