new york times with article this past sunday on use of prescription opoids (see http://www.nytimes.com/2013/06/23/sunday-review/profiting-from-pain.html?nl=todaysheadlines&emc=edit_th_20130623&_r=0), focusing on an economic analysis but in a broader context. major points:
–in past 10 years, huge increase in use of opioids (sales increased 110% to $8.34B) and number of prescriptions increased 33%. oxycontin has increased 4-fold. narcotic painkillers are the most widely prescribed class of meds in the US (i think it used to be statins)
–this huge increase, along with the potential for diversion etc, has led to dramatic collateral costs: medical, legal, and social. Eg
–use of urine tox screens (increased from $800M in 2000 to $2B om 2013) – we have some patients in drug treatment programs getting tox screens 3+ times/week. rather exorbitant….., and medically unnecessary
–with the increase in accessibility of prescription opioids, there has been a dramatic increase in using expensive drugs to deal with the associated increase in addiction, esp bupreoprphine/naloxone (suboxone) and naltrexone. at our health center, most of my suboxone patients have addictions to prescription narcotics. Suboxone is a really great drug for appropriate addicted patients and many of my patients have done fantastically on it, but its necessity (and high cost) are largely a result of the epidemic of prescription opioids,
–20 states apparently allow MDs to prescribe and sell drugs, noting eg that the price paid to physicians in illinois is about 3x that in the pharmacy; in connecticut the factor is 4x.
–hospitalizations have increased dramatically: with a 3-fold increase from 2004 to 2011 in ER costs for opioid-related issues (non-heroin); a 4x increase in overdose deaths from 1999 to 2010, to 16,651
–for legal issues: dramatic increase in states with (expensive) drug monitoring programs, from 16 in 2002 to 46 in 2012; explosion of “pain clinics”, basically pill mills, leading to dozens of doctors being arrested and, eg in florida (one of the worst states) ultimately to closing down many of these clinics (from 921 to 441 in 2 years after a crackdown). –as many of you know, there was a cape cod “pain clinic” which closed and sent many patients to us, prescribing unbelievable quantities of opioids (one patient on oxycontin 80 tid plus oxycodone 30mg 1-2 tablets every 6 hours plus fentanyl patch).
— and the data are not so good that these drugs are effective in treating long-term pain. unfortunately, many of the real pain clinics in boston, which had included a multi-disciplinary approach (psychologists, neurologists, anesthesiologists) have devolved into just giving injections (anesthesiology clinics), or just giving recommendations for primary care to give opioids, perhaps with adjuvants (tricyclics, gabapentin….). these patients typically need a very multi-disciplinary approach even when the use of opioids seems totally appropriate, though the accessibility to these services in the community is often poor
Pretty striking data. Opioid-seeking is by far the most difficult issue we discuss in our case conferences at the health center, and we do so regularly and repeatedly. opioid prescribing frequently sets up an antagonistic/distrustful relationship (providers being concerned about the true degree of pain/fear of diversion/etc — all very real issues in our community where diversion can lead to opioid deaths; patients who really feel they need opioids think the provider distrusts them and focuses all of their attention on getting these meds). these provider-patient relationships often are the antithesis of the therapeutic relationships we try to establish with our primary care patients.
geoff