We have a prescription drug problem in our country, as illustrated in Sunday’s Post & Courier cover story on pain pills, and it is not an easy fix. Americans make up only 4.6% of the world’s population, but we consume 99% of the global supply of hydrocodone (Lortab, Vicoden), and 80% of the global supply of all pain medications. As physicians, we share some of the fault for this problem, but there’s plenty of blame to go around.
The use of pain killers accelerated in 1999 when, prompted by a couple of pain societies, one of the primary healthcare oversight organizations (JCAHO) mandated that pain be given equal importance as heart rate, blood pressure, temperature and oxygen saturation. They promoted pain as the “Fifth Vital Sign”. Hospitals and healthcare providers had to prove they were recognizing and treating pain appropriately or face penalties. But there was a conflict of interest. The very pain societies pushing for these new regulations were being funded by the pharmaceutical companies manufacturing pain killers.
What must not be lost in this discussion is that many patients depend on prescription pain killers to relieve horribly debilitating pain that has eroded their quality of life. These medications are also vital in treating acute pain, such as after surgery. The vast majority of these patients use their medications appropriately and as prescribed. But, we do worry about doctor shopping, patient deception and forged or altered prescriptions. Just last week, a new patient came to my office wanting a prescription for oxycodone. A computer search revealed the patient not only was receiving fairly large quantities of this medication from one of my local pain management colleagues, but was also doctor shopping in Florida and Georgia for the same drug.
These medications are frequently prescribed in amounts that lead patients to save unused amounts in the medicine cabinet for later use. Recently I had surgery and was given 85 pain killers and used only 30. What about the patient who was given 30 pills for a kidney stone, tooth extraction or back injection? If my experience is typical of most (and I think it is), then there are a lot of pain killers stored in the home, which increases the chance of one of our children using them recreationally. Prescription pain killers are increasingly becoming the drug of choice for our children. Every day, approximately 2,500 teens use prescription drugs to get high for the first time, and more than half of them are under the age of 15. They are easy to get from our homes and are perceived to be safer because they are a prescription product from an FDA regulated industry.
Healthcare providers have little, if any, training in controlled substances. It wasn’t offered to me in my 8 years of medical school and anesthesiology residency, or my one year pain fellowship. To the best of my knowledge, it still isn’t offered now in any medical or pharmacy training programs.
Disposal of prescription medications has been confusing. Many patients don’t want to throw unused or expired medications away, or flush them down the toilet, for fear of the medications winding up in our water supply.
The public, in general, has become more insistent on getting prescriptions for our ailments, particularly antibiotics and pain killers. A 2005 CASA (National Center on Addiction and Substance Abuse) study identified that about half of all physicians surveyed thought patients tried to pressure them into prescribing a controlled drug.
Fortunately, there has been some progress on addressing this epidemic. Most states, including South Carolina, have privacy-protected prescription monitoring programs, allowing physicians to rule out doctor shopping in most instances. In 2005, Congress passed a bill (NASPER) to allow states to share their databases. And last year, the state of Washington implemented a promising, but controversial, law requiring doctors (and other prescribers) with patients who surpass a preset pain pill limit to seek a second opinion from a pain specialist. If Washington’s law proves successful, many other states will likely follow.
Lastly, there are efforts underway to allow pharmacies to collect unused or expired medications. For the time being, however, the DEA holds Drug Take Back programs across the country. Twice a year, the general public can take these medications to their local police station, where a DEA agent will collect and dispose of them properly, no question asked.