EK HEALTH

by Richard Thompson, MD
EK Health Services' Chief Medical Officer

On November 1, 2011 the CDC (Centers for Disease Control and Prevention) published in an early release in its Morbidity and Mortality Weekly Report (MMWR), their analysis of the epidemic use and abuse of prescription opioid pain relievers (OPR) in the United States.  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 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 workers’ compensation and indemnity insurers 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 actions that can be taken by the legislature, physicians and the medical community to control the use and abuse of OPR:

1. Physicians should never put a patient on an OPR for acute or chronic pain unless they have a definitive plan and explain to the patient that they will not continue prescribing them for more than a few weeks.

2. Emergency room physicians should almost never prescribe OPRs for chronic pain! This is very difficult to do on an individual case, but protocols must be developed. If prescribed, only a limited amount of a short-acting OPR should be used.

3. In emergency rooms and larger medical facilities, only a few doctors should prescribe opioids for chronic pain. These facilities should have a controlled substance monitoring committee, as well as develop protocols for the prescribing of OPRs, review patient and prescriber OPR patterns, and educate their health care providers regarding OPR use and legal issues.

4. Doctors denying OPR to suspect patients should not be held accountable for bad reviews by the patient on Patient Satisfaction scoring. This is particularly true for large hospital settings and their emergency room health care providers.

5. Physicians should only use OPRs in carefully screened and monitored patients when non-OPR medications are insufficient to manage the pain.

6. Physicians prescribing OPRs must learn to appropriately utilize their state Prescription Drug Monitoring Program (PDMP) and learn to utilize and interpret urine drug testing. Registering with their state PDMP should be mandatory.

7. State legislature and state medical societies should be encouraged to establish aggressive programs to regulate and limit the use of OPRs by requiring treating physicians to establish and document objective information on patients with chronic pain.

8. All states should be advised to have a PDMP. These programs allow physicians, public health officials, and law enforcement officials to see which controlled substances patients are getting and where they are getting them.

9. All states should be urged to require continuing education courses for physicians prescribing OPRs exceeding minimal quantities.

10. Utilization Review physicians, while not abruptly denying the use of OPRs, must rigidly adhere to evidence-based treatment guidelines and demand evidence of functional improvement, less pain, and improved quality of life from the prescribing doctor.

Next month I will address many things that can be done at the state and federal level.
To view the recent CDC/MMWR article and obtain additional information go to http://www.cdc.gov/vitalsigns.