Explaining the rise in legal narcotic misuse and addiction

Explaining the rise in legal narcotic misuse and addiction

Quick!  Can you name the leading cause of accidental death in the United States now?  It is prescription drug overdose.  Since 2009 death from legally prescribed narcotics has led auto accident deaths as the number one cause of accidental death in the United States.  More than 15000 die now annually.

On October 5, 2012 the Wall Street Journal on its front page published an article “Prescription for Addiction”, which detailed the complexities of prescription drug misuse.  It related the story of Jaclyn Kinkade, a doctor’s office receptionist, who died alone last year from an overdose of methadone combined with alprazolam.  Her addiction began with Endocet, a drug that contains oxycodone.  The doctor who wrote the prescription was her employer; he wrote it for her as she was experiencing pain in her back and neck.  Her father had this to say after her death:  “Jackie didn’t wake up one day and say, ‘Hey I’m going to be a drug addict today.’  Jackie pretty much got sent there by a doctor.”  Near the end of her life she was getting her prescriptions from a pain clinic.

How can we explain and try to understand the rise in legal narcotic misuse and addiction?  The answer: Not easily.  I believe that the problem has complex roots, including the failure to perceive correctly the breadth of the problem or the sources of the drugs.  For instance, if you were to ask someone to describe what comes to mind when they think of a drug addict, most likely the answer would be a picture of an individual in a crack house who is nodding out on cocaine or heroin; the picture is a myth.  The fact is that deaths due to legal pain medication far outstrip the number of deaths due to illegal drugs.  Most certainly most would not think of someone like Jaclyn Kinkade.  If you then informed them of their error and then asked where individuals who are misusing pain medication get their drugs, they more than likely would say that they came from someone, not a clinician, that they knew who had a legal supply of the drugs.  That could well be true but the fact remains that most of these drugs come from legal prescriptions—physicians, clinical staff who have privileges to write such prescriptions in their state, veterinarians and pharmacists.

Besides there being a gross misperception of drug overdoses and the sources of the drugs, the acceptance of the use of a variety of drugs to ease pain has steadily grown in recent years.  Many states now approve of the use of medical marijuana to ease chronic pain. Surveys nationally are showing an increasing use of marijuana by high school students.  This trend is reflected in the surveys of my nonprofit clients who are engaged in alcohol and drug prevention at various schools here in Michigan and in Washington.  The acceptance of marijuana by the general populace has lead to more liberal use of legal narcotics by patients, in my opinion.

Not only is the general public more accepting of the use of prescription drugs for the relief of pain, physicians are too.  Doctors previously mostly wrote prescriptions for oxycodone and Vicodin for patients who were undergoing cancer treatment or who were in hospice care.  Now these drugs are being prescribed for even minor pain, according to the article in the WSJ.  The number one prescribed drug in the U.S. now is the generic version of Vicodin.

A few days ago I was talking to one of my contacts at the Kent County Health Department of Michigan.  She was relating to me the story of one of her friends who she recently encountered one Sunday morning at church.  The friend was obviously very high.  My contact then asked her friend what was going on.  She replied that her doctor had been prescribing ever stronger does of pain medications such as Vicodin for her chronic back pain.  She added that she was now taking the most recently prescribed drugs and also the older ones, all concurrently.  My contact then insisted she visit her physician again to clarify the situation.  The physician was dumbfounded when he learned what was happening.  He just assumed that the patient would dispose of the older drugs and then take only the newer ones.  Poor communication between physician and patient is leading to serious problems with the use of legal narcotics.

I believe that besides cultural attitudes another source of the problems is that there are no good checks and balances for the prescription of prescription pain medication.  Many states now have databases that track the prescription and dispensing of schedule 2 to 5 controlled substances.  In Michigan the system is MAPS.  It requires prescribers to report twice a month to the database (every day beginning late 2013).  It can be accessed by pharmacists, clinicians and law enforcement personnel.  It is used to track individuals who may be using multiple sources to obtain opioids or other legal narcotics.  It is not commonly used to track physicians who are clearly out of line in their prescription habits.  For instance, according to a source at the Kent County Health Department, a physician who has a few patients for whom he has prescribed Vicodin in large amounts, such as three 30-day prescriptions, will not be noticed.

