Quick! Can you name the leading cause of accidental death in the United States now? It is prescription drug overdose. Since 2009 death from legally prescribed narcotics has led auto accident deaths as the number one cause of accidental death in the United States. More than 15000 die now annually.
On October 5, 2012 the Wall Street Journal on its front page published an article “Prescription for Addiction”, which detailed the complexities of prescription drug misuse. It related the story of Jaclyn Kinkade, a doctor’s office receptionist, who died alone last year from an overdose of methadone combined with alprazolam. Her addiction began with Endocet, a drug that contains oxycodone. The doctor who wrote the prescription was her employer; he wrote it for her as she was experiencing pain in her back and neck. Her father had this to say after her death: “Jackie didn’t wake up one day and say, ‘Hey I’m going to be a drug addict today.’ Jackie pretty much got sent there by a doctor.” Near the end of her life she was getting her prescriptions from a pain clinic.
How can we explain and try to understand the rise in legal narcotic misuse and addiction? The answer: Not easily. I believe that the problem has complex roots, including the failure to perceive correctly the breadth of the problem or the sources of the drugs. For instance, if you were to ask someone to describe what comes to mind when they think of a drug addict, most likely the answer would be a picture of an individual in a crack house who is nodding out on cocaine or heroin; the picture is a myth. The fact is that deaths due to legal pain medication far outstrip the number of deaths due to illegal drugs. Most certainly most would not think of someone like Jaclyn Kinkade. If you then informed them of their error and then asked where individuals who are misusing pain medication get their drugs, they more than likely would say that they came from someone, not a clinician, that they knew who had a legal supply of the drugs. That could well be true but the fact remains that most of these drugs come from legal prescriptions—physicians, clinical staff who have privileges to write such prescriptions in their state, veterinarians and pharmacists.
Besides there being a gross misperception of drug overdoses and the sources of the drugs, the acceptance of the use of a variety of drugs to ease pain has steadily grown in recent years. Many states now approve of the use of medical marijuana to ease chronic pain. Surveys nationally are showing an increasing use of marijuana by high school students. This trend is reflected in the surveys of my nonprofit clients who are engaged in alcohol and drug prevention at various schools here in Michigan and in Washington. The acceptance of marijuana by the general populace has lead to more liberal use of legal narcotics by patients, in my opinion.
Not only is the general public more accepting of the use of prescription drugs for the relief of pain, physicians are too. Doctors previously mostly wrote prescriptions for oxycodone and Vicodin for patients who were undergoing cancer treatment or who were in hospice care. Now these drugs are being prescribed for even minor pain, according to the article in the WSJ. The number one prescribed drug in the U.S. now is the generic version of Vicodin.
A few days ago I was talking to one of my contacts at the Kent County Health Department of Michigan. She was relating to me the story of one of her friends who she recently encountered one Sunday morning at church. The friend was obviously very high. My contact then asked her friend what was going on. She replied that her doctor had been prescribing ever stronger does of pain medications such as Vicodin for her chronic back pain. She added that she was now taking the most recently prescribed drugs and also the older ones, all concurrently. My contact then insisted she visit her physician again to clarify the situation. The physician was dumbfounded when he learned what was happening. He just assumed that the patient would dispose of the older drugs and then take only the newer ones. Poor communication between physician and patient is leading to serious problems with the use of legal narcotics.
I believe that besides cultural attitudes another source of the problems is that there are no good checks and balances for the prescription of prescription pain medication. Many states now have databases that track the prescription and dispensing of schedule 2 to 5 controlled substances. In Michigan the system is MAPS. It requires prescribers to report twice a month to the database (every day beginning late 2013). It can be accessed by pharmacists, clinicians and law enforcement personnel. It is used to track individuals who may be using multiple sources to obtain opioids or other legal narcotics. It is not commonly used to track physicians who are clearly out of line in their prescription habits. For instance, according to a source at the Kent County Health Department, a physician who has a few patients for whom he has prescribed Vicodin in large amounts, such as three 30-day prescriptions, will not be noticed.
What can be done to rein in the over prescribing of pain medication? One approach would be for states to more closely monitor the prescribing of these drugs in their databases and warn clinicians who misuse their license to prescribe. However, I would rather that the problem be tackled at a local level; I would not like to have the government involved if at all possible. I would like those who are involved in prescribing and dispensing the drugs as well as law enforcement agencies to become involved in community groups that work to reduce the misuse of alcohol and other drugs in their areas. This is a recommendation in the newly issued report Best Care at Lower Cost by the Institute of Medicine.
As you can see, the over prescribing of pain medication is having a very negative impact on the health of our communities. Physicians and other clinicians are being negatively impacted by the attitudes of their communities and are providing their patients with too easy an access to these drugs. It will take the work of clinicians with the help of their communities to reverse the tide.
Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.
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