If you can’t trust your pharma rep, who can you trust?
The US uses 80% of all the prescription opioids in the world, with only 5% of the world’s population. This does not include the street equivalents (heroin, fentanyl). The lack of controls for this drug, on the production, distribution and dispensing has led to the alarming addiction rates for legitimately prescribed and illegitimate narcotic use. Suddenly there is alarm because over 64,000 people die in the US due to opiod overdoses per year. That is more than five times the number of gun murders and more than three times the number of suicides in the US per year.
Twenty years ago…
While I was still doing some ICU nursing, I attended an in-service training covering, among other things, a fairly new drug called Oxycontin. This drug claimed special powers, a timed-release version of Oxycodone (think Percocet, Vicodin) that would gradually release the pain-killer over 12 hours. The company, Pharma, claimed their formulation made Oxycontin addiction-proof.
I was concerned because when I looked the drug up in Drug Facts and Comparisons, it appeared that the equivalent of 10 mg of morphine was contained in every mg of “Oxy,” as it became known. So 10 mg of Oxycontin would be 100 of Morphine! Given every 12 hours as directed, the patient with the lowest dose of Oxy would get the equivalent of 210 mg of Morphine (or Morphine Milligrams Equivalents, MMEs) a day!
A drug rep came to the hospital to answer questions about Oxy. I asked the drug rep about the addiction risk. ‘Oh, it’s easy to wean off, you just halve the dose each day until you wean it off. There’s no residual craving.’ This was a lie, of course, but in 1997 it would be difficult for an individual clinician to know what a disastrous outcome was unfolding regarding prescription narcotics (see chart of opioid use disorders below). Oxycodone and Oxycontin are the real gateway drugs leading to heroin abuse and overdoses. The sales of privately-held Purdue Pharma have landed one family on the Forbes richest families. What a legacy!
Currently the CDC recommends no more than 50 MMEs per day to address chronic pain, and does not recommend the use of sustained relief narcotic analgesics at all. This refers to those who do not have active cancer or are in a palliative care or hospice program.
Illegal Marketing Tactics
Compounding the problem is the unprecedented Oxycontin marketing push by Purdue Pharma. Starting in 1996, the company spent millions promoting to and “educating” doctors – using data to identify those who’d likely prescribe high amounts of the drug. They more than doubled their sales force and highly incentivized their reps – paying out some $40 million in bonuses in 2001 alone. Purdue also skirted FDA marketing regulations by sending out 15,000 educational videos that minimized addiction risk to doctors without first getting FDA approval. Sales grew from $48 million in 1996 to almost 1.1 billion by 2000. In 2007, three company executives ultimately pled guilty to criminal charges of misbranding.
Sun belt and rust belt states have the highest prescribing rates for opioids. In 2012, health care providers in the highest-prescribing state wrote almost 3 times as many opioid prescriptions per person as those in the lowest prescribing state.
How Insurers Are Part of the Problem
The New York Times has reported that insurers are making it harder to get non-addictive, pain-relieving drugs because they’re more expensive. Private pay and Medicare insurers require little or no pre-approval for drugs like long-acting morphine or even Oxycontin, and less out-of-pocket co-payment. This steers people suffering from chronic pain toward these habit-forming drugs. Patients have been left in a lurch after some drug companies stop covering drugs that are working for them.
To add insult to injury, the article reported that insurers are also making access the addiction treatment drugs difficult.
After Overdoses, Doctors Still Prescribe Opioids
According to the Journal of American Medicine, for every 1 overdose, there are 30 non-fatal ones – which represents an intervention opportunity. But, there is evidence that doctors are missing opportunities on many fronts. A 2002-2012 study in Pennsylvania reported high rates of post-overdose opioid prescribing. Another study showed a low rate buprenorphine treatment – which is one way to fight addiction. These studies were conducted with commercially insured patients. Little is known about Medicaid enrollees – who are at 3 times higher risk for overdose.