What can be done to rein in the over prescribing of pain medication?  One approach would be for states to more closely monitor the prescribing of these drugs in their databases and warn clinicians who misuse their license to prescribe.  However, I would rather that the problem be tackled at a local level; I would not like to have the government involved if at all possible. I would like those who are involved in prescribing and dispensing the drugs as well as law enforcement agencies to become involved in community groups that work to reduce the misuse of alcohol and other drugs in their areas.  This is a recommendation in the newly issued report Best Care at Lower Cost by the Institute of Medicine.

As you can see, the over prescribing of pain medication is having a very negative impact on the health of our communities.  Physicians and other clinicians are being negatively impacted by the attitudes of their communities and are providing their patients with too easy an access to these drugs.  It will take the work of clinicians with the help of their communities to reverse the tide.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.

Image credit: Shutterstock.com

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  • Duncan Cross

    Wrong wrong wrong: “Since 2009 death from legally prescribed narcotics has led auto
    accident deaths as the number one cause of accidental death in the
    United States”. Only *total drug poisonings*, which includes illegal drugs, are close to auto fatalities, and in 2010 auto fatalities were still slightly more than all drug poisonings: http://www.cdc.gov/nchs/fastats/acc-inj.htm

    But did you know that obsession with legally prescribed narcotics is the leading cause of healthcare consultants discrediting themselves on the medical blogs? It’s a tragedy sweeping the nation, and something must be done to ensure our healthcare consultants are using statistics responsibly, legally, and under close supervision.

    • C.L.J. Murphy

      You beat me to it.

      • ninguem

        “Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges.”

        Oh yeah, I really want to hire him as a consultant.

    • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

      Dear Mr. Cross,

      Thank you for pointing out the error of my opening paragraph. I went back to the WSJ article that I referenced and saw that I misread the information there. Based upon that and further investigation at the CDC websites as well as the National Transportation Safety Board, I believe that a more accurate opening would have been the following paragraph: “Can you name the leading cause of accidental death in the United States now? It is drug overdose. Since 2009 death from drug overdoses has led auto accident deaths as the number one cause of death in the United States. More than 15000 die now annually from opioid drug overdose. In 2010 about 23300 died in automobile accidents as either drivers or passengers. The rise in opioid drug overdose is the fastest rising cause of drug overdose and now exceeds heroin and cocaine combined.”

      Looking carefully at the data available online and extrapolating from the 2000-2010 trends, I calculated that the deaths per 100000 for auto accidents for 2012 would be 9.8/100000 and for accidental drug overdose 14.2/100000. Of course such extrapolation is open to error. Further, based upon the fact from CDC statements that prescription opioid overdose accounted for about 41% of all drug overdoses in 2008 but that the percentage was rising, one could use the 41% figure and conclude that there were about 6.0/100000 deaths due to prescription opioid overdose in 2012.

      If you are interested, the Wall Street Journal continued with an extensive series on prescription opioid overdose. One can access the articles for free on Google News by typing in “WSJ Investigation: The Prescription Painkiller Epidemic.” Also, the AMA has a free series of training with available CME’s at http://www.ama-assn.org/ama/pub/advocacy/topics/combating-prescription-drug-abuse-diversion.page.

      Again, thanks once again for pointing out my errors.

      Donald Tex Bryant

      • Duncan Cross

        DTB — Thank you for the correction. I appreciate your willingness to re-examine your numbers. I would point out that the CDC link I in my previous comment has the number of “Motor Vehicle Traffic Deaths” at 33,687 — still twice as much as prescription opioid drug overdose. I am still not clear on where the 23,300 number comes from.

        I don’t deny that opioid abuse is a problem. I just don’t think it’s a very big problem, and certainly not a crisis. As somebody who has struggled with severe pain — as in, hydrocodone saved my life — I don’t think your article gives sufficient value to the millions of people who are truly helped by these medicines. Moreover, it has been my experience that physicians (except in the ER) are very leery of treating pain, because of the hysteria on this issue.

        If all you can see are the fatalities, your perspective is too narrow. You are in effect asking the many sick and injured to suffer, in order to save a very few lives — while you yourself make no sacrifice and bear no burden either way.

        • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

          DDC–thank you for taking the time to add more details about your point of view. I take issue with the overuse of prescription opioid not only because of the fatalities, which are a serious tragedy, but also because of the misery and poor health caused by addiction to such substances. I have worked with prevention specialists and with addiction specialists for quite some time and have seen the lives destroyed by the misuse of alcohol and other drugs.

