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ROOM FOR DEBATE
UPDATED FEBRUARY 16, 2012 11:28 AM
How to Curb Prescription Drug Abuse
INTRODUCTION
Robert F. Bukaty/Associated Press
The toxicology reports on Whitney Houston’s death are still weeks from being released, but
many are already speculating that her untimely death may be the result of mixing
prescription drugs with alcohol, like so many other celebrities before her.
Celebrities, of course, are in a class by themselves: money, fame and proximity to power will
always inspire at least one doctor to prescribe something inappropriate. But prescription
drug abuse isn’t just a problem among celebrities; it is a growing factor in accidental deaths
nationwide.
What is the best way to curb prescription drug abuse while ensuring that patients still
receive the medications they need?
DEBATERS
How to Treat the Epidemic
KEVIN A. SABET, FORMER DRUG POLICY OFFICIAL
Prescribers, doctors and government and industry officials all have a role to play in attacking the
problem.
Opioids Are Rarely the Answer
ANDREW KOLODNY, PHYSICIANS FOR RESPONSIBLE OPIOID PRESCRIBING
Doctors need access to education and training programs that are free of industry bias.
A National Monitoring Program
LINDA SIMONI-WASTILA, UNIVERSITY OF MARYLAND SCHOOL OF PHARMACY
It would bring abusers into treatment, and do more to save lives than all the wars on drugs waged to
date.
Public Education Campaigns
CALVINA FAY, DRUG-FREE AMERICA FOUNDATION
No one action will fix this enormous problem, but comprehensive efforts can save one life at a time.
Parallels With Gun Control
JONATHAN CAULKINS, PROFESSOR OF PUBLIC POLICY, CARNEGIE MELON UNIVERSITY
Doctors, pharmacists, drug companies and patient advocates have a moral obligation to find a
compromise that serves broader public health interests.
Patients Must Also Be Responsible
CAROL J. BOYD, UNIVERSITY OF MICHIGAN'S SCHOOL OF NURSING
It is not only health providers and policy makers that must change, patients must change too.
http://www.nytimes.com/roomfordebate/2012/02/15/how-to-curb-prescription-drug-abuse
How to Treat the Epidemic
Kevin A. Sabet is an assistant professor in the College of Medicine, division of addiction studies, at
the University of Florida and a consultant. He served in three different administrations’ drug
policy offices.
FEBRUARY 15, 2012
Most Americans are surprised to learn that in 2008, the last year for which data is
available, poisonings killed more people than car crashes in the United States, making
them the leading cause of accidental death in the country for the first time. Ninety
percent of those poisonings resulted from a drug overdose, and the majority of drug
overdoses do not involve illegal drugs like cocaine or heroin, but rather legal,
prescription drugs like oxycodone and other opioids. These legal drugs were responsible
for 15,000 deaths in 2008, compared with 4,000 deaths in 1999. The Centers for
Disease Control has now classified prescription drug abuse as an epidemic.
Prescribers, doctors and government and industry officials all have a
role to play in attacking the problem.
Prescription drug abuse presents a unique puzzle to lawmakers because, as anyone who
has had an injury or lives with chronic pain can attest, painkillers can be incredibly
useful if taken appropriately. But the recent rise in the abuse of these drugs calls for
some radical changes to our relationship with them.
First, prescribers and physicians have to do their fair share. They should be subject to
mandatory education and training on proper prescription practices (methadone and
oxycodone, for example, are very different drugs, yet they are often prescribed
interchangeably, leading to unintentional overdose) and on the nature of addiction,
which is shockingly undertaught in mainstream medical education today. Prescribers
should also be required to actively use their state’s Prescription Drug Monitoring
Program (PDMP), an electronic database which collects designated data on substances
dispensed in the state. Most states have them, but they will only be effective if they are
used by doctors to identify cases of abuse.
