We have taken a number of actions at the FDA over the past several years to help reduce the number of people who become addicted, or who ultimately overdose from prescription opioids.
In bathrooms, bedrooms, and alleyways across the country, people are overdosing and dying every day. So we need to start talking about solutions.
You’ve probably noticed recent reports, within the Work Comp PBM industry and elsewhere, that prescription opioid use and overdoses are on the decline. It is a long journey and we cannot yet see the destination, but progress is being made. One of the goals has been to make it more difficult to secure clinically inappropriate prescription opioids thru legitimate (physician, dentist) and illegitimate (pill mills, street sales) means. Abuse deterrent formulations have also helped, creating a hassle factor for those that want to abuse them. The increase in focus on the subject in the media and government has made it more top-of-mind. Although even one death or the creation of one new addict is too many and we have lots of cleanup today on the damage already done to individuals and communities, the trends are heartening.
However, for every intended consequence, there are also unpredictable unintended consequences. And one of those that I’ve been following for some time, that two recent clinical studies have codified as accurate, is the dramatic increase in the abuse and misuse of heroin. We may be going from opioids to heroin. A good amount of that increase is theorized to be coming from those that may have become addicted or highly dependent upon the euphoric effect and/or dulling of the pain from opioids. Because today’s heroin is “pharma quality” and less expensive than opioids on the street, heroin has become the primary alternative choice. If you think this is a recent issue, this USA Today article entitled “OxyContin a gateway to heroin for upper-income addicts” was my initial warning on June 28, 2013.
The reasons for this switch are multiple and complicated. An excellent article on this issue was published in the June 2015 edition of “Pain Medicine News“.
Three quotes that struck me the most:
- “Fewer than 20% of chronic pain patients benefit from opioids”
- “The prolific normalization of opioid use for chronic pain within primary care has seeded the epidemic of heroin addiction”
- “We are going to see the biggest explosion of heroin addiction ever in the next five years”
Obviously, heroin is an illegal drug and therefore cannot be tracked or managed within a PBM. But this is an important turn of events that everyone needs to be watching. While heroin use may not be a Work Comp “problem”, it is a societal problem, which ultimately always rebounds as an issue for everyone (and everything) else.
By now, possibly you’ve read my second article (in a series of two) on WorkCompWire entitled “Rx Epiphany for Work Comp – Death Benefits.” The genesis of this article was a recent California decision awarding death benefits from the Work Comp payer to Brandon Clark’s family after an accidental overdose death. However, my concern about the combination of prescription drugs and potential death is much more personal.
After speaking at a conference recently, I rode on the shuttle bus to the airport with a fellow attendee. It was a 15 minute ride. After having spoken in front of an audience for an hour, I’m usually fairly quiet on any subsequent transportation (airplane, shuttle ride). However, we struck up a conversation about why I was there (she had attended a competing session) and my focus on prescription drug abuse and misuse. And then she started to share.
Her 29 year old son died of a prescription drug overdose a few years prior. She is a nurse. He had a PhD. He had OCD and had been on ADHD drugs since a child. He was driven to succeed and extremely intelligent. He was self-sufficient and living in Florida, working in a university setting. However, after a surgery he was given morphine, which began the downward spiral that led to his death. He doctor shopped. He pharmacy shopped. She knew about it and tried to help him. She felt like he thought he was too smart to be ensnared by addiction, but that’s exactly what happened. He had been dead for two days before she was able to arrange for someone to stop by his apartment. Her retelling of this story was factual and somewhat unemotional, as time had somewhat provided distance. But the call she received that day obviously dramatically impacted her life, her family, his friends, her friends … everybody that knew him and her. It was personal to her.
The next week, I received an e-Mail from someone who had read my Insurance Thought Leadership article “Next Tsunami of Work Comp Payments“. It resonated with him because his brother was prescribed “massive amounts of opioids” for a knee replacement by his Work Comp doctor. Unfortunately, he developed an addiction. The good news is that, after a long struggle through rehab, he is now clean and sober. The story of addiction and death from prescription drugs, again in follow-up to a surgery and someone who had not exhibited dependence issues prior, was personal to him. And to his brother, who will deal with the struggle of sobriety for the remainder of his life.
I recall a vendor who had sponsored one of my CE presentations last year who listened attentively to my content. He approached me afterwards, privately, to ask for a copy of my presentation. His brother-in-law had a serious addiction issue to many of the prescription drugs I discussed and wanted to share the content with him. But it didn’t just effect his brother-in-law. It effected his sister, and their kids. And it even effected their relationship because he and his wife wouldn’t allow his brother-in-law to come visit them any longer because of his abuse of drugs and of others. Although he had tried to intervene, it was a difficult circumstance (and conversation). It was personal to him.
A decision published on June 16 by the New York State Workers’ Compensation Board found that an injured worker’s intentional suicide by ingesting oxycodone and diazeapam, “was a consequence of her compensable injuries including her established consequential depression” (WCB file # 80017452; contact me if you want a PDF copy of the decision). Two cervical spine surgeries did not relieve her pain and led to total disablement. She was a self-admitted workaholic who, according to the psychiatrist, received self esteem from being “useful and helping her family”, but with the disability came the inability to work. Despite a three year regimen of Cymbalta for pain and depression, “she realized at that point that she would never have any definitive relief, and that she was always going to be in pain and physically incapacitated, and probably would never work productively, again.” In layman’s terms, she lost her purpose. She died on July 16, 2013. Based on this decision, it seems like death benefits will be awarded to her beneficiaries. The emotions laid out as evidence from the medical notes by her physician and psychiatrist paint a picture of withdrawal and despondency and loss of self-worth. A picture that is seen often with chronic pain. A sad, sad outcome of an injury at work. And intensely personal.
Finally, according to Charles Lane’s article “The legal drug epidemic” published by The Washington Post on March 11, from 1999 thru 2013 more than 175,000 people have been killed by prescription drug overdoses. That’s like the entire city of Knoxville TN going away. A completely man-made disaster. Opioid addiction and death.
I’ve been involved at the intersection of prescription drugs and non-malignant chronic pain since 2003. I have literally seen thousands of Work Comp claims since then with inappropriate polypharmacy regimens. I have seen many of those circumstances turned around by collaborative intervention, with many of those regaining their life by reducing or removing the drugs that were causing so many issues. I even remember a phone call from an injured worker to our office, thanking us for effectively saving his life. But I know that so many more slipped through the cracks, or would not respond to clinical common sense (prescriber and/or patient), or had improper motivations (or enabled by those with improper motivations). Opportunities lost.
So … To me … This is personal. These stories make it personal. That’s why I’m currently focused on educating claims adjusters, case managers, clinicians, legislators, employers, patients – anybody that will listen – to make better choices and to seek help.
I am heartened by an industry awakening to the issue and so many good people trying to do the right thing. By the emphasis this scourge has received from federal and state and local governments. By the increasing desire by both prescribers and patients to change old habits. By the increasing acceptance of conservative and alternative treatments and recognizing the importance of a biopsychosocial model. By not taking “no” for an answer when a life – and surrounding lives – are at stake.
If this epidemic is not personal to you … It should be. Humanizing the cost of inappropriate prescription drug use is the best way to spark action. Every life matters.