          My concern with clinicians is that some may not realize that they may be prescribing an opioid to a recovered alcoholic or recovered drug addict. If they do so then the addict is once again exposed to a substance that may quickly or immediately lead to a return of addictive substance misuse.

          Becoming addicted to a substance is not a well understood process. Some become quickly addicted while others do not. In all cases, the body does become more tolerant of addictive substances and will need more to maintain the effects of the substances as time progresses. Thus, it is important for clinicians to monitor the use of opioid in their patients and try to limit their use over the long term in order to avoid chemical dependency as well as negative health outcomes.

          i suggest that when at all possible that alternative routes be used to alleviate pain, other than long term use of opioid. My wife has severe osteoarthritis in both knees. She manages her pain with ibuprofen and water walking regularly. She is able to manage her pain quite comfortably. I am a firm believer in the use of various physical therapies and nonaddictive pain medications to manage chronic pain.

          You also asked for the source of data for auto accident deaths as a driver or passenger. You may find it at http://www-fars.nhtsa.dot.gov/Main/index.aspx. From that report, you can see that when highway fatalities are reported commonly the numbers also include motorcycles and pedestrians. i chose to focus on drivers and passengers, which I believe is what most people have in mind when thinking of auto fatalities.

    • http://www.facebook.com/people/Tom-Fitzsimmons/1405121136 Tom Fitzsimmons

      I don’t think the guy who wrote this is s doctor. It’s riddled with mistakes. Oh, more to the point there’s no ‘MD’ after his name.

  • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

    I think its absolutely hilarious that we have an endemic of narcotic drug abuse in this country yet we let NURSES with 1/4th the training of doctors, write prescriptions for narcotics with NO OVERSIGHT!

    And then we are shocked and awed when something like this happens? What a joke!

    I got an idea — how about we restrict the prescription of narcotic drugs to only EXPERIENCED AND WELL TRAINED PHYSICIANS, NOT NURSES OR PHYSICIAN ASSISTANTS OR OTHER DOCTOR WANNABES WHO HAVE NO IDEA WHAT THEY ARE DOING!

    • EE Smith

      At least I’ve never met a nurse who didn’t know the difference between “endemic” and “epidemic”.

    • kobukvolebane

      When I see some evidence that backs up your claims, I’ll start being concerned. Until then, I see you as simply trying to deflect the blame. Because I have seen, with my own eyes, plenty of physicians prescribing vast amounts of narcotics to people who claim to be in pain.

  • C.L.J. Murphy

    “Quick! Can you name the leading cause of accidental death in the United States now? It is prescription drug overdose.”

    No, it is poisoning. Yes, poisoning includes drug deaths from both legal and illegal drugs, but no, “prescription drug overdose” is not “the leading cause of death in the United States now”.

    From the CDC:

    “In 2008, the number of poisoning deaths exceeded the number of motor vehicle traffic deaths and was the leading cause of injury death for the first time since at least 1980. During the past three decades, the poisoning death rate nearly tripled, while the motor vehicle traffic death rate decreased by one-half. During this period, the percentage of poisoning deaths that were caused by drugs [not just "prescription drugs" - all drugs] increased from about 60% to about 90%.”

  • http://www.facebook.com/profile.php?id=100002542862252 Gaylen Marie

    i have depression. i bet every m.d. reading this has already decided that i am your typical patient with depression. we have millions of aches and pains that are not really something to treat – they are just magnified by the depression. so we can ignore them and pat the patient on the head and send them out the door.

    so let’s talk about meds and overdoses. i am extremely careful about medications. i keep a daily med log. in 1986 i accidently took 2 pills for my asthma.never again. i write things down. recently i had two falls. one outside in the snow and the other from a rug slipping in the bathroom. i went to my pcp after at least a week because i was in a lot of pain. broken toes, back pain, you know. those things you don’t even write down in a pt. with depression’s chart.
    my husband of 26 years was with me. i asked my m.d. for pain medication. he said NO. excuse me what? take nsaid’s. what? they interact with my bp med and my antidepressant. just take those. you’ll be fine.

    he would not give me anything for pain. i said i am waking up and packing myself in ice for the pain. i am sure he has already marked my chart as a drug seeker. this man has been my pcp for at least – oh gosh – 15 or 20 years now. he knows i do not ask for pain medication. that i rarely will take a tylenol.

    weeks have passed. i have not taken the advised nsaid’s because they also make my ankles swell. i still wake up in pain.

    no overdose here. i am still stunned and disappointed in a caregiver who i thought knew me. good luck getting pain meds when you need them. next time i will hit the street first.

