bs_bs_banner

Commentaries

7. Sutherland J. M., Fisher E. S., Skinner J. S. Getting past denial—the high cost of health care in the United States. N Engl J Med 2009; 361: 1227–30. 8. Fisher E. S., Wennberg D. E., Stukel T. A., Gottlieb D. J., Lucas F. L., Pinder E. L. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003; 138: 288–98. 9. Sirovich B., Gallagher P. M., Wennberg D. E., Fisher E. S. Discretionary decision making by primary care physicians and the cost of U.S. health care. Health Aff (Millwood) 2008; 27: 813–23. 10. Chou R., Ballantyne J. C., Fanciullo G. J., Fine P. G., Miaskowski C. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009; 10: 147–59. 11. Minozzi S., Amato L., Davoli M. Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction 2013; 108: 688–98. 12. Warner M., Chen L. H., Makuc D. M., Anderson R. N., Miniño A. M. Drug poisoning deaths in the United States, 1980–2008. NCHS Data Brief 2011; 81: 1–8. 13. Jones C. M., Mack K. A., Paulozzi L. J. Pharmaceutical overdose deaths, United States, 2010. JAMA 2013; 309: 657–9. 14. Gugelmann H. M., Perrone J. Can prescription drug monitoring programs help limit opioid abuse? JAMA 2011; 306: 2258–9. 15. Reifler L. M., Droz D., Bailey J. E., Schnoll S. H., Fant R., Dart R. C. et al. Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med 2012; 13: 434–42. 16. Hingson R., Heeren T., Winter M. Lower legal blood alcohol limits for young drivers. Public Health Rep 1994; 109: 738– 44. 17. Chou R., Fanciullo G. J., Fine P. G., Adler J. A., Ballantyne J. C., Davies P. et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10: 113–30.

PRESCRIPTION OPIOID DEATHS: WE NEED TO TREAT SICK POPULATIONS, NOT JUST SICK INDIVIDUALS In this issue, Fischer et al. describe why North America currently leads the prescription opioid (PO) drug epidemic [1]. Despite substantially higher per-capita expenditure on health care and pharmaceuticals than other high-income countries (HICs), the United States has relatively poor population health outcomes. In 2007, the United States ranked 37th in the world for life expectancy at birth, with large racial and geographic disparities. The United States differs from many HICs, as it lacks universal health insurance: 19% of the population do not have health insurance, and two-thirds of those insured rely on private insurance. The risk of PO overdose deaths is associated with lower socio-economic status [2,3]. Disturbingly, US life expectancy for the most disadvantaged has fallen by 4 © 2014 Society for the Study of Addiction

185

years since 1990 [4]. Increasing PO drug overdoses since 1990 disproportionately affecting non-Hispanic whites may have contributed to this decline. Added to this, clinical studies fail to demonstrate the long-term efficacy and safety of POs for chronic noncancer pain. However, HIC consumption continues to increase, despite more than a decade of documentation of serious harm and countermeasures such as prescription monitoring programmes (PMPs) and guidelines for prescribing. Voluntary use of PMPs [5] and compliance with guidelines is poor [6], and there is little evidence to support that patients at risk of aberrant behaviour can be identified reliably. Prescribers can be disadvantaged by dysfunctional funding arrangements, with pressure to contain costs, particularly where funded by for-profit insurance. This contributes to short consultation times and many nonreimbursed tasks involved in the comprehensive management of complex problems in patients suffering multiple comorbidities. As consultation times shorten, there is pressure to treat quickly: in Australia, 85% of general practitioner encounters results in a prescription, and oxycodone is the seventh most frequently prescribed medication [7]. It is now well established that inappropriate and intense marketing of OxyContin in the United States contributed to increased consumption [8]. Professional guidelines claimed inaccurately that the risk of addiction or other serious adverse effects was low [9]. In Canada, industry involvement in provision of training materials for medical students may also have played a role [10]. Developers of a transdermal oxycodone patch in Australia have made unlikely claims that their product will have lower abuse liability and prevent tolerance [11]— another manifestation of an ‘industrial epidemic’ resulting from the commercialization of potentially dangerous products [12]. A biomedical focus on downstream interventions with individual patients obscures structural factors, such as an increasingly ‘opioid-rich’ environment in many HICs. This may be a consequence of the ‘individualistic fallacy’, where undue attention has been paid to individual characteristics and the wider influence of population level determinants of this epidemic have been given less attention [13]. Epidemiological studies are now describing a temporal and spatial association between increased opioid consumption and adverse outcomes, including abuse, medical emergencies and death [14]. Widespread prescribing provides more opportunities for diversion, non-medical use and unintentional poisoning, including among children [15]. This results in stigmatization of patients considered ‘risky’ and undertreats those in need [16]. A public health response requires treating sick populations, not just sick individuals [17]; this means Addiction, 109, 182–188

bs_bs_banner

186

Commentaries

shifting expectations and practices around the total opioid supply. In the face of this unremitting epidemic of death and morbidity, it is now appropriate to consider shifting mean consumption by carefully decreasing the total supply of opioids to less dangerous levels. Collaboration across domains, including worker insurance organizations, health-care providers and other agencies, appears to have stalled the escalating numbers of deaths and other harm associated with PO misuse in Washington State [18]. A planned and systematic approach can result in considerable changes to identify risks and enhance safe supply, starting with those patients receiving high daily PO doses associated with a heightened risk of poisoning death. Patients prescribed high daily PO doses consume a staggeringly high proportion of all opioids: in two separate insurance populations, the top 5% of users accounted for 70 and 48% of total use [19]. Consumers need to be supported carefully in this process; those experiencing addiction cannot be abandoned. The inability to curb dangerous promotion, supply and consumption of PO demonstrates a regulatory failure to protect public health. Other countries must learn quickly from the North American experience to forestall the emergence of similar tragedies. Declaration of interests Malcolm Dobbin has received honoraria from Pfizer for lectures, which were donated to charity. ANGELA C. RINTOUL 1 & MALCOLM DOBBIN 2

