Drug Overdose Deaths Increase 14%
According to a recent article in the Detroit Free Press deaths due to Drug Overdoses in Michigan have increased by 14%, with most of these deaths due to heroin and prescription pain killers. The report goes on to talk about the findings of the of the Michigan Drug and Opiate Abuse Task Force. Key findings included that opiate and drug overdoses were the leading cause of accidental death in Michigan in 2014, accounting for 1745 deaths in urban, suburban and rural Michigan, that Michigan has seen a 4 fold increase in overdose deaths since 1999 and there were 22,000 deaths in the United States due to overdose in 2014.
The Source Data
While the article itself was alarming, a legislator should become familiar with the actual information, not a newspaper’s take on the information. As an Addiction Medicine physician, I am professionally qualified to review and discuss the Source Data from the State Report.
My major concern with this report is the panel that created it. Drug addiction and overdose is major medical problem in this state, and one would think that we would approach it from a medical standpoint. But looking at the composition of the task force- there appears to be 2 doctors and 2 pharmacists out of the 21 members of the panel. The rest were prosecutors, sheriffs, MSP, other law enforcement. There were some insurance and regulatory experts and some legislators assigned to round out the line up. The overall impression I got from the review was that this was being approached from a law enforcement and regulatory view, rather than from a treatment aspect. There were some good points made, despite the fact that only a fraction of the panel members were actually involved in the treatment of overdose and addiction.
The findings of the report came from the same medical literature I review, in fact several of the descriptions of the problem seem to have come from MY practice website. Some key information:
- Michigan Ranks 18 of 50 states in drug overdose deaths
- 745 million individual doses of scheduled medications were written in MI in 2014.
- 70% of people abusing scheduled medications (Opiates and Benzodiazepines) get them from family and friends.
- Heroin is increasing in purity and decreasing in cost. The supply of heroin to the Midwest is increasing per the DEA.
A typical scenario is that a patient has surgery or an injury. Their doctors prescribe opiate pain medications (generally short acting ones like norco) and refill them regularly. As the patient continues to take these medications, the develop tolerance and report decreased effectiveness. Their doctors increase the dose, until they suddenly realize the amount the patient is taking, become concerned, and cut the patient off. Rather than go through withdrawal, the patient ‘borrows’ excess medication from family and friends. They then are put in a position to have to pay for this medication, learn heroin does the same thing but is cheaper, and the rest continues to snowball. Lives are ruined, jobs are lost, and the patient enters the legal system.
Despite the make up of the panel, several good recommendations resulted from their work. I’ve broken these recommendations down by groups as the report did:
The panel recommended physicians in pain management receive specific training in the use of pain medications. To monitor this, there should be increase cooperation between state agencies to keep an eye on what doctors were writing what medications. Disposal bins should be made available to the public to safely dispose of unneeded and excess controlled substances to prevent diversion. Require patients to go to only one doctor for all controlled substances, which are to be filled at only one pharmacy. Increase public awareness of addiction, abuse and overdose of prescription medications.
Make narcan (the antidote to narcotic overdose) available over the counter in a similar fashion to pseudo ephedrine. Limit liability for those administrating narcan to an overdosing patient. Consider giving limited criminal immunity to low level users of narcotics if they ask for help. Encourage doctors to participate in the treatment of addiction and encourage insurances to pay for it. Pay special attention to pregnant abusers and get them into treatment.
Special Licensure of Pain Clinics. Update the licensure procedure for methadone clinics. Give pharmacists immunity for refusing to fill questionable prescriptions. Develop ‘best practices’ for pain management.
Establish a permanent review board to monitor pain management. Revise and update the Michigan Automated Prescription Monitoring Service (MAPS) and include ‘morphine equivalents’ to get a better view of the amount of pain medication being given a patient.
Dr. Robert Townsend Addresses Drug Overdose
I would bring my background in addiction medicine to address this very important issue as your State Representative for the 97th District. While this is a start in the right direction, it is mostly approached from the aspect of law enforcement and control, rather than our changing understanding of addiction. We also need to look at it from the aspect of appropriate pain management and assure the residents of Michigan do not suffer needlessly out of fear of addiction and overdose. Or regulatory action against doctors and criminal charges for patients. Not all patients suffering chronic pain are abusing their medications, and they deserve relief.
The policy recommendations are really not all that bad. Doctors that write pain medication should have better training. I see a lot of short acting narcotics being written multiple times a day. Short acting narcotics are best used for breakthrough pain, not chronic pain control. Doses need to be kept low, narcotics can to be used in combination with Motrin like medication (or even alternative medicines) to further reduce the needed doses of pain medications. If more than 3 doses of norco are required a day, consideration of longer acting medications such as methadone should occur to reduce the ‘rollercoaster’ effect and daily dose of tylenol.
Of particular concern to me is the suggestion that patients should only have one doctor giving them controlled substances, which should be filled by only once pharmacy. While this seems like a good idea it will tend to reduce good management of patients and access to care. With the current MAPS reporting system, I, along with all your doctors, can see who you are getting medications from, where you are filling them and how much you are getting. This system is in place, we use it EVERY VISIT and so should all doctors. This eliminates the need for this restriction. It also eliminates a barrier to care to people seeing doctors for different reasons or needing to fill at different pharmacies.
Narcan saves lives, it should be available to the people that save those lives including family members and the police. Paramedic level ambulances already carry it. It is relatively harmless and the fear of liability should not overcome the desire to save lives. Seeking help in an emergency should not result in criminal charges as a rule, asking for help should not be penalized and incarcerating someone for an addiction does nothing to help the problem.
As for new regulations, my only concern with this section is immunity for pharmacies. We are currently seeing pharmacies refuse to fill legitimate pain and addiction medications now. This is out of fear of local law enforcement and the DEA ‘counting their numbers’ and a recent history of prosecutions for pharmacies over filling pain medications. We are even seeing local law enforcement pressuring pharmacies to refuse to stock certain pain and addiction medications which hurt far more legitimate patients than preventing diversion. Legitimate and reasonable prescriptions from a license physician should be filled, and questions directed at the DOCTOR, rather than simply refusing to fill out of hand. As a physician I once successfully sued a pharmacy over this issue. I feel patients that are being denied service because they have chronic pain should be able to do the same.
I think the panel’s thoughts on methadone clinics is spot on. The licensure requirements need to be updated. Currently in Michigan there are NO methadone clinics North of Gaylord, including the entire UP. We need to change this, or all this talk about ‘treatment over incarceration’ is just that, talk. You have to give patient access to treatment which includes methadone clinics and suboxone treatment. Patients should be able to fill their prescriptions at their pharmacies and all physicians that do pain management should take the suboxone course and deal with addictions as appropriate.
But above all is that we must take the fear out of addiction and pain management treatment. Physicians are REFUSING to treat pain patients out of fear or regulatory action and/or law enforcement. So many of these new recommendations effectively restrict access by increasing regulations, fear, and barriers to getting and filling pain and addiction medications. Any approach to appropriate pain management and addiction needs to be treatment and access centric, rather than geared toward law enforcement and restriction.