The Painful Truth About Prescriptions
Has American medicine gotten too good at treating pain? The profession once took pain to be a positive sign of healing. As recently as 50 years ago, even patients recovering from surgery went without medicine to relieve the ache and discomfort. Today, when patients complain of pain, doctors listen and respond, and in many ways that’s a good thing.
It has brought about a new problem, however: an epidemic of overdose from opioid painkillers. The number of deaths -- 16,651 in 2010, according to statistics released last month -- has tripled since 1999 and is now greater than fatalities from heroin and cocaine combined. For every fatality, there are 35 emergency-room visits and 161 other reports of abuse or dependence. Statistics show that the rise in abuse has tracked a rise in doctors’ orders for the drugs.
To fight back, the federal government is expected to soon tighten the rules for prescribing a popular subset of painkillers, those containing the narcotic hydrocodone mixed with acetaminophen (Vicodin is one of these) or with ibuprofen. This would be a matter of moving hydrocodone combinations up a notch from Schedule III to Schedule II, the most-restricted category of legal drugs, as recommended by an expert panel. Then, no refills will be allowed; patients will be able to get additional pills only by new prescription, either written or prescribed through an electronic system.
This change may help a little. The real hope is that it will prompt a wider shift in the medical world -- one that puts the risks of addiction and abuse on par with a patients’ pain and recognizes that painkillers can end up, intentionally or not, in the hands of a patient’s children, spouse or friends. Notably, more than 70 percent of people who abuse prescription pain relievers get them from family members or friends.
Information is key. One promising strategy to reduce prescription drug abuse has been to give doctors, pharmacists and police more information via electronic databases. For a decade, Congress has helped states fund such prescription drug monitoring programs, and at this point almost every state either has one or is planning one. Studies so far suggest they can prevent “doctor shopping” by ensuring that each prescriber knows if the patient has recently been to another one.
The monitoring programs haven’t been as effective as they could be, however, because so many are voluntary and allow doctors and pharmacists a lag time in reporting prescriptions. In Pennsylvania, for instance, the database can be accessed by law enforcement agents only, not doctors or pharmacists. That means an emergency room doctor treating an unfamiliar patient can’t log into the system to find out if the person has already been getting painkillers.
In addition to full access, monitoring programs need to operate in real time, so that the ER doctor can know if the patient filled a prescription as recently as an hour earlier.
A good model is one recently enacted by the New York legislature. Beginning this year, doctors in the state will be required to prescribe painkillers electronically, so that the database is automatically updated in real time. Oklahoma’s system also has real-time reporting, and other states should change theirs accordingly.
New York is leading the way, too, on another strategy to fight painkiller abuse, which is to help people dispose of unused pills before they end up in the hands of recreational users. The state Department of Health has been directed to establish secure disposal sites at police stations.
Drug makers can help by formulating painkillers to make them more difficult to abuse. Crush-resistant capsules -- for example, the new form of the painkiller Oxycontin -- deter abuse by making it impossible to inject the drug. Also promising are combinations of opiate agonists and antagonists, still in the works, that would relieve pain but block the opioid effects when taken in larger-than-prescribed quantities.
And as Medicare, Medicaid and the private insurance industry experiment with new models of paying for health care, they should devise ways to ensure that doctors are reimbursed for spending the time it takes to treat patients’ pain properly and to address signs of overuse and addiction.
No one wants doctors to stop caring about pain -- only to ensure that the treatment doesn’t bring another kind of agony.
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