January 22, 2012

The Devil in the Medicine Cabinet

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Rosemary Orr with her son, Robin, at his high school graduation in June, 2000.
Photo courtesy of the Rice family.

Dr. Rosemary Orr didn’t see it coming that day. It was the morning after Mother’s Day. She needed a ride to work, so her 24-year-old son Robin drove her. She was in a hurry to get to Children’s Hospital and Medical Center in Seattle, where she is a pediatric anesthesiologist. Otherwise, she says, she would have spent more time talking with him.

She’d been worried about his sleeping habits, his weight loss lately. She knew her smart, handsome son had struggled with addiction to OxyContin in the past. But he’d kicked it. He’d assured her of that. He’d looked her in the eye and said, ‘You don’t have to worry about me, Mom.”

No parent wants to believe her child is using. Not even one who is a doctor.

“I was stupid and desperate enough to believe that explanation,” Orr says now, five years later, over coffee a few miles from her work, where she takes care of the pain of others. Her own pain, she takes with her.

When she got home from work that day, Robin’s phone was ringing, but he wasn’t answering in his room downstairs. She knocked. And knocked again. She went around her house and peered in through his bedroom window.

Her son was on the floor, dead of an overdose.

Orr’s son is one of thousands of Americans, including a growing number of young people, who have died from prescription pain medications, powerful opiates that one emergency room doctor described as “just a fancy form of heroin.”

With a law that took effect this month, Washington State is making a bold attempt to reduce overdose deaths by launching the first-ever dosing limits for doctors and others who prescribe these medicines. The law has been heralded as one of the toughest in the nation, but loopholes and pitfalls in the system remain.

Prescription drug abuse is at epidemic levels throughout the state, and elsewhere in the country, despite lawmakers’ attempts to get a grip on it.  Washington now has one of the highest death rates in the nation. Deaths from prescription drug overdoses in this state have skyrocketed nearly twenty-fold since the mid-1990s, and now outstrip those from traffic accidents.

In King County, deaths from prescription opiates exceed deaths from heroin, meth and cocaine combined.

Washington has been one of the hardest hit states in the country, in part because of aggressive prescribing practices. That, coupled with lack of oversight of doctors who over-prescribe, has led to the spectacular run-up in the number of deaths from prescription overdoses.

Dr. Russell Carlisle, head of Swedish Medical Center’s Cherry Hill Emergency Department in Seattle, was shocked by the volume of painkillers doctors were prescribing in Washington when he first moved here from California in the mid-1990s.

Running between exam rooms during a recent busy afternoon in his ER, Carlisle recalled that California maintained tight control of pain medication, requiring triplicate documentation for opiate prescriptions at the time. But in Washington, emergency room doctors were routinely handing out prescriptions for 30 to 40 pills at a time, even to people with histories of drug habits.

Why? “Because then they wouldn’t come back,” he said.

But that efficiency turned deadly.

“The higher deaths, and probably abuse, too, I believe has to do with higher supply or availability,” said Jennifer Sabel, an epidemiologist with the state Department of Health.

An InvestigateWest analysis of U.S. Drug Enforcement Administration data shows Washington ranked fourth highest nationally in per-capita prescribing of methadone in 2006 (the most recent year for which reliable data is available) and 11th for oxycodone – the two biggest killers.

Even more disturbing, more than half of all prescription drug-related deaths in the state occur in the state’s poorest and most vulnerable population – people on Medicaid, a population that is itself exploding in our recent economy. A 2009 federal study showed the age-adjusted risk of death from prescription opiates in Washington was nearly six times higher for Medicaid enrollees than those not on the program.

“Medicaid has about a death a day from prescription narcotics, and in the last two years, it’s continued to escalate,” said Dr. Jeff Thompson, medical director for Washington’s Medicaid program.

Many of those deaths are among young people, he said, a trend that also has public health experts concerned.

New addicts are getting hooked at younger and younger ages, said Caleb Banta-Green, a research scientist at the University of Washington’s Alcohol and Drug Abuse Institute.

“The largest group of people entering treatment for prescription abuse right now is made of young people between the ages of 18 and 24.”

