Pharmacy & Therapeutics - April 2008 - (Page 199) PRESCRIPTION: WASHINGTON Actor’s Overdose an Unfortunate Eye Opener Prescription Drug Abuse a Bigger Problem Than Cocaine Stephen Barlas Stephen Barlas is a freelance writer based in Washington, DC, who covers issues inside the Beltway. Send ideas for topics and your comments to sbarlas@verizon.net. T he publicity from actor Heath Ledger’s unfortunate death has produced a new awareness on the part of many people about the rise in prescription drug abuse and its dramatic dangers. Before the popular Australian died at age 26 from an apparent accidental overdose of seven different drugs, the man or woman on the street, including present company, would have sworn that cocaine and heroin were the big drug overdose threats in the U.S., as they have been for decades. Little did we know that for about the past five years, abused prescription drugs have become a much larger concern. And we wouldn’t have been aware of this, nor would the Senate Judiciary Committee have held hearings on it on March 12, if Heath Ledger were alive today. To begin with, deaths from accidental drug overdoses are at a historic high, according to the Centers for Disease Control and Prevention (CDC). The biggest of the three problem categories, according to the CDC, is “narcotics,” which includes prescription painkillers such as oxycodone (a Schedule II controlled substance) and hydrocodone (a Schedule III substance), both found in Mr. Ledger’s system after his death. They are opiates, as are cocaine and heroin. The second most common was “other and unspecified drugs,” most of them prescription drugs. The third most common was a group containing sedatives and other psychotherapeutic or psychotropic drugs. The CDC has noted a large increase from 1999 to 2004 in deaths from prescription drug abuse. This increase was driven largely by opioid analgesics, with a smaller contribution from cocaine and essentially no contribution from heroin. The number of deaths in the narcotics category that involved prescription opioid analgesics increased from 2,900 in 1999 to at least 7,500 in 2004, an increase of 160% in just five years. By 2004, the number of deaths from opioid painkillers was more than the total number of deaths involving heroin and cocaine in this category. Maybe the rise in opioid analgesic deaths should have been anticipated. Nora D. Volkow, MD, Director of the National Institute on Drug Abuse, says that the total number of stimulant prescriptions in the U.S. has soared from around five million in 1991 to nearly 35 million in 2007. Prescriptions for opiates have escalated from around 40 million in 1991 to nearly 180 million in 2007, with the U.S. the largest consumer. The U.S. receives 99% of the world’s total supply for hydrocodone and 71% for oxycodone. Generally, the problem of prescription drug abuse is being addressed at the state level, with some assistance from the Bureau of Justice Assistance (BJA) within the U.S. Department of Justice. States have enhanced their laws to help combat the diversion of prescription drugs and, more recently, have also set up prescription drug-monitoring programs (PDMPs). With these programs, pharmacies repor t prescription data mostly involving Schedule II controlled substances, on which most of the abuse is centered, to a central state database. This database then crunches the numbers, looking for individuals who have filled multiple questionable prescriptions written by numerous physicians. In other words, the databases kick out the potential “bad apples,” whether they be the abusers, the physicians, or the drugstores. The states receive funding from the BJA’s Harold Rogers Prescription Drug Monitoring Program, which Congress created in 2002. Since then, Congress has appropriated about $7.5 million a year, which the BJA parcels out among the 20 states with par ticipating programs. Another 23 states are in the process of creating programs. It is not clear how ef fective these PDMPs are. A report completed in 2006 by consultants hired by the BJA found two types of plans. One plan seeks to reduce the supply of controlled substances by altering physicians’ prescribing patterns. The second plan assumes that the supply of opiates and other agents will remain constant, or will even grow, and it attempts to reduce the number of those drugs dispensed by pharmacies. But that 2006 report was inconclusive in terms of whether such programs worked. Ironically, in fact, the report noted that abuse of prescription pain relievers tended to be higher in states with PDMPs than in states that did not have them. Leonard J. Paulozzi, MD, MPH, a medical epidemiologist at the CDC, told the Senate Judiciary Committee on March 12 that the CDC plans to conduct a study to evaluate these PDMPs nationwide. The study will compare changes in prescription drug sales and overdose rates in states that start these programs with changes in states that do not initiate these programs. Such a study is long overdue, it seems, given the jump in prescription drug abuse deaths. There is no way to avoid the impression that despite oxycodone and hydrocodone diversion and misuse, the problem remains on the back burner. Maybe Heath Ledger’s death will bring it to a boil and push the problem to the front burner. I Vol. 33 No. 4 • April 2008 • P&T® 199
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