“First do no harm” is often quoted from the translation of the Hippocratic Oath. Scholars say that is not an accurate quote. Rather according to a Harvard ethicist, it says “Doctors should help their patients as much as they can by recommending tests or treatments for which the potential benefits outweigh the risks of harm”.
As research changes, those treatments change. The situation with opioids is a perfect example of this. Historically they were rarely prescribed due to addiction risk. The pendulum swung to a much more free use of the drugs when physicians were told that OxyContin had almost zero risk of addiction. With the current opioid addiction epidemic, the pendulum has swung back to advising much more caution in the use of these powerful drugs. But it is taking time to make those changes.
In 2007, Purdue Pharma and its top executives pleaded guilty to charges that it misled doctors and patients about the addictive properties of OxyContin and misbranded the product as "abuse resistant”. They paid $600 million in fines.
In the past it was a common perception that opioid addicts were the heroin junkies shooting up in a seedy location. Today, that stereotype could not be further from the truth. During the Medicare Part D Rx open enrollment period, our clients provide us with a list of their current medications. I am astounded at the number of opioids that are being taken by these clients.
I see the same situations with many of my younger clients as well. One story is near to my heart.
Whenever I would encounter Dylan, he was quick to share his mischievous smile and dry sense of humor. You simply couldn’t help but like this guy. Following surgery for a sports injury, he was prescribed opioids by the surgeon. His ultimate addiction resulted in his death at age 29 from a heroin overdose. His is a common tale.
This epidemic is expensive in both hard and soft dollars. A 2016 study from Castlight Health covering nearly 1 million Americans showed that nearly 1 of 3 opioid prescriptions is being abused. The abuse includes over-usage and sharing medications. This study revealed that these abusers cost the plan nearly twice as much ($19,450) as non-users.
Locally, we have our own issues with this epidemic. It has to be confronted on several levels. The primary level is the source of the initial prescriptions. Physicians must unlearn this fraudulent message provided by big pharma.
Clearly there is still work to be done. According to a recent report for the period 109/1/2015 to 98/130/2016 the top 20 local prescribers (3.16%) accounted for over 50almost 28% of the prescriptions for opioids. Equally disturbing is the report that Opioid prescriptions were filled by 55,692 unique Shasta County residents during that time-> 1/3 31% of our adult population!
Insurance companies recognize this epidemic and have been placing stricter rules around filling opioid prescriptions. Initial prescriptions may be limited to low doses and just a few pills. Since starting their Narcotic Safety Initiative in 2015, Blue Shield has “reduced the proportion of new opioid utilizers progressing to chronic use by 25 percent, and has seen an overall reduction in all opioid consumption”.
Anthem has implemented a similar program directed at those considered to be a safety risk. According to their website: “Even after overdosing on opioids – more than nine out of 10 people continued to get prescriptions for them”, according to a 2015 study published in the Annals of Internal Medicine. Seventy percent of patients who overdosed later received prescriptions from the same health care professional who prescribed opioids before their first overdose.
I serve on a local task force called No Rx Abuse. The group is trying to educate physicians on the danger of these prescribing habits. It is not an easy task. Reports that identify the problem with prescribers, do not allow access to the identity of the prescriber. So there is no way to specifically direct training to those that need help understanding the danger of their prescribing patterns.
Clearly we are in the process of reversing the trend at the initial supply source: prescribers. But what about all those who are addicted? How will that be addressed before they progress to heroin when they can no longer access their prescriptions? A methadone satellite clinic will be opening this month. It’s a start.