Monday, December 29, 2008

Prescription drug abuse

JAMA has a paper looking at patterns of opioid abuse/use amongst people who died of unintentional drug overdoses in West Virginia. The vast majority of deaths involved prescription drugs (mostly opioids), multiple drugs ingested at once, and most involved either diverted drugs or patients who acquired their drugs via 'doctor shopping.' Methadone was disproportionately represented compared to other opioids (for unclear reasons). It's a sobering view of the prescription drug abuse epidemic in the US.


An accompanying editorial provides a reasonable gloss on the data, and tries to contextualize it in physician behavior (ie - what should we be doing about this?). It leads off early asking if it's time to restrict the use of opioids for chronic pain, only to say no (thankfully) and to give a lot of good reasons why: there are no data in this study suggesting this was from 'iatrogenic addiction' (patients became addicted after receiving prescriptions of opioids for pain), plenty that hefty amounts of diversion are involved, and there's still no clarity on what fraction of diverted meds actually come from physician prescribing (may instead be prescription forgery, pharmacy/supply-chain burglary, etc.). They make some generic and uncontroversial recommendations: ask patients about any abuse history, use urine toxicology screens and opioid contracts.

What gave me pause here is that the editorial writers felt it that we were living in a time in which it was possible to even ask that question: is it time to restrict the use of opioids for chronic non-malignant pain? There is certainly a backlash against chronic opioid use, in part due to the epidemic of prescription drug abuse, although I'm not aware of data that directly link the abuse epidemic with physician behavior/prescribing (it may be indirect - increased prescribing caused increased opportunities for criminal diversion - there were simply more drugs to be diverted/stolen, etc.) but no one really knows. Regardless, consider the alternative. Restrictions by who? Who decides that? How chronic (are 2 months ok but not 4?)? Why is cancer an exception - can't arthritis, vascular diseases, and a whole bunch of other things hurt like hell for a long time? Seems like an ugly ugly situation to me, and one that we'd never want to get into unless there was some compelling reason to, which there clearly isn't right now. We'll see, and I'm still waiting to see if this backlash will spill over to the cancer pain world, particularly with those patients receiving curative therapy....

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