Prescription Drug Abuse: Executive Summary of a Policy Position Paper From the American College of Physicians Free

Robert Newman, MD, MPH

Beth Israel Medical Center

December 30, 2013

Prescription drug abuse: problem of demand as well as supply

It is disappointing to note that the American College of Physicians “policy statement” regarding prescription drug abuse focuses almost exclusively on the supply end of the problem while ignoring demand – specifically, demand by those who are today dependent on prescription painkillers. In fact, the word “dependence” appears in only one paragraph of this lengthy paper, and that in a section subtitled, “Drug Enforcement Administration.”

Surely physicians, more than any other segment of society, should be keenly aware that drug dependence is a chronic medical condition that in the majority of cases requires treatment. Without treatment the dangers to the individual as well as to society are actually exacerbated by successful efforts to curtail supply. As prescription painkiller availability decreases and price rises, many who are dependent will turn to misuse of heroin; precisely such a change has been widely reported in the past few years.

The explanation for the distressing and unexpected failure of the College to emphasize first and foremost the need for treatment seems to lie in its focus on “abuse” rather than on its medical and social consequences. The fact is that drug abuse is not a clinical diagnosis! It is respectfully urged that in addition to providing guidance on appropriate prescribing of potentially harmful medications, the College advocate strenuously for ready access to treatment of dependence for those who want it, need it, and may well die without it.

Stuart Lewis MD

NYU School of Medicine

February 9, 2014

Burden of suffering

A minor correction- though the burden of suffering related to chronic pain is enormous, the estimate often quoted ,116 million adult Americans is not accurate. As noted in the Institute of Medicine Report, Relieving Pain in America, a re-analysis reduced the estimate to approximately 100 million American adults. Still, no doubt, a very large number and still worthy of our deep attention to establishing effective policies and programs for prevention and treatment not just of opiate abuse of but chronic pain as well.

J. Walden Retan, MD, FACP

Cooper Green Mercy Health Services

February 21, 2014

Comment

A substantial majority of the people to whom narcotics are prescribed for treatment of chronic pain take the medication responsibly.  A minority don’t (1).  The Annals recently published a position paper and an editorial dealing with the irresponsible minority (2).  

The position paper advocates the use of random (urine) drug testing of ‘Patients…at significant risk of prescription drug abuse.”  Apart from questions of who really should be tested (3) and what should be done with test results (4), the fundamental question is whether there is evidence that random drug screening diminishes drug overdose deaths.  For if urine drug testing does not have demonstrable societal benefit, if it is not used to benefit the patient, it’s unethical.

The editorial argues that we should prescribe less pain medication (5).  It suggests that “clinicians should rely on functional status, rather than on reported pain, as the metric of success for management of chronic, non-malignant pain.”  It notes that “Long-term opioids…may not improve and may in fact worsen functional status” (6).  But shouldn’t the patient, rather than a clinician, be empowered to choose his own metric of success?  Pain moderation today vs. only the possibility of adverse effect on functional status sometime in the future?

Finally, the editorial advocates increased use of buprenorphine.  8 mg buprenorphine, with or without added naloxone, costs our pharmacy about $2.00 a pill.  Butrans-20, the sustained release transdermal formulation of buprenorphine, costs just over $100 for each patch; a week’s worth of medication.  Generic Lortab-10 or 10 mg. methadone, costs about $0.08 a pill.

(1)              The resemblance to  patterns of alcohol use is apparent

(2)              Annals of Internal Medicine, 2014;160:198 and 207

(3)              One could make the argument that drug diversion is as apt to come from the people you don’t suspect as it is from people you do.

(4)              At first glance, a urine that is devoid of opiates when opiates have been prescribed should lead to suspicion of diversion.  But some of my patients are in so much pain despite my prescriptions that they take more than ordered one day, knowing that they’ll pay the price when that prescription runs out before the next is due.  Others try to ‘tough it out’, saving their narcotics for especially bad days.  And so on, with other plausible reasons why urine is clean.And a urine that contains evidence of cannabis or of cocaine?  Self-medication to augment my prescriptions?  Or recreation?  And if recreational drugs were found in the urine of someone with COPD or heart failure, but no pain, should the response be the same as it is for someone who’s prescribed opiates?  Should the pain patient, the heart failure patient, the person with COPD who uses recreational drugs all have medications that make life tolerable withdrawn.

               In essence, is there evidence that anyone who makes recreational use of drugs is any more likely to make problematic use of his prescriptions than someone who doesn’t?

(5)              “While we rein in our use of opioids for less appropriates indications like chronic lower back pain…”  That perceived wisdom is so counter-intuitive, it begs for at least a reference, if not a rebutting study of its own.

(6)           Though, it goes without saying, many patients report that long-term opioids allow them to function much more effectively than they did before therapy.

Thomas Tape MD FACP, Neil Kirschner PhD

Health and Public Policy Committee, American College of Physicians

April 3, 2014

Prescription Drug Abuse: Replies to Drs Newman and Reitan

The authors appreciate the comments of Drs. Retan and Newman on the position paper “Prescription Drug Abuse: Executive Summary of a Policy Position Paper from the American College of Physicians” 1

Dr. Retan asserts that the paper supports the use of random (urine) drug testing for patients at significant risk of prescription drug abuse and then questions the appropriateness of this position. In actuality, the paper does not take this position. The paper only recognizes in Policy #8 that third parties (e.g. public and private payers and law enforcement officials) may require such testing in patients identified at significant risk and makes recommendations when such testing is mandated. These recommendations are that physicians should not conduct such tests without patient consent and that “neither the patient nor the physician should bear the financial cost of random drug testing mandated by a third-party authority.” Further, commentary pertaining to the policy states that participating physicians should also be aware of the limitations of the monitoring procedure used and how various factors can affect the validity of the findings.

Dr. Newman states the paper focuses on the “supply side” of the problem and does not give sufficient attention to the problem of drug dependence . He urges the College to “advocate strenuously for ready access to treatment of dependence for those who want it, need it, and may well die without it.” Frankly, the authors were surprised by this critique. In the very first recommendation, the College “supports appropriate and effective efforts to reduce all substance abuse. These include educational, prevention, diagnostic, and treatment (author’s bold) efforts”. The College, in the accompanying text to the position statement, further indicates its position that treatment and prevention are essential to eradicating drug abuse in our society, and reflects a history of advocating for the development of treatment guidelines to provide the best-quality treatment of all who need it, recognizing that addiction is a chronic condition that must be treated continuously throughout the life of the drug dependent patient and calling for adequate funding to ensure that treatment is available.

1 Kirschner N, Ginsburg J, Sulmasy LS, for the Health and Public Policy Committee of the American College of Physicians. . Prescription Drug Abuse: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med. 2014;160(3):198-200.