Last week, a new patient came to see me for spells of coughing. I diagnosed bronchitis and prescribed an antibiotic. As he was about to leave he casually asked if I could refill his Vicodin prescription, which he said he was using for muscle aches at night. He said his previous doctor had been giving it to him for years following a shoulder surgery.
I told the patient that I wasn’t comfortable with that arrangement and discussed with him the possibility that he was addicted to the drug. I explained that the brain’s neurotransmitters for pleasure (especially dopamine and endorphins–the brain’s own opiates) are released in response to the drug and the body begins to crave this release. What starts off as a treatment for pain easily devolves into a doctor-supplied fix.
My new patient didn’t seem happy hearing this and I doubted he would return or accept my referral to an addiction specialist. Unfortunately, statistics show that most of my fellow internists continue prescribing the drug. The doctors who most often prescribe narcotics for supposed pain are family practitioners, followed by internists and dentists.
Painkillers are overused and abused in part because doctors overprescribe them, making large quantities readily available. A new survey from IMS Health, a health care consulting firm, reveals that Americans take 80 percent of all the painkillers in the world both on and off prescriptions, and Vicodin--which is listed as a Class III rather than a Class II drug, making it less restricted and easier to prescribe--is the most popular painkiller in this country.
Why are we at the top of the heap in terms of painkiller use? For one thing, we are popping more pills in general. Recent statistics show that one third of all Americans take two or more prescription drugs, a shocking number. Second, the most frequently prescribed drugs here are narcotics. By contrast, in Eastern Europe, opioid drugs are so well restricted that cancer specialists are concerned that thousands of patients who really need the drugs can’t get them. A recent study from Israel published in the Annals of Oncology and a report released by the European Society for Medical Oncology and the European Society for Palliative Care both confirmed that laws, which are aimed at preventing a black market in opioids, are very effective at limiting the use of these drugs. In Ukraine, patients are only allowed one day of medicine at a time, while in Georgia, they must actually obtain approval from a police station before they can get these drugs. In Russia, Lithuania, Albania, Belarus, and Georgia, supplies are restricted to a week or less.
Severe formulary deficiencies have been reported in several Eastern European countries and special forms are required in others including Russia, Albania, and Ukraine. Physicians cannot call in emergency supplies of prescription painkillers in Eastern Europe the way they can here in the U.S.
These rules, restrictions, and formulary shortages create an environment where abuse of the drugs is not easy. By contrast, here in the U.S., the black market for opioids thrives in an unrestricted environment.
The numbers here are staggering. IMS Health has determined that there are 50 percent more narcotics prescribed in the U.S. than a decade ago. Vicodin use alone has grown from 116 million prescriptions in 2006 to 131 million prescriptions this past year. In fact, Vicodin is more frequently prescribed than the most common blood pressure and cholesterol-lowering drugs, which have a much more easily justified medical role.
Perhaps most concerning of all are the number of accidental overdoses resulting from this overuse. According to the Centers of Disease Control and Prevention, 17 states report that accidental overdose kills more people than motor vehicle accidents.
In Florida, where 85 percent of the oxycodone in the U.S. is prescribed, neighboring states collect the overflow on the black market. Florida-bound buses filled with people seeking these drugs are known as The Oxycontin Express.
Over half a million doctors prescribe narcotic painkillers in the U.S., though it is a small percentage of these doctors who perform the greatest harm by prescribing the largest amounts. This overflow of drugs filters out to people who aren’t even the patient of the original doctor. A recent survey from the Substance Abuse and Mental Health Services Administration revealed that 70 percent of the people who abuse prescription painkillers got them from a friend or relative. Without these over-prescribing doctors, there wouldn’t be the same available supply.
The prescription painkiller epidemic in the U.S. cannot be solved overnight. It will require a national tightening of the belt. We must adopt some of the very policies and restrictions that Eastern Europe is rebelling against. Of course we can’t go nearly that far; cutting into the narcotic supply for the patients who really need them. But it won’t be until we can worry whether our formularies still have enough painkiller choices, whether our forms and restrictions on supply are too severe, whether our education of doctors is effective, before we know that we have gone far enough.
Marc Siegel MD is a professor of medicine and Medical Director of Doctor Radio at NYU Langone Medical Center. He is the author of the new book, The Inner Pulse; Unlocking the Secret Code for Sickness and Health.
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