    • http://www.facebook.com/amy.j.townsend.7 Amy Judice Townsend

      If you are still having pain weeks after an acute injury, you need to try some non-narcotic mode of pain relief like physical thereapy. Only in rare circumstances should narcotics be used for weeks. The fact that it sounds like your depression is inadequately controlled is even more of a reason to NOT prescribe narcotics. It is not an uncommon phenomenon to see people addicted to

  • reddirtg

    Super lame. The blame belongs squarely on abusers & no one else. Attitudes like those reflected in this piece only contributes to punishing those w/ legitimate pain management needs.

    • kobukvolebane

      You evidently have no knowledge of the nature or causes of drug addiction, and are dodging the fact that these medications generally get to patients through their doctors. Jacklyn Kincade isn’t the only victim out there.

  • Caitlin Peebles

    “Since 2009 death from legally prescribed narcotics has led auto accident deaths as the number one cause of accidental death in the United States.”

    Are there any responsible adults administering this blog? Is anyone going to issue an update to this post admitting that it opens with an easily debunked lie?

  • http://www.facebook.com/scott.carpenter.9638 Scott Carpenter

    Yes, but, what about all of the “mandatory” pain ratings required on every patient at every visit? What about the mandate of “pain is subjective, who are you to say they arent in pain?”. In this day and age, it appears that no amount of pain is acceptable, which directly leads to over prescribing… Not to mention that a script improves satisfaction scores….

  • doc99

    The decision to convert a symptom into a sign was a really bad idea.

  • Mandy

    My elderly aunt died after she accidentally kept taking the warfarin her old doctor prescribed, along with the coumadin her new doctor prescribed. Deaths like hers, and deaths from adverse drug reactions, and deaths from doctor/pharmacy mistakes, and deaths from street drugs (meth, heroin, cocaine) also count as “accidental drug deaths”.

    Not all poisonings and drug deaths are from prescribed narcotics.

  • http://www.facebook.com/dale.green.92 Dale Green

    What about doctors accepting responsibility for their actions? Stop shunting responsibility to others, stop over prescribing.

  • Sam Moskowitz

    Generally I do not prescribe opiates for chronic non cancerous pain. Sometimes I wonder how this affects my patient satisfaction scores on medicinal-consultant created surveys.

  • SarahJ91

    Here’s the one experience my husband and I have had with narcotics: He had pacemaker surgery. The doctor prescribed a whopping 20(!) oxycodone. I tried to only get three or four, partly to see how well they worked and partly because of the problem of disposal if they didn’t. We have frogs with legs growing out of their foreheads from the drugs we’re pouring into our water supply and this is a concern to me.

    It seems I could only use the script once, couldn’t go back if they worked well to get more of the prescribed 20. I knew he wouldn’t need 20 so I guessed and took 12. He used four of them for post-op pain.

    I broke my arm about a month later. I came home from the ER with a script for 20 vicodin. I never asked for pain pills at all and didn’t fill it because we still had 8 oxycodones in our medicine chest.

    I had to wait a week for surgery on the arm. I used one and a half of the oxycodones. They were pretty useless because they did little for the pain unless I took enough to wipe out my brain.

    Post surgery, what did I get? ANOTHER script. This one was for 30 oxycodones. I never filled it.

    We still have three or four of the original oxycodones, plus scripts for a total of 50 oxy/vicodins we’ll never use. My neighbour has a prescription drug problem. I could easily fill these scripts and pay my mortgage selling the pills to her. I’ve decided not to, but it was definitely tempting.

    I was shocked beyond belief at the ease with which these three doctors handed out the pills. There’s no question doctors are part of the problem. It doesn’t wash to flood the place with pain pills and then blame the addicts for taking them.

  • Mandy

    Over 100,000 deaths due to medical error occur every year. When is THIS going to be addressed as a “national emergency” the way opioid abuse is? It is obviously a far worse problem, killing nearly 10 times as many people.

  • meyati

    Why is it that a teenager can get an opioid and I can’t? Something is wrong with this system. Try having part of your nose and lip being removed, and not having a prescription for any thing? Try jamming your arm in the rotor cuff and not being able to move it and leaving the ER without anything?