Dr. Kevin Most: Opioid Crisis
Over the past 2 years we have discussed the current Opioid Crisis we are going thru in this country. Our discussions have mainly been on the medical side of the crisis, what do we have to treat an overdose, what are we doing to minimize the use of opioids while still treating pain, what are we doing to help treat the addicted patient and what changes have been made in how we prescribe these powerful medications. That has been our focus and will continue to be as we hope to educate as many listeners as we can about this issue.
If we went back a few years, many felt this was an urban problem with inner city drug abusers and drug runners. What we have seen is this is not only an urban issue and not focused on a simple demographic. This crisis is hitting us from the inner city of Los Angeles to the rural mountains of West Virginia and every setting , in every state in the US. No area is immune to this problem. It is hitting the young drug addict and it is hitting the successful professional business leader, from the patient side it has no boundaries.
Just a few brief stats to set the tone. How did we get to this point? In 2001 a paper came out that essentially said we as a society are doing a poor job in managing pain and in fact it is so important that we should make “pain” the fifth vital sign and our goal should be to eliminate pain. Couple that with pharma companies coming out with synthetic morphine pain medications that they touted as non-addicting and this seemed like a layup. Fast forward 15 years and here we are now, estimates are that we have close to 5 million individuals addicted to pain medications, we have 50,000 deaths from accidental overdoses with more than 20,000 of them specific to opioids. Wait, what about the companies telling us that these drugs were not addictive, well that is not actually true, in fact the most recent studies show that addiction rate is actually quite high.
When you look at data between 1999 to 2010, you see a common theme, sales of prescription drugs went up four times from the base, overdose deaths went up four times and substance abuse treatment went up six times. So pushing physicians to act on that 5th vital sign surely accelerated where we are at today.
However we could not have done it alone, we need companies to make the medications and we needed distributors to get them out, and they did. In 2012 there were 260 million prescriptions written for opioids in the United States, that is enough to give every American their own bottle of pills. As physicians we have some ownership in this problem. Given the challenge to eliminate pain and given a tool we were told was non-addicting we marched on and did it. Insurance companies and regulatory bodies were asking out patients how well did the care giver treat your pain. We were rewarded or penalized based on these surveys.
One of the problems that is actually sitting under the iceberg of the legal prescriptions is the illegal distribution of opioids mainly heroin and fentanyl. These drugs are big problems now as many drug addicts have found that these drugs on the street are easier to get and less expensive than the actual prescription opioids. That being said we have a big problem with medications being prescribed to individuals who then turn and sell them on the street. Big business? You bet, if you have a good insurance plan, chances are that generic opioid drugs may be covered for a minimal co pay. That same drug may bring up to $25 / pill on the street. This is a big problem as there are pain clinics and pharmacies that in some parts of the country dispense huge numbers of opioids. The example shared on 60 Minutes on Sunday had a county in West Virginia was legally receiving 11 million opioid pills in a year, for a total population of 25,000. To put this in perspective, that would mean that every single person in the county, got a prescription for 36 pills, every single month. Many listeners are probably thinking how can that happen, how can that be allowed……
This past Sunday 60 Minutes took on that different view on the problem. It looked at the legal distribution side of the business and the power that these companies have over our elected government officials. If you did not have a chance to watch it, go on line and view it, it will have you angry with how things work in Washington, and how the people we expect to protect us may in fact be working against us in this case. If you have a loved one who lost their battle with addiction you will find the story disturbing. The strategy of the DEA was to stop it at the front end before it gets to the patient, just as many doctors are trying to do, however the DEA had its tools to slow or curb this taken away. The DEA used to be able to look at a distribution pattern and identify where a variation well outside of the expected was occurring and act on that variation. The ability to do this was taken away by a bill that no congressman or senator apparently had an issue with. Was this poor information, poor over sight or the large reach of big pharma and bigger distribution companies?
Drug companies are saying that they produce to demand, distributors are saying they deliver based on orders and any restriction on either of these may impact the care of the patient in pain. The DEA had been saying something completely different they have been saying, we are looking at use patterns and demographics of the community and we couple that with overdose deaths and statistically they have been able to investigate the outliers in this process and can show that these are not legitimate pain patients receiving these prescriptions for the most part. The DEA was attempting to prosecute those who were distributing illegally, it is thought that many of these drugs find their way to the black market. They started by identifying the rogue pain clinic or bad doctor, but found this made little or no impact. They next decided to go up stream to the distributors. The distributor was required to report any unusual large or frequent orders but many did not. When things like this were brought forward by a specific DEA agent the power of money and Washington reared its ugly head and he was removed from his position.
A bill that had the false foundation of ensuring that patients had access to pain medications actually stripped the DEA of its ability to enforce the Controlled Substance Act, which would try to curb the black market distribution of opioids. The sponsor of the bill Congressman Marino of Pennsylvania has recently been put forward as President’s Trump Drug Czar, which has many concerned especially with his recent bill as well his apparent interactions with the pharma industry. Actions like this as well as the number of DEA staff who have left the DEA to go and work for Big Pharma or Big Pharma law firms for salaries well north of their previous federal salaries. The ex DEA now working for big pharma know the rules and no the shortcomings of the DEA and can exploit them. I am not saying all ex DEA that went to work for Pharma Law Firms or big Pharma are bad people, but the concern is that the pharma and distribution side of this problem do not appear to be in any way to restrict or slow the growth of the problem.
This problem is only getting worse and will continue to unless we attack it from many fronts. If we are going to call it a war, act like it is a war. Attack it from every angle, from manufacturing, distribution, treatment, physician partnering, …… every side. It will not be long before each one of us is touched by a needless overdose from a problem that is growing in front of us, yet we don’t see the urgency of this yet. We have more overdoses every day than we do shootings, yet shootings lead the news each day. If we had an infectious disease that claimed 20,000 lives a year it would get a lot of attention and we would all be aware. Influenza ring a bell??