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Rx for Survival

G. Caleb Alexander takes on the crisis of prescription drug abuse

Interview by Jackie Powder • Photo by Dan Dry

It may be the biggest public health epidemic that you’ve never heard of: prescription drug abuse. America’s fastest-growing drug problem claims a life every 19 minutes.

G. Caleb Alexander, MD, MS, co-director of the Bloomberg School’s new Center for Drug Safety and Effectiveness, says that pain is at the center of the epidemic’s trajectory, beginning with the medical community’s well-intentioned efforts in the 1980s and 1990s to more aggressively treat chronic pain. Sales of opioid painkillers like Vicodin and Percocet soared, as did abuse of the drugs, emergency room visits, drug treatment admissions—and deaths.

In 2008, there were nearly 15,000 prescription painkiller deaths—more than cocaine and heroin combined. Yet Alexander believes that the epidemic may have reached a “tipping point.” Federal and state agencies are stepping up enforcement and regulatory efforts, and many other stakeholders are also responding to a call to action.

“Finding a way to promote the appropriate treatment of pain while reducing opioid use and diversion is the holy grail,” says Alexander.

You’re a general internist. What’s your approach to prescribing opioids?

Generally, I’m very cautious about using opioids and won’t prescribe anything more than, in most cases, a short-term supply of a low-dose opioid. One of the striking things that I’ve observed as I’ve been training residents in the inpatient setting, is how comfortable they were writing prescriptions for heavy-hitting narcotics—Dilaudid, morphine, fentanyl. Now it’s true that patients admitted are often in severe pain. Nevertheless, I was surprised. And this extends to the outpatient setting as well.

Someone recently told me that they went in for a dental procedure, went to the pharmacy and there were 100 Vicodin waiting there. They only needed eight!

How important is health care provider training for reversing the epidemic?

It’s vital. There needs to be more education at every level of clinical training. Given that so many people who abuse or misuse opioids get them from friends or family members, the current epidemic also suggests that clinicians … have to ask themselves, “Are these opioids that I’m prescribing going to get into somebody else’s hands?”

Don’t patients with chronic pain expect their doctor to give them a prescription for a powerful pain medication?

I think we underestimate the degree to which patients are open to alternative treatment approaches. One of the important questions that clinicians have to ask themselves, and that patients have to be aware of, is have we tried all the appropriate alternatives prior to reaching for this type of medicine? We [can] use acetaminophen, nonsteroidal anti-inflammatories, topical treatments and a whole host of other agents.

Who is abusing prescription drugs?

Prescription drug abuse spans a wide spectrum of people, in part because opioids are so liberally dispensed and so prone to nonmedical use. Patterns of nonmedical use vary, ranging from a high school kid who may have picked up a few Vicodin from a family member, to an executive misusing OxyContin to manage chronic lower back pain, to a senior with chronic anxiety and headaches [who] is taking Percocet when other therapies would be both safer and more effective.

Is there a particular group that is more at risk of death from prescription drug abuse?

Deaths from prescription opioids are more common among adolescents and young adults, males, those with less education, living in rural areas, and individuals with a history of alcohol or substance abuse. This latter point is noteworthy because it is easy for people to underestimate the synergistic effects of combining opioids with alcohol or other drugs. But keep in mind, for every overdose death, 10 patients are admitted for treatment of abuse, 25 patients are evaluated in an emergency department, and more than 700 people report nonmedical use during the past year. So the deaths—while catastrophic and highly visible—represent just the tip of the iceberg of this public health problem.

What research at your Center targets prescription drug abuse?

We have a number of projects under way. In one recently completed investigation, we used nationally representative data from ambulatory office practices to characterize the treatment of opioid dependence with buprenorphine. In another, we are conducting a 10-year survey [2001–2010] of the diagnosis and treatment of chronic nonmalignant pain to look at how care patterns for chronic pain have changed over time, and to answer some key questions: Are we diagnosing more pain than we did a decade ago? Has our threshold for using opioids changed substantially? In a third, we are using pharmacy records to rigorously evaluate the policy impact of states’ prescription drug monitoring programs, one of the key ways that states are working to stem the epidemic.

Why has this epidemic been so tough to get a handle on?

This is a complex issue, and there are no magic bullets. Just consider one of many challenges—how to continue to improve the care of patients with pain, some with severe pain, while reserving these therapies for those who need them most. And consider the issue of diversion, which can take place at any point along the supply chain of prescription drugs, from warehouse robberies to a patient whose medicines are inappropriately taken by a family member. The epidemic also touches a huge number of different stakeholders: pharmaceutical manufacturers, health plans and health insurers, professional societies, patient advocacy groups, law enforcement, state departments of public health, pharmacies, pharmacy benefit managers, employers—and we’re just getting started.