Second, our governments must lead a more coordinated and vigorous attack on this
problem. That means more investments in community-based drug prevention and
treatment (President Obama’s just-released budget does call for a funding increase on
this front), but it also means stopping the subsidization of abuse which occurs through
Medicare fraud, as a G.A.O. report recently discussed. The government must also ensure
that these monitoring programs operate smoothly across state lines. Additionally, since
we know that most prescription drug abuse starts with the medicine cabinets of family
and friends, Americans need easier ways to safely dispose of their unwanted medication
(last year, a Drug Enforcement Agency ―take-back‖ event collected more than 189 tons
of prescription drugs).
Finally, industry has a part to play in this too. The formulation of drugs that cannot be
abused (yes, ―abuse-deterrent‖ drugs are possible) and funding for education efforts in
health care settings need to become higher priorities for pharmaceutical companies.
We are in the midst of a troubling epidemic: these measures are essential if we are to
beat it.
http://www.nytimes.com/roomfordebate/2012/02/15/how-to-curb-prescription-drugabuse/how-to-treat-the-prescription-drug-epidemic
Opioids Are Rarely the Answer
Andrew Kolodny is president of Physicians for Responsible Opioid Prescribing and chairman of the
department of psychiatry at Maimonides Medical Center in New York City.
UPDATED FEBRUARY 16, 2012, 10:39 AM
Doctors have contributed to an epidemic of overdose deaths and addiction by
overprescribing opioids. We didn’t do this out of malicious intent. For most of us, it was
a desire to treat pain more compassionately that led to overprescribing. To bring this
public health crisis under control, doctors must prescribe more cautiously.
In response to an industry-funded campaign, sales for opioids increased exponentially.
Doctors were taught that unrealistic fear of addiction was resulting in needless suffering
and that opioids would provide long-term relief of chronic pain. Doctors were
misinformed.
Doctors need access to education and training programs that are free
of industry bias.
Prescribing opioids short-term for acute pain and in palliative care is not controversial.
But their widespread use for chronic pain may actually harm more people than it helps.
Many patients on long-term opioids continue to suffer from significant pain and
dysfunction. We have also come to realize that addiction and other serious side effects
are common.
Overprescribing of opioids isn’t just bad for patients. As opioids have become readily
available in our medicine chests and classrooms, teenagers are experimenting with
them. Unaware that these pills are similar to heroin, many recreational users are
becoming addicted and dying from overdoses.
The Centers for Disease Control has demonstrated a strong association between
increased opioid sales and overdose deaths. This suggests that prescribing needs to be
reduced. Opioid manufacturers, and the pain advocacy organizations they fund, do not
agree with this approach. They argue that opioids are still underused for chronic pain
and that prescribing needs to increase.
For doctors to prescribe more cautiously, an accurate appreciation of risks and benefits
is required. For this to happen, they need access to education and training programs
that are free of industry bias.
Untreated chronic pain is a serious problem. But opioids are rarely the answer. Chronic
pain patients need and deserve compassionate care and evidence-based treatment.
http://www.nytimes.com/roomfordebate/2012/02/15/how-to-curb-prescription-drug-abuse/opioids-arerarely-the-answer
A National Monitoring Program
Linda Simoni-Wastila is a professor at the University of Maryland School of Pharmacy and blogs
at leftbrainwrite.
UPDATED FEBRUARY 16, 2012, 10:39 AM
To battle what the Office of National Drug Control Policy terms the ―prescription drug
abuse crisis,‖ many states have authorized Prescription Drug Monitoring Programs
(P.D.M.P.s). By tracking prescribing, dispensing and consumption patterns of controlled
prescription medications, states with these programs can easily analyze information
necessary to identify — and prosecute — fake prescriptions, ―pill-mills,‖ doctor shoppers
and insurance fraud.
It would bring abusers into treatment, and do more to save lives than
all the wars on drugs waged to date.
