Los Angeles Times: Prescription Drug Diversion

Photo Credit: Iowa Department of Public Safety

The LA Times is running an article on the impact of prescription drug abuse on urban Los Angeles.. I suspect most of us have been burned on this issue and have adjusted our prescribing accordingly. In my case, I was torn between my desire to provide enlightened pain management and the evidence of diversion by the minority of patients to whom I prescribed schedule II drugs.

It became a case of a few bad apples, and those few spoiled the whole bushel. One of the major reasons I left primary care is because I was tired of the all the record-keeping and fact-checking I had to do for my schedule II patients, most of whom were appropriate in their medication use but all of whom needed monthly refills on a certain schedule, so if I was off by even a day it created a cascade of phone calls and drama for my clinic. A few things the LAT article did not address that I have observed in my rural community:

1. The title of the article asserts that "Prescriptions supplanting illegal substances as drugs of choice," but it should be noted that prescription drug abuse provides an entry point to illegal drug abuse. I had one patient who came to me for Vicodin after a car accident. Within a few months he was scoring OxyContin off the street, and before the year was out, he was shooting heroin.
2. In economically depressed rural areas, prescription drug abuse thrives because people rely on the money they get from selling their prescriptions. Last I heard, OxyContin was going for $1 per milligram, so a patient taking 40mg twice daily could sell half their monthly supply for $1,200 and still keep half for their own use. For this kind of money, even non-criminal retirees will divert their prescriptions to supplement their SSI income--I've met 70 year old grandmothers who have done so. Believe me, I'm not trying to justify this practice, but I've pushed a few families into economic collapse by restricting their access to schedule II prescriptions.
3. Prescription drug abuse accounts for a significant number of preventable deaths in small counties. For example, in the county in which I live, the successful suicide rate for 2005 was 18 times greater than the national average, and prescription drug abuse was implicated in the majority of those deaths. Furthermore, deaths from accidental overdoses in this county exceeded both state and national averages. People who die from drug-related suicide and overdose tend to be younger than those who die from non-drug related causes, so the effect of this trend over time is to rob a community of its youth.
4. The not-so-hidden cost of prescription drug abuse includes the hundreds of thousands of dollars of public money spent treating overdose patients who actually survive. I work at a very small hospital and we regularly have 4-6 overdose admissions per week. All of them get a head CT, IV fluids, and more than a few need a Narcan drip for a few days. I have no idea how much this is costing my community every year, but I can tell you this: we can't afford it.
5. A truly hidden cost of prescription drug abuse is its impact upon the primary care shortage. As I mentioned above, escaping the schedule II treadmill was a significant contributor to my decision to withdraw from primary care, and I know a number of other hospitalists who were similarly influenced. How many other doctors are making the same decision? Their numbers are hidden among the other, more measurable reasons for leaving primary care (better hours, higher earning), and in the desire not to appear unsympathetic to treating pain in general.

These are a few thoughts I had upon reading the LAT article, but I know they in no way fully unpack the consequences of prescription drug diversion. I'd love to know how the rest of you are dealing with this.

Comments

[drug intervention]

The information stated above are true because prescription drug abuse usually leads to addiction. Which is why new laws must be made so that the selling of prescription drugs would be regulated, to those people who only has recommendations from their doctors.

[Chris]

We've had similar issues with our buprenorphine studies.

http://www.helpreformhealthcare.org/

[adolescent drug rehab]

This article is very informative, I agree with it. Drug Diversion is one thing that we could be focused on.

-mj-

[Theresa]

I agree absolutely, Dr. D.

I was quite open to treating pain syndromes as long as the patient and I shared the same expectations and the patient was responsible about keeping appointments, taking meds as prescribed, etc. Then a number of things pulled me away from primary care, including the burnout of keeping up with my schedule II patients.

Thanks for stopping by.

[Doctor David]

Great post. This comes up quite a bit in my pediatric oncology practice. I've had some bad experiences (the teenager who became a heroin addict after becoming dependent on opiates after an orthopedic procedure hurt a lot) and some scary ones (the guy we put on Cymbalta for neuropathic pain who had a bad reaction to the drug and took a month's supply of oxycontin and washed it down with a 6-pack)... but overall, my patients have used their drugs appropriately. And if I have to choose between the occasional "bad egg" on the one hand, and adequate pain relief for a child dying of cancer on the other hand, I'll clearly opt for giving out the drugs every time. One child suffering because he didn't get enough pain medication is too many.

Great blog, by the way!

[Theresa]

James, You're absolutely right that we have a systems problem when it comes to rx abuse. The current medical culture has shifted towards treating chronic pain syndromes more generously than it did a few decades ago. Big Pharma played a big role in that (a good book on the topic: Pain Killer/Barry Meier). Some docs are more liberal in their prescribing policies than others, but I would say the majority in my area are acting in good faith. There are some, however, who act from purely financial motives or some kind of psychological neediness and end up overlooking obvious rx abuse.

My community has tried to create some cross-communication between PMDs, ERs, hospitalists, specialists, etc. The result was imperfect, for sure, but at least there were some attempts.

Ultimately, I have to come back again to the individual patient's actions. When OxyContin hits the streets, I'm not the one who sold it for $1/mg and neither are my colleagues. However, you raise and excellent point. I have a few examples I'll try to write about in future posts.

Thanks for the comment.

[James]

That's a really nice overview of the problem. But, what's your feeling on the degree to which doctors are responsible for the consequences if patients are abusing their prescription drugs? Clearly, there are some patients who are drug-seeking and some physicians who prescribe irresponsibly. Then there are those whose conditions clearly warrant prescription analgesia who then make the choice to start dealing or abusing etc. In which cases do think the prescriber is responsible and in which cases not?