Tag Archives: addiction

Recycle to Reduce Drug Overdoses

Recycling and prescription drug overdoses have something in common.

Recycling has become second nature in many parts of America. Bins and containers to collect excess paper, bottles and cans are ubiquitous. Yet, only a few a few decades ago, recycling seemed foreign, was not convenient, and took some effort and resolve on an individual’s part.

Keith N. Humphreys, Ph.D. (Sherry Boschert/Elsevier Global Medical News)

That same evolution has to happen in the way that we handle leftover medications, Keith N. Humphreys, Ph.D., told physicians at the American Academy of Pain Medicine annual meeting. There’s an epidemic of opioid overdose deaths in the United States, and the most common source of misused opioids is leftover medications obtained from friends and family.

He’s talking about a huge cultural shift – with consumers going from saving and sharing costly medications that can be hard to come by in the current health system to recognizing their potential for harm and routinely returning leftover drugs on “take-back days” organized by law enforcement or even depositing them in specialized “recycling” bins.

The number of opioid prescriptions dispensed by U.S. retail pharmacies increased from 76 million in 1991 to 210 million in 2010, according to a report by the National Institute on Drug Abuse. And since 1990, the rate of drug overdoses has tripled, increasing approximately from 4 per 100,000 people to 12 per 100,000 people, the Centers for Disease Control and Prevention report.

As someone who worked in hospices for a decade, Dr. Humphries knows the valuable role that opioids can play in relieving pain. So, how do we make opioids available but reduce the risk of addiction, abuse and accidental overdose?

There is no policy framework that will eliminate the tension between these two goals, but some policies will help avoid it, said Dr. Humphreys, acting director of the Center for Health Care Evaluation, Veterans Health Administration, Menlo Park, Calif., and a professor of psychiatry at Stanford University. He recently served as senior policy adviser at the White House Office of National Drug Control Policy, and  reports having no financial conflicts of interest on this issue.

Here, he said, are five emerging public policies, codes of practice, and cultural norms that “most people can agree on” while working toward harder-to-implement options like expanding addiction treatment programs:

1) Build prescription monitoring programs (PMPs). The idea is that physicians could check to see if a patient has received another opioid prescription recently before handing over a new prescription, to prevent drug-seeking patients from “doctor-shopping” to get more opioids. Thirty-six states have PMPs, though most are early versions that are slow, clunky and virtually worthless. Fourteen states and the District of Columbia have enacted legislation to create PMPs, and two states have no PMP plans.

PMPs “may be resisted and resented by many professionals, but they’re inevitable” and deserve support to quickly improve, Dr. Humphreys said. Plus, there’s a bonus for prescribers: In some states, checking with the PMP before prescribing an opioid gives physicians presumptive immunity from legal liability.

2) Lock doctor shoppers into one prescriber. Every week, a West Virginian dies of a drug overdose while holding prescriptions from five or more health care providers. Public and private insurers could tell patients who have opioid prescriptions from multiple providers that they must get all prescriptions from a single provider if they want their insurance to cover costs.

Recycling bins at the Palm Springs (Calif.) Convention Center, where the AAPM met. (Sherry Boschert/Elsevier Global Medical News)

3) Make prescription “recycling” a cultural norm. Legally, opioid narcotics can be returned to any Drug Enforcement Agency law enforcer, though some states also allow pharmacies to take back leftover drugs. When sheriffs in one small Arkansas town (population 20,000) organized a drug take-back day, residents brought in 25,000 pills, Dr. Humphreys said. A physician at the meeting from Santa Maria, Calif., said a drug take-back day organized by sheriffs there was so successful that they installed a permanent drop-off box outside the sheriff’s office. Dr. Humphreys urged physicians to promote drug take-back days in their communities.

4) Make abuse-resistant medication approvals easier. Currently, developing an abuse-resistant version of an addictive medication requires a new drug application, engendering a lengthy approval process and potentially hundreds of millions of dollars in costs. Government regulators should find a way to ease this massive disincentive for pharmaceutical companies to develop safer pain medicines, he said.

5) Change opioid-related medical practice. A potpourri of short- and long-term strategies could improve practice, he suggested. Patients should be told that sharing opioids is dangerous and illegal. Both patients and physicians need to learn that opioids are not the only response to pain. Emergency physicians should break their habit of automatically writing prescriptions for 30 days’ worth of a drug, and write for shorter time lengths when appropriate. Health care workers need to get better at recognizing addiction, and more attention should go toward ways of preventing “iatrogenic” addiction caused by the health care system itself.

Physicians need to lead the way in these efforts. “Who else?” he asked.

–Sherry Boschert (@sherryboschert on Twitter)

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Filed under Anesthesia and Analgesia, Drug And Device Safety, Emergency Medicine, Family Medicine, Geriatric Medicine, Health Policy, Hospice and Palliative Care, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Primary care, Psychiatry, Uncategorized

Video of the Week: Time to Get Rid of the Addiction Stigma

The National Institute on Drug Abuse (NIDA) has launched of its Addiction Performance Project — a CME program designed to help primary care providers break down the stigma associated with addiction. The program includes dramatic interpretation of a family’s struggle with addiction — the third act of Eugene O’Neill’s “Long Day’s Journey Into Night” —  followed by a dialogue among participants aimed to foster compassion, cooperation, and understanding for patients living with this disease.

Of the 23.5 million patients who needed specialized treatment for a drug or alcohol problem in 2009, nearly 90% had not received it. Research suggests that primary care providers could significantly help reduce drug use, before it escalates to abuse or addiction. However, many express concern that they do not have the experience or tools to identify drug use in their patients, according to NIDA press release.

