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Rx for Survival

G. Caleb Alexander takes on the crisis of prescription drug abuse

It may be the biggest public health epidemic that you’ve never heard of: prescription drug abuse. America’s fastest-growing drug problem claims a life every 19 minutes.

 G. Caleb Alexander, MD, MS, co-director of the Bloomberg School’s new Center for Drug Safety and Effectiveness, says that pain is at the center of the epidemic’s trajectory, beginning with the medical community’s well-intentioned efforts in the 1980s and 1990s to more aggressively treat chronic pain. Sales of opioid painkillers like Vicodin and Percocet soared, as did abuse of the drugs, emergency room visits, drug treatment admissions—and deaths.

In 2008, there were nearly 15,000 prescription painkiller deaths—more than cocaine and heroin combined. Yet Alexander believes that the epidemic may have reached a “tipping point.” Federal and state agencies are stepping up enforcement and regulatory efforts, and many other stakeholders are also responding to a call to action.

“Finding a way to promote the appropriate treatment of pain while reducing opioid use and diversion is the holy grail,” says Alexander.

You’re a general internist, what’s your approach to prescribing opioids?
Generally, I’m very cautious about using opioids and won’t prescribe anything more than, in most cases, a short-term supply of a low-dose opioid. One of the striking things that I’ve observed as I’ve been training residents in the inpatient setting, is how comfortable they were writing prescriptions for heavy-hitting narcotics—Dilaudid, morphine, fentanyl. Now it’s true that patients admitted are often in severe pain. Nevertheless, I was surprised. And this extends to the outpatient setting as well.

Someone recently told me that they went in for a dental procedure, went to the pharmacy and there were 100 Vicodin waiting there. They only needed eight!

How important is health care provider training for reversing the epidemic?
It’s vital. There needs to be more education at every level of clinical training. Given that so many people who abuse or misuse opioids get them from friends or family members, the current epidemic also suggests that clinicians … have to ask themselves, “Are these opioids that I’m prescribing going to get into somebody else’s hands?”

Don’t patients with chronic pain expect their doctor to give them a prescription for a powerful pain medication?
I think we underestimate the degree to which patients are open to alternative treatment approaches. One of the important questions that clinicians have to ask themselves, and that patients have to be aware of, is have we tried all the appropriate alternatives prior to reaching for this type of medicine? We [can] use acetaminophen, nonsteroidal anti-inflammatories, topical treatments and a whole host of other agents.

Who is abusing prescription drugs?
Prescription drug abuse spans a wide spectrum of people, in part because opioids are so liberally dispensed and so prone to nonmedical use. Patterns of nonmedical use vary, ranging from a high school kid who may have picked up a few Vicodin from a family member, to an executive misusing OxyContin to manage chronic lower back pain, to a senior with chronic anxiety and headaches [who] is taking Percocet when other therapies would be both safer and more effective.

Is there a particular group that is more at risk of death from prescription drug abuse?
Deaths from prescription opioids are more common among adolescents and young adults, males, those with less education, living in rural areas, and individuals with a history of alcohol or substance abuse. This latter point is noteworthy because it is easy for people to underestimate the synergistic effects of combining opioids with alcohol or other drugs. But keep in mind, for every overdose death, 10 patients are admitted for treatment of abuse, 25 patients are evaluated in an emergency department, and more than 700 people report nonmedical use during the past year. So the deaths—while catastrophic and highly visible—represent just the tip of the iceberg of this public health problem.

What research at your Center targets prescription drug abuse?
We have a number of projects under way. In one recently completed investigation, we used nationally representative data from ambulatory office practices to characterize the treatment of opioid dependence with buprenorphine. In another, we are conducting a 10-year survey [2001–2010] of the diagnosis and treatment of chronic nonmalignant pain to look at how care patterns for chronic pain have changed over time, and to answer some key questions: Are we diagnosing more pain than we did a decade ago? Has our threshold for using opioids changed substantially? In a third, we are using pharmacy records to rigorously evaluate the policy impact of states’ prescription drug monitoring programs, one of the key ways that states are working to stem the epidemic.

Why has this epidemic been so tough to get a handle on?
This is a complex issue, and there are no magic bullets. Just consider one of many challenges—how to continue to improve the care of patients with pain, some with severe pain, while reserving these therapies for those who need them most. And consider the issue of diversion, which can take place at any point along the supply chain of prescription drugs, from warehouse robberies to a patient whose medicines are inappropriately taken by a family member. The epidemic also touches a huge number of different stakeholders: pharmaceutical manufacturers, health plans and health insurers, professional societies, patient advocacy groups, law enforcement, state departments of public health, pharmacies, pharmacy benefit managers, employers—and we’re just getting started.



  • Jennifer Kinsey

    NH 02/26/2013 04:39:17 PM

    I am an licensed clinical social worker, who works as a staff therapist in a community mental health center. Many of my therapy clients are older adults who report chronic pain and see pain specialist who prescribe a host of pain rx, get anti anxiety medications and take a host of other prescription drugs for their various health problems. They often ask me if they are taking too many medications I I urge them to discuss this with their Primary Care MDs. It is rare that the PCP or anyone else ever sits down with them and carefully goes over all their medications to help them better understand what they are taking and why OR are some of the medicaitons ones that might be eliminated or the dose reduced. In my older clients, the pain and psychiatric medications often increase the risk of falls and likely undermine their abilty to drive or manage ADLs. It is real problem and their are few available strategies to help them. Any suggestions?

  • G. Caleb Alexander

    Bloomberg School of Public Health 02/26/2013 08:57:11 PM

    Jennifer -

    You raise a number of important points, including: the potential for polypharmacy among older adults, the challenge that individuals' face in understanding WHAT they are taking and WHY they are taking it, and the fact that all too often, as primary care physicians, we fail to adequately scrutinize patients' medicines and slim their regimens accordingly. These shortcomings also have real world implications, such as the ones you mention, for millions of Americans. Health care providers have an important role to play in addressing these issues, and don't discount the potential influence you can have by encouraging patients to "check up on their prescriptions" by carefully and critically reviewing their prescription regimens with their primary care provider. Family and other caregivers also play a vital role in this process, especially for many elderly patients, and thus these individuals are crucial allies that can help patients' navigate the health care system. Finally, most primary care providers are well versed at the treatment of pain, and although there is a benefit to tapping the expertise of pain physicians, there are costs as well, particularly with respect to the fragmentation of care that you allude to. Primary care physicians not only have a vital role to play in helping to curb epidemic of opioid addiction and misuse, but also in working closely with patients and their families to ensure that patients' prescription regimens are as clinically sensible and judicious as possible.

  • Rachel McLean

    CA 02/27/2013 01:32:27 AM

    There are models (e.g. Project Lazarus in NC) for prescribing opiate antagonists (naloxone) alongside prescription opiates to reduce the risk of fatal overdose. We have found in San Francisco that lay people can be quickly (<5 mins.) trained to save their friends and family members. I would hope that any response to reducing opiate-related overdose morbidity and mortality would include naloxone prescriptions and education in overdose recognition and response (e.g., rescue breathing).

  • Brian Simpson

    Editor, Johns Hopkins Public Health 02/27/2013 02:36:56 PM

    Dr. Alexander and colleagues published an op-ed about Naloxone issues in the Baltimore Sun:

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