(Doctor) Shop Till You Drop
January 15, 2009 6 minutes read
(Doctor) Shop Till You Drop
Abstract & commentary
By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips reports no relationship to this field of study.
Synopsis: Most deaths due to overdose in West Virginia involved men who took opioids that were not prescribed for them.
Source: Hall AJ, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008;300:2613-2620.
West Virginia had the highest increase in accidental overdose during the 5-year period between 1999 and 2004. The authors of this study, who are from the Centers for Disease Control and Prevention, the West Virginia Board of Pharmacy, the West Virginia Health Statistics Center, the West Virginia Office of the Chief Medical Examiner, and the Charleston WV Area Medical Center, wanted to find out why.
Using death certificates coded for unintentional poisoning, they identified 355 unintentional pharmaceutical overdose deaths between 1999 and 2004. After excluding duplicate reports, those with coding errors, and those which lacked autopsy or adequate toxicology, they had a study sample of 295 well-documented, well-described drug overdose cases. In West Virginia, the Office of the Chief Medical Examiner extensively reviews deaths that are suspected of being due to drug overdose, including board of pharmacy records, medical records, police investigative reports, and toxicology reports; each case receives final peer review to determine which factors, including drugs, are contributory to death. In addition, the authors obtained histories from the state's Controlled Substances Monitoring Program and all 8 opiate treatment programs in West Virginia. In those individuals for whom prescription pharmaceuticals were found as part of the cause of death, the authors investigated whether they had ever had a documented prescription for the pharmaceutical.
These authors particularly evaluated 2 mechanisms by which those who overdosed got drugs: drug diversion and doctor shopping. Drug diversion was defined as prescription drug used without documented prescription records. The clear implication here is that the patient got the drug from someone else. Doctor shopping was defined as having received prescriptions for controlled substances from 5 or more clinicians during the year prior to death. They also classified deaths by the specific causal drugs. For each drug, they calculated the proportion of deaths with prescription documentation as well as the proportion with documentation within 30 days of death. They also calculated the proportion of overdose victims that were using each drug who also were using other contributory prescription drugs, illicit drugs, or alcohol.
The 295 well-documented and described cases accounted for a death rate of 16.2 per 100,000. Men accounted for 67% of the deaths, and the mean age was 39 years. A majority of those who died were 18-54 years of age. Lower socioeconomic status and being single were also associated with an increased risk of fatal overdose.
Of those who died of drug overdose, 63% obtained the drugs without a prescription (drug diversion) and 21% had been doctor shopping. Women and older individuals were more likely to be doctor shoppers. Those who obtained drugs by diversion were younger; 91% of those aged 18-24 did not have documentation of a prescription for the drug. Notably, few (about 8%) individuals engaged both in doctor shopping and in drug diversion.
At least one substance abuse indicator (defined as history of substance abuse, any diverted pharmaceuticals, nonmedical route of administration, ≥ 5 physicians prescribing controlled substances, contributory alcohol, previous overdose, contributory illicit drug use, or current opiate treatment program) was seen in virtually all (94.6%) of those who died from drug overdose. Further, most (about 79%) of those who died of drug overdose had used multiple substances contributing to their death. The vast majority (93%) of drugs involved in these fatal overdoses were opioids, including methadone (40%), hydrocodone (22.7%), oxycodone (20.7%), morphine (15.6%), and fentanyl (10.5%). Of the 227 individuals for whom Schedule II opioid analgesics contributed to death, only 66 (29.1%) had prescriptions dispensed within 30 days prior to death, as is the law in West Virginia.
Psychotherapeutic drugs, particularly benzodiazepines, contributed to almost half of the deaths, but almost all of the deaths related to psychotherapeutic drugs also involved opioids. In other words, among the 61 single-drug deaths, only 1 was due to a psychotherapeutic drug (amitriptyline), suggesting that fatal overdose is less likely with a single psychotherapeutic drug than with a single opioid analgesic. Alcohol was involved in fewer than 20% of cases.
Commentary
Two expert panels introduced guidelines for chronic pain management in 1997,1,2 and state medical boards subsequently have encouraged more compassionate pain policies.3 Since that time there has been an explosive increase in per capita retail purchases of methadone (13-fold), hydrocodone (4-fold), and oxycodone (9-fold).4 Unfortunately, as opioids have become more widely available, abuse of these agents has also increased. Some of the unintended consequences of this change in prescribing practice have been increased experimentation by children,5 increased emergency department visits for opioid overdose,6 and increased fatal drug overdose.7 Although West Virginia is among the states with the highest rates of opioid use and abuse, it is by no means unique.
What can we learn from the detailed study of drug overdose in West Virginia? Drug diversion was the most common method of obtaining the drugs that killed the patients in this report. An analysis of drug diversion in Appalachia by the Drug Enforcement Agency discovered that the primary methods of diversion were illegal sale and distribution by health care professionals, employee theft, forged prescriptions, and the Internet.8 So, one lesson here is to control your prescription pads carefully, and to pay attention to workers in your area.
Another practical finding of this study was the profile of the doctor shopper. In this study, doctor shoppers were 48% women, and most were older than age 35. They tended to come from higher-income counties, to be less likely to have been drinking when they overdosed, and to take their drugs orally. So, beware of the older woman who is seeing several physicians and who has chronic pain. In this study, methadone, which is prescribed in smaller volumes than other opioids, was involved in more deaths than any other agent. The authors concluded, "This suggests either that methadone is for unknown reasons favored by drug diverters or that methadone is more risky to users than other opioids."
What else can we do? The authors of this study made several other practical suggestions, including counseling patients who receive opioids about the risk to themselves and others; following recently published guidelines; and using state prescription drug monitoring programs to determine whether patents are getting scheduled drugs from other clinicians.
References
1. Practice guidelines for chronic pain management. A report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997;86:995-1004.
2. The use of opioids for the treatment of chronic pain: A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain 1997;13:6-8.
3. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Federation of State Medical Boards of the United States Inc. Available at: www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf. Accessed Dec. 16, 2008.
4. ARCOS: Automation of Reports and Consolidated Orders System. U.S. Department of Justice, Drug Enforcement Administration. Available at: www.deadiversion.usdoj.gov/arcos/index.html. Accessed Dec. 16, 2008.
5. The National Survey on Drug Use and Health Report: Patterns and Trends in Nonmedical Prescription Pain Reliever Use: 2002 to 2005. Substance Abuse and Mental Health Services Administration. Available at: www.oas.samhsa.gov/2k7/pain/pain.pdf. Accessed Dec. 16, 2008.
6. Drug Abuse Warning Network, 2005: National Estimates of Drug-related Emergency Department Visits. Substance Abuse and Mental Health Services Administration. Available at: http://dawninfo.samhsa.gov/files/DAWN-ED-2005-Web.pdf. Accessed Dec. 16, 2008.
7. Centers for Disease Control and Prevention. Unintentional poisoning deathsUnited States, 1999-2004. MMWR Morb Mortal Wkly Rep 2007;56:93-96.
8. National Drug Intelligence Center. Drug Market Analysis 2008: Appalachia High Intensity Drug Trafficking Area. Washington, DC: U.S. Dept of Justice; 2008. Report 2008-R0813-001.
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