The Making of an Epidemic

Washington’s emergence as a state with one of the highest rates of both opiate prescriptions and deaths was not, in hindsight, an accident.

In 1995, Purdue Pharma introduced OxyContin along with an aggressive marketing campaign pitching the drug as a salvation for chronic pain. The next year, Washington’s medical profession did an about-face in its approach to pain management. The state’s Medical Quality Assurance Commission issued new liberalized guidelines addressing the under-treatment of chronic pain. By 1999, they had been codified into law.

The 1999 law specified “No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opiates prescribed.”

The relaxation of the rules resulted in a run-up in prescriptions. “Since the law changed, the average daily doses in morphine equivalents have gone through the roof,” said Dr. Gary Franklin, medical director for the state’s Department of Labor & Industries.  In 1998, the average daily dose was 80 mg. By 2002, it had nearly doubled to 140 mg.

The same trend was going on around the country. In 1997, prescription opiate sales amounted to 96 mg per person in the United States. By 10 years later, they had mushroomed to 698 mg per person, Franklin said. “That’s enough for every American to take 5 mg of Vicodin every four hours for three weeks.” In 2010, the levels increased still further, enough to medicate every adult around the clock for a month.

Franklin was among the first to notice an alarming corollary effect: the drugs used to kill pain were also killing people.

“Workers were coming in for low back sprains, and dying,” he said. Franklin and his colleagues published the first paper in the country to link worker deaths to prescription drugs in 2005. But when he presented his findings at medical meetings, he faced backlash from the profession and the drug industry.

Many in the profession had fought long and hard to get access to these drugs for better pain management of chronic pain patients, Franklin said. “They didn’t want to hear it might be killing them.”

In May, 2007, Purdue Pharma even sent Franklin a three-page letter blaming deaths on patient abuse and disputing Franklin’s contention the drugs were being overprescribed.

A day after he received the letter, Purdue executives pleaded guilty to misleading the public about the addiction potential of OxyContin, and agreed to pay a $600 million fine.

 “Preferred Drug”

As the deaths and hospitalizations continued to mount, an even more unsettling trend emerged — the disproportionate escalation of deaths among the state’s Medicaid population.

Looking back, the rise in the death rates of Medicaid patients tracks along with the state’s cost-saving decision to move many of its poorest residents to the cheapest, most potent pain reliever available: Methadone.

In 2003, the state agency that administers Medicaid made methadone the “preferred drug” for long-acting opiates on its formulary, the list of drugs Medicaid covers.  Because methadone is so much cheaper than oxycodone or other types of pain pills, the move drove down costs considerably, said Thompson. A few years ago, the agency was spending $20 million annually on pain meds for Medicaid patients. Now it spends about $12 million, he said.

But as costs came down, deaths went up. And many patients are still on high doses of painkillers. Medicaid has between 3,000 and 4,000 patients in Washington who are already over the new legal threshold of 120 mg a day, he said. About 700 of them are over 1,000 mg a day, and a few people are on up to 10,000 mg a day.

Studies have shown the risk of death increases up to nine-fold at 100 mg a day.

“You have to be careful with methadone because it accumulates in the body,” Thompson said.

A Fix in the Works

A few years ago, Rep. James Moeller of Vancouver, WA, who is a drug-abuse counselor by trade, noticed a strange thing happening in his practice. More people were coming to him addicted to legal drugs than illegal ones.

“People would be sitting in my office, wondering how they got there,” he said.  “Often it had started with a minor injury.”

Franklin of the state’s Department of Labor & Industries, and University of Washington pain expert Dr. Alex Cahana were seeing the same trends. They were also seeing more people dying from addiction to these drugs. Together, the three began a battle to set rules around prescribing pain meds. Their efforts culminated in the passage in 2010 of RCW 2876, which repealed the old rules and put into effect strict new rules for pain medications. The rules, which don’t apply to patients suffering acute pain from injury or surgery, or to those with cancer pain or in end-of-life care, went into effect Jan.2.