School of Public Health and Preventive Medicine, Monash University, 3rd Floor Burnet Building, Alfred Hospital, Melbourne, Vic. 3004, Australia1 and Department of Forensic Medicine, Monash University, Melbourne, Vic., Australia.2 E-mail: [email protected] References 1. Fischer B., Keates A., Bühringer G., Reimer J., Rehm J. Nonmedical use of prescription opioids and prescription opioidrelated harms: why so markedly higher in North America compared to the rest of the world? Addiction 2014; 109: 177–81. 2. Morbidity and Mortality Weekly Report. Overdose deaths involving prescription opioids among Medicaid enrollees – Washington, 2004–2007. Morb Mortal Wkly Rep 2009; 58: 1171–5. 3. Rintoul A. C., Dobbin M. D. H., Drummer O. H., Ozanne-Smith J. Increasing deaths involving oxycodone, Victoria, Australia, 2000–09. Inj Prev 2011; 17: 254–9. 4. Olshansky S. J., Antonucci T., Berkman L., Binstock R. H., Boersch-Supan A., Cacioppo J. T. et al. Differences in life expectancy due to race and educational differences are widening, and many may not catch up. Health Aff 2012; 31: 1803–13. © 2014 Society for the Study of Addiction

5. Feldman L., Williams K. S., Coates J., Knox M. Awareness and utilization of a prescription monitoring program among physicians. J Pain Palliat Care Pharmacother 2011; 25: 313–7. 6. Krebs E. E., Ramsey D. C., Miloshoff J. M., Bair M. J. Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Med 2011; 12: 740–6. 7. Britt H., Miller G. C., Charles J., Henderson J., Bayram C., Pan Y. et al. General Practice Activity in Australia 2010–11, in Bettering the Evaluation and Care of Health. Sydney: Sydney University Press; 2011. 8. Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health 2009; 99: 221–7. 9. Jovey R. D., Ennis J., Gardner-Nix J., Goldman B., Hays H., Lynch M. et al. Use of opioid analgesics for the treatment of chronic noncancer pain—a consensus statement and guidelines from the Canadian Pain Society, 2002. Pain Res Manag 2003; 8: 3A–28A. 10. Persaud N. Questionable content of an industry-supported medical school lecture series: a case study. J Med Ethics 2013; doi:10.1136/medethics-2013-101343. 11. BRR Media. Phosphagenics Limited—ASX Small to Mid Caps Conference in Singapore and Hong Kong. 2011. Available at: http://www.brrmedia.com/event/88799/esra-ogru -chief-executive-officer (accessed 18 June 2013) (Archived at http://www.webcitation.org/6HRDuwv2r on 17 June 2013). 12. Jahiel R. I., Babor T. F. Industrial epidemics, public health advocacy and the alcohol industry: lessons from other fields. Addiction 2007; 102: 1335–9. 13. Pearce N. The ecological fallacy strikes back. J Epidemiol Commun Health 2000; 54: 326–7. 14. Fischer B., Jones W., Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009. Pharmacoepidemiol Drug Saf 2013; 22: 438–42. 15. Burghardt L. C., Ayers J. W., Brownstein J. S., Bronstein A. C., Ewald M. B., Bourgeois F. T. Adult prescription drug use and pediatric medication exposures and poisonings. Pediatrics 2013; 132: 1–10. 16. Dowell D., Kunins H. V., Farley T. A. Opioid analgesics— risky drugs, not risky patients. JAMA 2013; 309: 2219–20. 17. Rose G., Day S. The population mean predicts the number of deviant individuals. BMJ 1990; 301: 1031–4. 18. Franklin G. M., Mai J., Turner J., Sullivan M., Wickizer T., Fulton-Kehoe D. Bending the prescription opioid dosing and mortality curves: impact of the Washington State opioid dosing guideline. Am J Ind Med 2011; 55: 325–31. 19. Edlund M. J., Martin B. C., Fan M., Braden J. B., Devries A., Sullivan M. D. An analysis of heavy utilizers of opioids for chronic non-cancer pain in the TROUP Study. J Pain Symptom Manage 2010; 40: 279–89.

CONSIDERING PRESCRIPTION OPIOID-RELATED HARMS IN THE POPULATION: RESPONSE TO COMMENTARIES The commentaries to our recent paper [1] make some important and insightful points to which we Addiction, 109, 182–188

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.

Prescription opioid deaths: we need to treat sick populations, not just sick individuals.

Prescription opioid deaths: we need to treat sick populations, not just sick individuals. - PDF Download Free
80KB Sizes 0 Downloads 0 Views