There is nothing novel about these monitoring programs. In 1936, California
implemented the first P.D.M.P. to stem a growing opium problem. Since then, 35 states
have implemented them and another eight have passed laws requiring these programs.
Despite P.D.M.P.s’ wide-scale adoption, little is understood regarding their impact on
abuse, and whether they curb access to necessary medications. The few rigorous studies
demonstrate that they reduce use of targeted drugs, but whether such reduction comes
from decreases in abuse, medical use or both remain untested. Hence, virtually nothing
is known about their influence on treatment, overdose, mortality or other outcomes.
So why am I a proponent of a national P.D.M.P. when data fail to provide conclusive
evidence? A national Prescription Drug Monitoring Program will provide uniform
expectations of appropriate use that affects all players— prescribers, dispensers and
consumers. As well, a national program will relieve the growing onus on states without
such programs that find their backyards filled with diverters fleeing states that have
them. A national P.D.M.P. would bring much-needed standards for data collection,
analyses, outcomes and evaluation.
The most important reason for implementing a national P.D.M.P., however, and one I
see as its greatest opportunity, is the potential to bring prescription drug abusers into
treatment. With few exceptions, P.D.M.P.s are run by law enforcement or medical
boards. The recently legislated P.D.M.P. in Maryland, run by the state’s Alcohol and
Drug Abuse Administration, could serve as a model for a national program. Housing a
national program in an agency dedicated to the prevention and treatment of
prescription drug abuse could do more to save lives due to overdose and destroyed
hopes than all the wars on drugs waged to date.
http://www.nytimes.com/roomfordebate/2012/02/15/how-to-curb-prescription-drug-abuse/we-need-anational-prescription-drug-monitoring-program
Public Education Campaigns
Calvina Fay is the executive director of Drug Free America Foundation and Save Our Society From
Drugs, national organizations with missions to help prevent drug abuse.
FEBRUARY 16, 2012
Prescription drugs are typically diverted for nonmedical use by friends and family,
doctor shopping, stolen or fraudulent scripts, pill mills and street dealers. There is no
silver bullet to effectively end this national epidemic. Efforts to curb prescription drug
abuse must address each sector and should include at a minimum the following:
• Public educational campaigns illustrating the importance of not sharing medications,
locking or otherwise securing them in a safe place and responsibly discarding unused or
expired prescriptions.
• Official prescription programs requiring a single source, state specific prescription pad
or secured online prescribing.
• Real-time prescription monitoring programs that require use by the prescriber and the
dispenser.
• Formal regulations on pain clinics that do not impede legitimate patient care but
effectively weed out pill mills.
• Dependence and addiction education requirements for physicians who prescribe
powerful narcotics.
• Food and Drug Administration approval of tamper resistance formulas for opioids and
requirements for insurance coverage of these new technologies.
Regulations and prescribing guidelines can be implemented to tighten down on
operations of pain clinics. A logical requirement would be to prohibit treating physicians
in most settings from dispensing addictive pain meds.
Another effective measure to consider is tracking the type and quantity of drugs that
pharmacies buy from wholesale distributors. Better regulations of online pharmacies to
both reduce abuses and protect innocent customers from doing business with criminals
who are producing poison in a bathtub and selling it disguised as a legitimate medicine
are needed. Requiring online pharmacies to be certified and to post their certification
number to be routinely monitored by officials while encouraging the public to avoid
sites without certification would help.
Clearly, no one action will fix this enormous problem that we face with prescription drug
abuse, but comprehensive efforts can save one life at a time.
http://www.nytimes.com/roomfordebate/2012/02/15/how-to-curb-prescription-drug-abuse/needed-publiceducation-campaigns-on-drug-abuse
Parallels With Gun Control
Jonathan Caulkins is a professor of operations research and public policy at Carnegie Mellon
University.
