ACP Issues Wake-up Call on Prescription Drug Abuse

December 19, 2013

The American College of Physicians (ACP) has issued a policy position paper on prescription drug abuse in an effort to stem the "epidemic" of deaths from prescription drug overdose that is occurring.

Recommendations in the position paper, published online in the Annals of Internal Medicine on December 10, include the following:

  • Establishment of a national prescription drug monitoring program;

  • Evidence-based, nonbinding guidelines regarding recommended maximum dosage and duration of therapy for controlled substance medications;

  • Greater use of random drug testing in patients receiving certain medications; and

Molly Cooke, MD, ACP president, explained to Medscape Medical News that ACP issued the position paper because the problem of deaths and adverse consequences due to abuse of certain classes of prescription drugs has become "more than evident" over the past 10 to 15 years.

She explained that since the mid-1990s there has been excessive enthusiasm about relieving symptoms of pain, anxiety, and depression and a parallel inattention to the fact that the drugs being used are dangerous and can be abused. "We have been lulled into an overconfidence about using these drugs. We are reminding doctors to try and find the right balance between relieving symptoms versus safety."

Welfare Reforms Have Fueled the Problem

In an accompanying editorial, Phillip Coffin, MD, San Francisco Department of Public Health, California, and Caleb Banta-Green, PhD, University of Washington, Seattle, welcome the ACP statement. But noting that part of the problem is welfare reforms that have stopped reimbursement for comprehensive pain management clinics because of expense, leaving opioids as one of the few therapeutic options available, they say they remain concerned that "those supporting burdensome and punitive policies may not be swayed."

They report that overdoses involving opioid analgesics killed almost 17,000 people in the United States in 2010 — nearly as many car accidents — and the number of people with opioid analgesic use disorders has increased to nearly 2 million.

The editorialists add that the reasons for prescribing opioids should be limited, noting that long-term opioids for chronic nonmalignant pain may not improve and may worsen functional status. They also state that clinicians should focus on functional status, rather than reported pain, and that the infrastructure of nonopioid pain management needs to be rebuilt. This includes accessible physical and occupational therapy, as well as more use of buprenorphine as a safer alternative to opioids; if opioids have to be used, the addition of the opiate antagonist naloxone reduces the risk for opioid overdose.

Dr. Cooke told Medscape Medical News she first became aware of the extent of the problem 10 years ago when she was preparing for a talk on opioid abuse. "In my work at San Francisco General — a public hospital — I see many IV [intravenous] drug abusers. These are classic American skid-row clientele. For my presentation on opioid abuse, I assumed I would be talking about these types of patients. But when examining data from emergency rooms across the country, I started to discover that there were more opioid overdoses and deaths due to prescription drugs than from street drugs such as heroin."

"Many of us have a mental image of what a drug abuser looks like. This has dulled our ability to recognize people who are abusing prescription drugs," she added.

She said she hopes the ACP position paper will encourage doctors to broaden the conversation with patients when prescribing drugs that could be subject to abuse or misuse, and to recognize that some patients need more structure around these medications.

Opioid Epidemic

"There is an epidemic in ERs [emergency rooms] in terms of opioid prescription. And there is also a fair amount of use of cocktails of drugs in people inclined to misuse these drugs," Dr. Cooke noted.

One of the most abused prescription drugs is oxycodone, she reported. "There has been an eye-popping increase in the number of prescriptions written for this drug in the US each year. People are getting just as addicted to oxycodone as they are to heroin."

Other commonly used drugs that are a particular problem with regard to misuse are other opiates; benzodiazepines used for anxiety or sleep; and stimulant drugs used for attention-deficit disorder, such as methylphenidate or phentermine, often used to help manage weight.

"People with chronic pain also often suffer from depression and tolerate anxiety poorly so they may be on 2 or 3 different drugs subject to abuse and may also be self-medicating with alcohol. This is a lethal cocktail which is not uncommon. We do not want doctors to stop prescribing these drugs. We are just asking them to be more cautious," said Dr. Cooke.

Dr. Cooke believes the increasing use of opioids has been encouraged by various sets of recommendations that promote the aggressive treatment of pain symptoms. "The WHO [World Health Organization] is one of the organizations that advocated this approach. Proposals of escalating steps to manage pain have created in the minds of physicians the idea that the goal was zero pain."

Weighing Risk-Benefit

She pointed out that with all these symptoms, such as pain, anxiety, and fatigue, the goal should be to alleviate symptoms enough for the patient to have a functional life but not necessarily abolish them if this increases the risk of abuse.

"We need to help the patient to be able to get out of bed in the morning, participate in life and work if possible. On a scale of 1 to 10, if a patient comes in at 7, I don't think we should always be aiming for 0 straight away. Zero would be great if we can do it safely, but if there is a risk of abuse maybe 3 or 4 may be a better goal."

The ACP is encouraging doctors to pay more attention to who each individual patient is.

"Have a frank conversation with your patient to ascertain their history and assess the risk of them abusing the medication. For example, if they have a long history of mental health problems and several suicide attempts, think carefully about which drugs you are prescribing and how much you are giving them.

"If the patients is someone who may not be able to be relied on to manage their medicines, ask the pharmacy just to issue 1 week's supply at a time. Pay attention to their refill pattern. Many people may need a pain contract, which will specify that lost prescriptions will not be replaced, and that they have to agree to being monitored," Dr. Cooke said.

The position paper recommends that physicians ask for urine or blood tests more often to make sure patients are actually taking the drugs and is not selling them on the street, and that they are not taking other substances as well.

"For example, if they are being prescribed methadone, we don't want to find heroin in there as well," Dr. Cooke said.

The paper also encourages doctors to think about nonpharmacologic ways to relieve anxiety and depression.

"If the patient is a polypharmacy abuser, try not to prescribe another drug that may be subject to misuse. So instead of handing out a benzodiazepine, consider counselling, hypnotherapy, acupuncture, et cetera," Dr. Cooke said.

The ACP is also calling for a national monitoring system for certain medications. Dr. Cooke noted that at present, medicines are regulated at the state level. "If you go to a different state your prescription record won't show up on the pharmacy computer system, which encourages abuse."

Ann Intern Med. Published online December 10, 2013. Full text Editorial

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