Abusive Prescribing of Controlled Substances — A Pharmacy View (New Eng Jour Med)

[pinto]

Interesting piece. Not sure how I feel about "the use of a national prescription-drug–monitoring database". Nor how professionals involved would view that. I can confirm a significant increase in prescription opiod use from a small-scale street level. I work with a local syringe exchange program - we've seen a spike in prescribed opiod use, via injection, self-reported by our clients. ~ pinto

Abusive Prescribing of Controlled Substances — A Pharmacy View

Mitch Betses, R.Ph., and Troyen Brennan, M.D., M.P.H
N Engl J Med 2013; September 12, 2013

Public health advocates are increasingly focused on illness and deaths caused by inappropriate use of controlled substances — in particular, opioid analgesics. Opioid prescriptions have increased dramatically, by more than 300% between 1999 and 2010.1 This increase has led to substantial iatrogenic disease. Most strikingly, the number of deaths due to overdose in the United States increased from 4000 in 1999 to 16,600 in 2010.2 Indeed, overdose is now the second-leading cause of accidental death in this country, where more than 2.4 million people were considered opioid abusers in 2010.3

The causes of increases in prescriptions and the prevalence of abuse are manifold. In the mid-1990s, advocates for treatment of chronic pain began arguing that pain was largely undertreated and appropriately exhorted clinicians to be more liberal in their treatment. In addition, a number of new formulations of opioid agents became available, with purported advantages in analgesia.

But perhaps just as important, inappropriate prescribing has grown. The worst form of such prescribing occurs in so-called pill mills, wherein fully licensed physicians with valid Drug Enforcement Administration (DEA) numbers write prescriptions that provide large quantities of powerful analgesics to individual patients. Such bogus pain clinics cater to younger patients, operate on a cash basis, and draw clients from a broad geographic area. States and the DEA have attempted to curb pill-mill activities — the best example being Florida's closure of 254 “pain clinics” — but the efficacy of such regulation is unclear.4

Pharmacies have a role to play in the oversight of prescriptions for controlled substances, and opioid analgesics in particular. Under the Controlled Substances Act, pharmacists must evaluate patients to ensure the appropriateness of any controlled-substance prescription. In addition, state boards of pharmacy regulate the distribution of opioid analgesics and other controlled substances through the discretion of pharmacists. Yet in the majority of cases of potential abuse, pharmacists face a patient who has a legal prescription from a licensed physician, and they have access to very little other background information. That makes it difficult for individual pharmacists to use their own partially informed judgment to identify prescriptions that have come from a pill-mill doctor.

http://www.nejm.org/doi/full/10.1056/NEJMp1308222?query=TOC

[alfie]

1. I am a retired ER nurse

We dealt with a lot of patients needing and/or seeking pain medications. Our state's Medicaid program started using a database of pain medications and the doctor's involved in prescribing them. After one of our docs gave a prescription for pain meds to one patient, he was notified that she was a patient at two pain clinics and receiving large amounts of drugs from two different drugstores. Most pain clinics make their patients sign a promise not to seek drugs from any other source. She obviously was not complying with this provision. This is a small rural community. The "word on the street" was that she supported herself by selling the pills she did not use herself. She never admitted to us that she was being treated in a pain clinic.

This is an isolated incident, but it did make me in favor of a database of prescription drugs. I saw too many young people who died from drug overdoses, either intentional or accidental (it is usually not evident which it is unless they left a suicide note).

[pinto]

2. Thanks for your input. My limited take is that OD's are usually unintentional.

Some syringe exchange programs provide Naloxone in a quick single use injector. We don't, but the availability appears to have concrete benefits, on-site. i.e. at the point of use and OD.

[Aristus]

4. Fortunately for conscientious providers, the treatment modalities for chronic pain have moved away

from narcotics, and toward a combination of treatments including tricyclic antidepressants (which have been found to be efficacious for treating chronic pain), various forms of physical therapy, orthopedics, therapeutic massage, etc. I prescribe programs including some or all of these treatments for patients with chronic pain.

But you should hear the abuse I come under from patients addicted to narcotics, and even from well-meaning advocates for sufferers of chronic pain who insist I am denying patients narcotics out of some sort of sadism.

Several times a week, I'll have new patients in my clinic, seeking narcotics for some vague, unspecified pain, and then denouncing me when I don't scribble out a scrip for their favorite pill.

[pinto]

5. Thanks for your first hand input.