UPDATED FEBRUARY 16, 2012, 10:50 AM
Prescription drug abuse takes many forms. At a minimum one must distinguish between
individuals who abuse substances their own doctors prescribe, as opposed to those who
obtain the drugs in other ways (with phony prescriptions, buying directly or indirectly
from others who have prescriptions, stealing, etc.). The medical profession can deal with
the former in unobtrusive ways -- via physician training, information systems that warn
when dangerous combinations have been prescribed and so on. The latter requires a
more comprehensive response, such as third-party review when quantity thresholds are
exceeded (either to a single patient or by a single doctor) or limiting insurance coverage
for opioids to prescriptions written by a single provider (to deter doctor shopping).
Doctors, pharmacists, drug companies and patient advocates have a
moral obligation to find a compromise that better serves broader
public health interests.
The prospect of controls raises red flags. Why should law-abiding citizens have to suffer
through treatable pain just to prevent others from abusing? They should not, and
frankly need not. The compromise is not so much access to pain relief, as access to pain
relief without hassles, monitoring and loss of privacy.
In an ideal world patients could get pain relief through a customer-friendly system
designed solely around their convenience, but we live in an imperfect world -- one in
which people are dying unnecessarily in very large numbers. The death rate from
prescription drug abuse matches that suffered by U.S. armed forces at the peak of the
Vietnam War. The medical establishment collectively, including doctors, pharmacists,
drug companies and patient advocates, has the political power to preserve the status
quo, but in my opinion they have a moral obligation to find a compromise that better
serves broader public health interests.
Oddly, there are parallels with gun control. The parallels are far from perfect, but it is
usefully provocative to match up the corresponding stakeholders. Just as gun
manufacturers profit when guns purchased within a loosely supervised regulatory
system get diverted to drug trafficking organizations, so too do pharmaceutical
companies profit when their drugs are diverted into unsupervised use, and a single longterm dependent recreational user is a much more profitable customer than is a
legitimate patient who will most likely get well.
http://www.nytimes.com/roomfordebate/2012/02/15/how-to-curb-prescription-drug-abuse/drug-controlhas-parallels-with-gun-control
Patients Must Also Be Responsible
Carol J. Boyd is the Deborah J. Oakley professor at the University of Michigan's School of Nursing.
FEBRUARY 16, 2012
―Prescription drug abuse‖ refers to the misuse and abuse of controlled medications.
These drugs are often prescribed to control pain, treat A.D.H.D., reduce anxiety and aid
in sleep. In the United States, these ―controlled‖ drugs are manufactured, distributed
and prescribed within highly regulated systems that involve the Drug Enforcement
Administration and the Food and Drug Administration;our systems are designed to
protect patients from potentially addictive medications, all the while making efficacious
medicine available.
Despite our relatively robust regulatory system, we find the system bypassed – friends
and family share pain pills, college students swap their stimulants, patients ―doctor
shop‖ and addicts seek ―pill mills.‖ The very breadth of the diversion makes the
prescription drug problem difficult to curb. There are too many pills, too little education
and too few ways to safely and efficiently dispose of unused medicines. If we are to curb
our prescription drug in the United States, we must change our ways. I propose that:
• Health providers reconsider their refill and prescribing practices, and only prescribe
what patients are likely to need (not what they request);
• Providers – physicians, dentists and nurses -- advise patients about proper use and
risks of misuse;
• Policy makers enhance their state's prescription monitoring programs to thwart
patients who doctor shop; and
• Communities provide safe and efficient ways for people to dispose of their unused
medications
However, it is not only health providers and policy makers that must change, patients
must too. Most of us will have a prescription for a controlled medication in our lives, so
let us not forget to use the medicine only as advised; beware of sharing, it is against the
law to divert; control pills and keep them safe; and dispose of unused medicine
correctly. If we are to curb this problem, we must all take some responsibility.
http://www.nytimes.com/roomfordebate/2012/02/15/how-to-curb-prescription-drug-abuse/patients-mustalso-be-responsible-in-using-prescription-drugs