Deaths from Prescription Opioids Not Evenly Distributed

Last November, the CDC issued a report detailing the rise of prescriptions for opioid (narcotic) pain killers such as oxycodone (Percocet, Oxycontin), hydrocodone (Vicodin, Norco), methadone, morphine (MS Contin), fentanyl patches (Duragesic), and others, from 1999-2008. As expected, prescriptions for these medications have increased pretty dramatically. Here's the chart from that report, showing sales of opioid pain relievers (OPR), admission for addiction treatment related to OPR and OPR deaths per 100,000 persons. Basically, sales more than tripled, treatment admission quadrupled and deaths almost tripled. Since 2008, these trends have continued if not accelerated. In Minnesota for instance treatment admissions for opioid addiction are now greater than that for cocaine, methamphetamine, cannabis or other non-alcohol drugs. (Alcohol of course, continues to be the elephant in the room, with all indicators much higher than all other drugs combined.)

However, the rates for these indicators are not evenly distributed across the states. Here are two graphs from the same report showing rates across the US. What they show is that the rates for OPR sales and rates for overdose deaths vary widely across the country. For the most part, the rates of sales and deaths track together although there are exceptions (Oregon, Hawaii for example.) The national rate for overdose deaths is 11.9/100,000 but rates vary from 5.5 in Nebraska to a whopping 27 in New Mexico, a five-fold difference. Of note, nearly all of the deaths are in people taking them for medical purposes and the rates of non-medical use are low across the country. What these figures indicate is that there is no single solution for the entire country. Rather, the approaches need to be tailored to the particular states and regions with the highest figures. Not surprisingly, given the number of older adults living there, Florida tops the country for example in kilgrams of OPR sold.  However, the overdose death rate is 8th highest. New Mexico, however, with the highest overdose death rate, has OPR sales lower than the national average. Unfortunately, the federal government has taken a blanket approach focused on training physicians, which suggests that the appearance of doing something is more important than actually doing something that works.

Comments on Comments

I appreciate readers of my blog, especially those who comment. This kind of dialogue is important and informative. However, I have some suggestions if you wish to leave a comment.

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MW

An Ordinary Weekend

Last weekend I was on call for psychiatry at United, the hospital in St. Paul that I work for. It's been a moderately busy weekend for me, but not because there isn't any more demand for services, but because our inpatient beds are full. And guess what? So are the inpatient psychiatry beds not only throughout the Twin Cities Metro Area, but also the entire state! Halfway through the weekend we sent a patient to the last open adolescent psychiatry bed in Fargo, ND! So there are two patients this weekend who have had to stay in the emergency department, because there is no place to admit them. I continue to be amazed that I live in a country that would send its mentally ill children hundreds of miles away from their families because it's not willing to pay for the services they need locally.

And as usual, among the patients newly hospitalized whom I saw, about half were addicted to a psychoactive substance, usually alcohol. This is also typical. Now that I'm cutting back on my clinical practice, I'm unable to offer them a new form of treatment, one that is oriented around treating the disease as it is, rather than as we would like it to be. I was able to offer that for the last 2 years, but now I'm moving more into efforts to change things more broadly, to help others provide that kind of service and thus leverage my knowledge and skill. And that is going well and finally seems to be picking up speed. This stuff really takes a lot of time and effort!

But I still find it hard not to offer these patients an alternative to another run through a rehab program they've already experienced multiple times before. Any treatment that has been shown to be ineffective in a particular patient ought no longer to be pursued. I don't continue to prescribe naltrexone or Prozac to someone after it repeatedly fails to alter the course of illness, thinking that perhaps someday it will become effective! But embracing fully another approach is not without its problems too.

That's because to do so takes us right into some painful insights. Our treatments are modestly effective at best. There are many people for whom we have no effective treatment. And it's not their fault, it's because the science isn't yet at a point where we can understand what's wrong and help correct it. Our instruments are crude, primitive. Well-meaning, yes. We can always provide comfort, understanding, and a willingness to stay with someone to the end. But all too often, there is nothing we can do to change what we see as the inevitable conclusion of a process we don't understand: addiction. And I can tell you that it is difficult indeed to stay engaged with someone who is dying of an addiction neither she nor I nor you nor AA nor rehab nor medication nor the criminal justice system nor anyone else can help. We accept that grim reality with other diseases like heart disease or cancer. But we have a hard time accepting that brain diseases like addiction or bipolar disorder can be incurable and ultimately fatal. And most importantly, it's not because the person dying does not want to live or isn't trying in every way to stop the march towards death. We have to stop blaming the victims when our treatments fail and at least offer them succor along the way.

Implementing the NIAAA Guide in Primary Care Clinics

After two years, it finally feels like things are coming together. Allina Health continues to be a great place to try out new ideas for addressing alcohol and pain, across hospitals and clinics. I've been able to recruit up to three primary care clinics in the SBIRT+ project, which is focused on addressing alcohol in primary care. (SBIRT+ stands for Screening, Brief Intervention and Referral to Treatment, Plus Point of Service Care. Point of service care reflects treatment for alcohol dependence (not just at-risk drinking) in primary care. The NIAAA Clinician's Guide uses this model.) Allina is also developing a collaborative care model at a pilot clinic and I expect to be involved in that effort, which is focused on coordination of care and reduction in preventable hospitalization for patients with complex chronic illnesses. Heavy drinking is common among people with chronic diseases who demonstrate high cost and poor outcomes. To reach the goals of reducing costs and improving outcomes requires addressing drinking and other co-morbidities such as depression in addition to improving care for their other chronic medical conditions.

This is a very ripe time for new ideas. Health care clinicians are disillusioned with the time-limited rehab system, where there is only one option that doesn't change even after repeatedly showing lack of effectiveness. They want guidance on what to do next. They are intrigued by the NIAAA Guide's clear guidelines for addressing heavy drinking across the spectrum of severity (from risk drinking to functional dependence to severe recurrent dependence) and by medical treatment options, especially anti-relapse medications. Contrary to what many in the addiction treatment field believe, doctors and other primary care clinicians want very much to help but have pretty much been told to "leave it to the addiction experts," which for the most part means counselors alone, and for relatively short periods. However, the patients spend much more time in primary care than they do in any treatment programs.

In the last week, I've presented SBIRT+ at two primary care clinics, and in the next week I'll be talking to two or three more. I'll fill you in as I go.

MW