PRESCRIPTION OPIOIDS - AN EPIDEMIC OF POOR POLICIES

Prescription Opioids – An Epidemic of Poor Policies1

Willem Scholten ConsultancyWillem Scholten PharmD, M.P.A.Consultant – Medicines and Controlled Substances

PRESCRIPTION OPIOIDS – AN EPIDEMIC OF POOR POLICIES

A view on the facts



USA opioid OD epidemic

It is said that there is an ongoing prescription opioid overdose (‘OD’) epidemic in the US

It is said that it is driven by pain patients

As a result, many pain patients no longer have access to adequate pain management

Some want to impose restrictions on pain management globally similar to the US



Is the OD epidemic about prescribed opioids?

Sensationalizing press, politicians and some physicians would suggest “Yes”

Prescription opioids is NOT the same thing as prescribed opioids

There is a long history of non-medical opioid use in the US since the Vietnam War and before

There does appear to have been a move from street heroin to pills (which could be considered safer from a public-health perspective)



This clearly suggestsa continuation of the decade-

long non-medical use of heroin

What this means?



Effective policies = accurate analysis

Non-medical use of opioid analgesics and heroin has been a continuous problem since 1960’s

If this is to be addressed by one comprehensive policy - it should be based on accurate evaluation of cause-effect relations



Do the pain patients cause the OD epidemic?

While a survey of West Virginia’s death registry showed 25% of OD deaths had opioid analgesics prescribed in the last 3 months, this would suggest that at least 75% were not pain patients.



Counter-productive policies

In 2010, new policies stabilized prescription overdose deaths in the USAHowever, the heroin overdose deaths started rising againThe overall effect being a shift to the more hazardeous use of street heroin



Age-adjusted rates for drug-poisoning deaths, by type of substance

Year Opioid analgesics Heroin Number Deaths Number Deaths per 100,000 per 100,000

2000 4,400 1.5 1,842 0.7 2001 5,528 1.9 1,779 0.6 2002 7,456 2.6 2,089 0.7 2003 8,517 2.9 2,080 0.7 2004 9,857 3.4 1,878 0.6 2005 10,928 3.7 2,009 0.7 2006 13,723 4.6 2,088 0.7 2007 14,408 4.8 2,399 0.8 2008 14,800 4.8 3,041 1.0 2009 15,597 5.0 3,278 1.1 2010 16,651 5.4 3,036 1.0 2011 16,917 5.4 4,397 1.4 2012 16,007 5.1 5,925 1.9 2013 16,235 5.1 8,257 2.7

NOTES: Deaths are classified using the International Classification of Diseases, Tenth Revision. Drug-poisoning deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14. Drug-poisoning deaths involving opioid analgesics are drug-poisoning deaths with a multiple cause code of T40.2, T40.3, or T40.4. Drug-poisoning deaths involving heroin are drug-poisoning deaths with a multiple cause code of T40.1. Each year a small subset of drug-poisoning deaths involved both opioid analgesics and heroin. For example, in 2013, 1,342 deaths involved both opioid analgesics and heroin. Deaths involving both opioid analgesics and heroin are included in both the rate of deaths involving opioid analgesics and the rate of deaths involving heroin. Depending on the year, 22% to 25% of drug-poisoning deaths lack information on the specific drugs involved. Some of these deaths may involve opioid analgesics or heroin.

SOURCE: Data Brief 190: Drug-poisoning Deaths Involving Heroin: United States, 2000–2013 CDC/NCHS, National Vital Statistics System, Mortality.

CDC data

stable accelerating



A complex issue

This is clearly a highly complex and emotive issue and knee jerk policy changes must never be allowed to prevent patients receiving the pain relief medicine they require



Myths about opioid consumption CDC and Physicians for

Responsable Opioid Prescribing (PROP) claim that the 2010 annual opioid consumption in the US was enough for a 30 days supply for every adult.

The US authorities reported a 7.3 day’s supply for opioid analgesics (see next slide).

PROP states that the US is consuming 99% of the world’s hydrocodone: not surprising as hydrocodone is hardly available outside of the US.



US opioid consumption 2010

Total Defined Daily Doses for opioid analgesics 2290225370Total Defined Daily Doses all reported opioids 5113874807

Total population USA 2010 314799000Population 16 yrs and over USA 2010 284546314

Per capita monthly consumption in DDD Adults only (>=16 yr )

All ages

Claimed by CDC and PROP 30 - 31Opioid analgesics 8.0 7.3All reported opioids (including cough suppressants, anti-diarrhoeals and experimental substances)

18.0 16.2

Calculations based on data below; consumption as reported by US authorities to the INCB



Pain treatment is a human right

Access to pain treatment is part of the right to health and recognized in multiple treaties• CDC Guidelines withhold access to adequate

treatment for chronic non-cancer pain patients

• CDC guidelines for chronic pain were developed with involvement of only certain elements of the pain specialist community



Proper access

Pain patients in the USA and the rest of the world should have access to adequate and effective pain mangement, including pharmacological treatment



The USA is not the rest of the world

United States Netherlands Italy India Ghana0

100

200

300

400

500

600

700

GHANAINDIA

IT

NL

584 mg 263 mg 132 mg 0.3 mg 0.1 mg

Expressed as equivalents of morphine

Scholten W, based on data International Narcotics Control Board

Per capita opioid analgesic consumption (2013)

USA



A perspective

Damage expressed as Disability Adjusted Life Years (DALYs)• From opioid use disorders:

8 million DALYs• Total from low back and neck pain +

neoplasms305 million DALYs

Scholten W, based on WHO data



The real problem

The greatest problem is that5.5 billion people live in countries where there is no or very limited access to opioid analgesics for the treatment of pain



Original article

Willem Scholten & Jack E. Henningfield Negative outcomes of unbalanced opioid policy supported by clinicians, politicians, and the media.Journal of Pain & Palliative Care Pharmacotherapy, (2016) 30:1, 4-12. DOI: 10.3109/15360288.2015.1136368

For more details and for references on the topics of this presentation

http://www.tandfonline.com/doi/full/10.3109/15360288.2015.1136368





Additional readingWillem Scholten PharmD MPA: Opioid overdose death epidemic sensationalised at the cost of pain patients

Dr Carl Hart, professor of psychology at Columbia University: Mandatory Opioid Training for Doctors Isn’t Necessary

Maia Szalavitz, who has been addicted on cocaine and heroin, and who is the author or co-author of seven books: Focus on Preventing Addiction Instead of Prescribing Medication

https://eapcnet.wordpress.com/2016/03/02/opioid-overdose-death-epidemic-sensationalised-at-the-cost-of-pain-patients/

https://eapcnet.wordpress.com/2016/03/02/opioid-overdose-death-epidemic-sensationalised-at-the-cost-of-pain-patients/

http://www.nytimes.com/roomfordebate/2016/05/05/should-opioid-training-for-doctors-be-mandatory/mandatory-opioid-training-for-doctors-isnt-necessary









http://www.nytimes.com/roomfordebate/2016/05/05/should-opioid-training-for-doctors-be-mandatory/focus-on-preventing-addiction-instead-of-prescribing-medication

http://www.nytimes.com/roomfordebate/2016/05/05/should-opioid-training-for-doctors-be-mandatory/focus-on-preventing-addiction-instead-of-prescribing-medication



Conclusion

All pain patients should have access to adequate pain management, whichever part of the world they live

andPolicies on the non-medical use of substances are based on health and proper situational analysis

Date post:	16-Apr-2017
Category:	Health & Medicine
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PRESCRIPTION OPIOIDS - AN EPIDEMIC OF POOR POLICIES

Health & Medicine