The statistics are alarming: some 40 people a day die in the U.S. from opioid drug overdoses, more deaths than cocaine and heroin combined. The Centers for Disease Control calls it an epidemic. While America makes up less than five percent of the world's population, it uses 95 percent of the global Hydrocodone supply and 80 percent of opioids in general.
It's a number that's been increasing steadily for the last couple of decades, according to Bill Kanich, MD, physician consultant in the Patient Safety Institute of MagMutual, the Southeast's largest medical professional liability insurer.
The demographics are equally disturbing. "The people who get caught up in addiction are generally not the elderly or the ill, but young people who are otherwise healthy," Kanich says. "So it's not just the sheer numbers. The loss of youth is tragic as well."
How did the problem begin? "Some 20 or 25 years ago," Kanich says, "there was a big push in the medical community who felt like we weren't addressing pain adequately. And at the same time there has been the development of a lot of new narcotic formulations, such as extended release, that have made narcotic prescription easier.
| Bill Kanich, MD |
"Opioids are very good for pain control and in certain settings they're perfectly appropriate. But there were sometimes misunderstandings about the long-term benefit of drugs such as Oxycontin, and I think the medical community has gotten to the point where we're sometimes over-prescribing when they're not indicated."
A typical scenario, says Kanich, is a primary care physician seeing a patient who has already been prescribed opioids for whatever reason--back pain is a frequent example--and continuing that prescription. "I think we've come to the realization," he says, "that there are a couple of things that have to be in place. One is a good physical exam and a good history to make sure those medications are appropriate for the patient's problem, and the second is that for the vast majority of chronic pain patients there are other treatment modalities that may be appropriate in place of opioids.
"What we're seeing in primary practice is the necessity of looking into alternative therapies that don't have the dangers or the side effects of the narcotics."
There's a new tool for addressing the over-prescribing problem: pharmaceutical databases in 49 of 50 states (excluding Missouri) that make it possible for practitioners to find patients who are receiving multiple prescriptions of the same drug.
"This makes it possible," Kanich says "to have some objective evidence that a person is getting too many prescriptions. If they're not in the database at all, for example, the doctor can prescribe something for pain if necessary."
Kanich, who practices emergency medicine in addition to his consultant role, says he has the advantage of only prescribing the patient a few days of a medication and instructing them to see their primary physician for further care. "I think it's a harder situation for the primary care physician, who really wants to do the right thing for the patient. If the patient is in pain, they want to address that.
"But because of the potential danger, physicians are beginning to realize that sometimes prescribing opioids for chronic pain isn't the best thing we can do, considering that opioids can have some very serious side effects, including death."
A related problem, according to Kanich--who makes presentations to groups and individual physicians on the topic of over-prescribing--is the term "diversion," meaning that the person who's prescribed a drug is not its ultimate user.
"There are a lot of scenarios where that happens," he says. "Some patients who get the prescriptions sell them, and sometimes caregivers for the elderly or others who can't care for themselves, take medicine intended for the patient. Diversion even includes instances where users break down drugs such as Oxycontin and shoot them into their veins.
"I think the real question is whether you can accurately quantify these situations, and I'm not sure that anybody can. I get the feeling, though, that whatever numbers you hear about opioid diversion most likely underestimate the problem."
The Patient Safety Institute of MagMutual, says Kanich, is dedicated to patient safety and raising the quality of care for people throughout the Southeast. Its consultants talk to policyholders and also put information such as webinars online.
"My number one piece of advice is that there are alternate therapies. I can't find any study that shows long-term chronic pain is relieved by long-term opioid prescribing.
"The CDC put out their new guidelines, which got a lot of press, and I think they're pretty well written and not too restrictive. They make it clear that this doesn't apply to cancer patients and other end-of-life care. That's a different category.
"What they basically say is that yes, we're over-prescribing a little bit, and we should think about prescription methods and alternative therapies. If you need opioids, use them, but just be aware of the associated risks."