Vermont Governor Devotes Entire State of the State Address to Drug Addiction

From yesterday's NY Times:

In Annual Speech, Vermont Governor Shifts Focus to Drug Abuse

In a sign of how drastic the epidemic of drug addiction here has become, Gov. Peter Shumlin on Wednesday devoted his entire State of the State Message to what he said was “a full-blown heroin crisis” gripping Vermont.

“In every corner of our state, heroin and opiate drug addiction threatens us,” he said. He said he wanted to reframe the public debate to encourage officials to respond to addiction as a chronic disease, with treatment and support, rather than with only punishment and incarceration.

“The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards,” Governor Shumlin said, “while we fear and fight treatment facilities in our backyards.”

...

Read the rest of the story here: 

http://www.nytimes.com/2014/01/09/us/in-annual-speech-vermont-governor-shifts-focus-to-drug-abuse.html

Is Florida Turning a Corner?

According to a brand new study, published online this week in the journal, Pharmacoepidemiology and Drug Safety, Florida's recent legislative actions to 1.) strengthen the state's prescription drug monitoring program, and 2.) toughen the regulation of the state's pain clinics, seem to be having the desired effect: drug diversion has been dropping steadily since 2011. In addition, according to the state's commission of medical examiners, prescription opioid overdose deaths are dropping too. Here's the abstract from the article and a figure of the models of longitudinal change, according to each drug: 

Reductions in prescription opioid diversion following recent legislative interventions in Florida

Surratt, et al., 2013

Purpose
Florida has been at the center of the nation's ongoing prescription opioid epidemic, with largely unregulated pain clinics and lax prescribing oversight cited as significant contributors to the opioid problem in the state.

Methods
In an effort to mitigate prescription opioid abuse and diversion in Florida, legislative interventions were implemented during 2010 and 2011, which included two primary elements: (i) comprehensive legislation to better regulate the operation of pain clinics; and (ii) a statewide prescription drug monitoring program to promote safer prescribing practices. Using systematic longitudinal data collected on a quarterly basis from law enforcement agencies across Florida, this report examined changes in prescription opioid diversion rates following implementation of these regulatory initiatives. Quarterly diversion rates for buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, and tramadol were calculated, and subsequently, hierarchical linear models were fit to test for differences in diversion rates over the 15 quarter period of interest.

Results
Significant declines in diversion rates were observed for oxycodone, methadone, and morphine; hydrocodone displayed a marginally significant decline.

Conclusions
This study documented reductions in statewide opioid diversion rates following implementation of Florida's pain clinic and prescription drug monitoring program legislative interventions. Although these initial findings appear promising, continued surveillance of diversion is clearly warranted. Copyright © 2013 John Wiley & Sons, Ltd.

Responding to the Prescription Opioid Problem

Here's my response to a column by Maia Szalavitz on the recent recommendation by an FDA panel to change hydrocodone (Vicodin, Norco and others) from Schedule III (where prescriptions can be phoned or faxed in) to Schedule II (where prescriptions have to be printed.)

You can access her column here.

I think the idea is to reduce the number of opioid pain medications circulating in the community. Opioids are now the most prescribed medications in the US. Between 1998 and 2008 the number of prescriptions for hydrocodone (the opioid in Vicodin, Norco and others) increased 53%, from about 80 million to 120 million, whereas the increase in other opioids was 20-34%. Hydrocodone accounts for more emergency department visits than any other opioid as well. As someone who treats chronic pain as well as addiction, I don't like the restrictions on schedule II drugs, and I worry about undertreatment of chronic pain. But deaths from overdosing on opioid painkillers has more than tripled since 1990. I think there is a major gap in the continuum of care for people with chronic pain, especially the lack of pain medicine specialists, as opposed to interventional pain specialists, who like to do a lot of very lucrative injections. Strategies to close this gap are needed. As you note, Maia, most opioids used for non-medical purposes come from medications prescribed for someone else. Thus, the strategy to make prescribing them more difficult in order to reduce the availability. The issue is complex and there are no easy solutions. However, one thing I would like to see everyone get behind is that anyone who is addicted to opioids have immediate and affordable access to opioid maintenance therapy with Suboxone or methadone. If we aren't doing that, we aren't getting serious about opioid addiction in America

Our Hysterical Approach to Chronic Pain and Opioids

SAMHSA recently issued a report about addiction program treatment admissions where the primary problem was a combined dependence on benzodiazepine anti-anxiety and opioid pain medications. There has been a marked increase in such admissions, in the face of overall decrease admissions for other psychoactive substances (see chart below.)

Number of admissions for combined benzodiazepine and opioid dependence:

What is interesting is that the prevalence (the proportion of people in the country with a disorder) of each has not risen since 2002. Here is the annual prevalence of opioid and other illicit drug dependence or abuse according to NSDUH data. As you can see, dependence upon prescription opioids has remained stable between 2002 and 2011. What has changed is the number of people presenting for treatment, and deaths due to prescription opioids, both of which have risen dramatically in recent years. It is very likely that the increase in people seeking treatment is a result of the increase in opioid addiction that occurred between 1998 and 2002. Many, if not most opioid addicts seek treatment only after several years of addiction. Thus, there is not a new epidemic of opioid addiction. There is an increase in treatment seeking.

It is important to note the downturn in 2011. Drug epidemics typically end when drug users and, especially, potential drug users become aware of the dangers of using certain drugs, and elect to stay away from the dangerous ones. PCP was once a national scourge, as was cocaine and methamphetamine. Usually, the epidemic starts to wane about the time that there is a national hysteria whipped up about them, and lawmakers typically invoke all sorts of draconian laws amidst many lofty and moralistic statements. Thus, it appears that policies resulted in reduced drug use, but more often, the drug use was decreasing before the policies took effect. That fact, of course, is never acknowledged by the policymakers, but why would they, when their job is to get re-elected?

And just a brief note about proportionality of the problem. In spite of all the hysteria, it is important to remember that cigarette smoking kills almost 500,000 people in the US annually, and alcohol about 80,000. The number of opioid overdose deaths? Recently, the CDC reported that almost 15,000 deaths occurred from opioid overdose in 2008, a number that has almost certainly risen since then. Yes, this is a serious problem that must be addressed. But considering that cigarette smoking causes about 30 times as many deaths helps keep this in perspective.

We are currently in an era of hysteria over an increase in prescription opioid addiction which is already on the wane. Unfortunately, what we can anticipate now are ill-advised, arbitrary and draconian policies to deal with this problem. I'm not suggesting there is not problem; it is a serious one. But by approaching this with hysterical and moralistic fear-mongering and condemnation, we are going to hurt many people, especially people with chronic pain and the physicians who treat them, without necessarily doing much if any good.

Right now, there are a group of moralistic medical scolds with fervent beliefs not supported by solid empirical evidence who have the national attention. The vacuum created by the lack of evidence is filled with hot air and strong opinion, and because their moralistic pronouncements fit with most peoples' prejudices and ignorance, and this country's Calvinistic attitudes, they are accepted without appropriate skepticism. We now have a full-blown witch hunt going on that will result not in appropriate modification of treatment of chronic pain. Instead, it will increase suffering, result in preventable deaths due to opioid overdose, lack of access to appropriate opioid maintenance and mental health treatment and increased suicides among chronic pain sufferers, and destroy the professional lives of physicians who treat pain. There is a better way, but I doubt we will take it.

MW

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.