The new rules specify that when a patient exceeds a dosing threshold of 120 mg per day of morphine-equivalents (a standard measure of narcotic strength), the patient must be evaluated by a certified pain management specialist. The law also contains requirements for pain evaluation, and continuing education for providers.

Dr. David Tauben, a clinical associate professor and director of medical education in pain management at the University of Washington, said the new law will give doctors better tools to treat pain, which is among the most difficult conditions physicians see.

Historically, doctors haven’t understood the limitations of using opiates to treat pain, he said. “They thought, if some is good, more is better, and when more stops working, give even more.” That thinking followed a shift in the medical culture during the late 1990s toward more aggressive treatment of chronic pain. And it’s one reason there are so many people on high doses of pain meds right now.

The trouble is, the pain medications themselves can worsen the problem, contributing to heightened sensitivity to pain, a condition called “opioid-induced hyperalgesia.” As a result, many people find it difficult to taper off the medications. Others unwittingly get dependent after taking narcotic medication for long periods of time.

The law will help better educate doctors about what does work for pain management, Tauben said.  “We’re trying to fix the mess the pain community inadvertently created.”

Not everyone is happy with the tightened statute, however.

The pharmaceutical industry has opposed the law.  Some drug companies have mounted campaigns fronted by patient advocacy groups or policy centers.

The University of Wisconsin’s Pain & Policies Group, one of the most influential policy advisors in the nation, for example, was recently revealed to have failed to disclose its funding relationships with drug-makers.

In Washington, the American Pain Foundation, which bills itself as an independent nonprofit, but receives the bulk of its funding from Endo, the makers of generic OxyContin, has mounted a sophisticated media campaign critical of the pain-management laws and claiming pain patients are suffering unnecessarily.

Some in the medical community also say it unfairly penalizes legitimate pain patients, and doctors who prescribe for them.

Dr. James Rotchford of Port Townsend has been critical of the new law. Rotchford, who lost both his Drug Enforcement Administration registration and his Medicaid contract after the DEA raided his Port Townsend offices in 2010, said the real problem is inadequate pain management and addiction treatment for those who are already on the drugs.

“The law is on the other end of it,” he said. “The problem starts before they get to 120 mg (a day.) We’re not doing anything to prevent the problem.”

“The Biggest Pushers”

There’s plenty of blame to go around for what caused the epidemic –aggressive marketing of opiates by drug companies, nonexistent tracking of overprescribing, lack of  insurance coverage for alternative treatments for pain, and demand by patients for quick fixes, to name a few.

Ending the epidemic will require attention to all these issues, but also a fundamental change in the way the medical culture deals with pain.

The pain that Rosemary Orr felt when found her son dead of an overdose sparked an effort to protect patients: She helped start P.R.O.P. , Physicians for Responsible Opioid Prescribing, which is dedicated to promoting cautious, safe and responsible prescribing practices.

Orr is haunted by a quote from her son: “Mom, you have to see – doctors are the biggest drug pushers in the country.”

She wants to change that.

“Teenagers are given oversupplies of Vicodin for things like wisdom teeth extractions. Surgical patients get more pills than they need when they leave the hospital. People take them all because they figure, ‘Gee, if a doctor prescribed it, it must be safe,’ ” she said. “Before they know it, they’re addicted.”

She points out, too, that this is an American problem.

“The U.S. is responsible for about 90 percent of the world’s prescribing of Vicodin,” she said.

In Britain, where she grew up, she recalls breaking her leg in three places when she was 14 years old. ‘My father was a doctor,” she said. “He gave me an aspirin.”

Americans are notorious for their pill-popping. Addiction is minimized and glamorized by shows, such as House, featuring a doctor who pops Vicodin like Chiclets.

There are consequences to that, said Orr, whose son is never far from her thoughts. She writes: “Sometimes, I feel his presence and sense that he is encouraging me to tell others what I now know so that perhaps one life will be saved.”

Next: New Law Holds Promise, but Concerns Linger

This story is part of an ongoing collaboration between InvestigateWest and public broadcast station KCTS 9. If you’d like to support our work, please consider becoming a member for just $5 a month.

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