Our reporter Naseem Miller talked with NIDA director Dr. Nora Volkow about the need for this program.

We’re trying to generate empathy, as opposed to the stigmatized reaction that a lot of people get with drug addiction … There is still significant stigma on addiction in health care — whether it’s primary care physicians or specialized physicians.

 

To learn more about the the program, read the story in Internal Medicine News.

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Cancer Treatment: Problems Come With Success

Image courtesy of Wikimedia Commons user LadyofProcrastination

Thanks to earlier diagnosis and better treatments, we’ve started thinking of some cancers as chronic diseases — similar to asthma and diabetes. Cancer survivorship is definitely on the rise. The CDC recently reported that the number of cancer survivors in the United States rose from 3 million in 1971 and 9.8 million in 2001 to 11.5 million in 2007.

With a growing number of cancer survivors — who can live for years and  decades after diagnosis — there is a corresponding risk for pain medication addiction.  Gone are the days when oncologists can prescribe opioids like candy, according to a session at the annual meeting of the American Academy of Pain Medicine. Opioid misuse — and substance abuse in general — is a growing problem among cancer patients, according to experts at the session.

“We’re starting to see a lot more in the way of substance abuse of every stripe, in people – not necessarily who are developing substance abuse problems after they are exposed to opioids for their cancer pain – but actually the opposite. There are a lot of folks making it to tertiary cancer care centers with a history of addiction.”

Dr. Passik gave an example of a female patient, who lived with metastatic breast cancer for 11 years and who had a pre-existing polysubstance abuse problem as well. “What’s different about this case from before I had gray hair and before I spent 25 years working in psycho-oncology? When I first started in this field, this woman’s life expectancy would have been measured in months and now it’s measured in years to decades.”

Cancer patients need to be screened for abuse potential, said Steven Passik, Ph.D., a professor of psychiatry and anesthesiology at Vanderbilt University. Abuse risk management strategies are regularly used in non-cancer pain management, he said. It’s time for oncologists and other cancer specialists to start using the same strategies.

WHO Pain Ladder (courtesy of WHO)

Currently, in the WHO and NCCN guidelines, opioids are a mainstay for the treatment of cancer pain, said Dr. Dhanalakshmi Koyyalagunta, who is an associate professor of pain medicine at the MD Anderson Cancer Center in Houston. But “cancer is not a terminal disease any more … we have to change our paradigms as to how we approach these patients and how we treat them.” A good place to start is with a familiarity of the Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain.

It’s also important to identify and treat coexisting conditions that are frequently faced by cancer patients, said Diane Novy, Ph.D., who is a professor of pain management at MD Anderson. These include affective disorders, acute stress, problems related to cancer pain or treatment pain, family stress, and problems with work — and there are non-opioid treatment options for these issues.

Of course all this is not to say that opioids should never be used for pain management in cancer patients. Rather, clinicians need to screen for abuse risk factors before they prescribe these drugs and set up a monitoring system (random urine checks, pill counts, etc.).

Still — and not to belittle the suffering associated with substance abuse — having to change the way we look at cancer pain management to consider long-term treatment seems like a welcome challenge.

Kerri Wachter

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Smoking, Genes, and Volcanos – Oh My!

Dr. Thorgeirsson's slide on the Icelandic volcanos. (Photo by Sherry Boschert)

From the annual meeting of the American Society of Addiction Medicine.

The lives of thousands of physicians, reporters, and others have been disrupted by a volcano whose name they can barely pronounce. Can you say Eyjafjallajokull? Does it even help to see a phonetic spelling (EYE-a-fyat-la-jo-kutl)? For me, not so much. For more giggles, try pronouncing the name of the glacier next to it—Myrdalsjokull—which covers the even larger Katla volcano that very well may go off within the next couple of years, causing even more travel mayhem.

During a talk on the genetics of nicotine addiction, Thorgeir E. Thorgeirsson, Ph.D., director of medical genetics at the University of California, Santa Cruz, diverged briefly to talk about the big, bad smokers in his native Iceland. Take a listen:

The genetics involved in the other kind of smoking—the kind that involves cigarettes and nicotine addiction—also will likely have a huge effect on lives, though its applications aren’t quite ready for clinical practice. Dr. Thorgeirsson noted that “For the price of a fancy car, you can have your genome sequenced. The price is dropping rapidly.” Although he acknowledged that researchers are “still stumbling in the darkness” trying to understand the genetic influences on addiction, they’re starting to learn enough that he suggested, “Perhaps our definitions of nicotine dependence need to be addressed” to incorporate genetic underpinnings.

Individuals respond differently to drugs of abuse because innate differences protect or predispose them to addiction, added another speaker in the same session, Dr. Laura Bierut of Washington University, St. Louis. She and other researchers already have identified gene variants that appear to contribute to nicotine or cocaine dependency, but some startling findings make them wonder how these might eventually prove useful clinically.

“We were shocked” to find that each time a gene variant was identified as a risk factor for nicotine dependence, it appeared to be protective against cocaine dependence, and vice versa, she said. The implications raise concerns about possibly designing gene-based treatments to reduce one kind of dependency and having it boomerang by increasing the risk of another kind of dependence.

So far, the only clinically useful knowledge in this area is the risk of addiction within families. If parents have substance dependence or addiction problems, their children are highly likely to have the same vulnerabilities. Young patients need to hear this, and pediatricians need to know if a parent is addicted in order to best help their patients, she said.

–Sherry Boschert (@sherryboschert on Twitter)
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Filed under Cardiovascular Medicine, Family Medicine, Genomic medicine, IMNG, Internal Medicine, Medical Genetics, Oncology, Pulmonary Diseases and Sleep Medicine