News From the End Of Life
Study: Opioids not always available in nonwhite areas
More than 50% of New York City pharmacies do not have adequate medication in stock to treat people in severe pain, a study reported in the New England Journal of Medicine.
New York researchers surveyed pharmacies throughout the five boroughs of New York City to examine the availability of commonly prescribed opioids in the city’s pharmacies.
They discovered that pharmacies in predominantly nonwhite neighborhoods are significantly less likely to stock opioids than pharmacies in predominantly white neighborhoods.Two-thirds of pharmacies that did not carry any opioids were in neighborhoods where the majority of the residents were nonwhites, according to the study, which was published in the April 6 issue.
"Previous research has shown that members of racial and ethnic minority groups are at substantial risk for the undertreatment of pain," said R. Sean Morrison, MD, lead author of the study and assistant professor at The Lilian and Benjamin Hertzberg Palliative Care Institute of the Depart-ment of Geriatrics and Adult Development at Mount Sinai School of Medicine in New York City. "Our research identifies a barrier to treating the pain of these groups effectively. When patients are prescribed opioid analgesics by their physicians but do not have access to these pain medications at their neighborhood pharmacies, they are needlessly suffering."
Access denied
Of the 347 pharmacies in the five boroughs — 81% of all pharmacies contacted — that responded:
• 176 (51%) did not have opioid supplies that were sufficient to provide adequate treatment for a patient with severe pain;
• 54 (16%) had no opioids in stock;
• Although 116 (95%) of the pharmacies with incomplete supplies had a combination of products in stock that could be used for the treatment of moderate pain, only 55 (45%) carried a strong opioid preparation that could be used for the treatment of severe pain.
According to surveyed pharmacists, the three major reasons for not having adequate supplies of opioids were:
• regulation with regard to disposal, illicit use, and fraud;
• low demand;
• fear of threat.
Other reasons given by pharmacists included the additional paperwork required by state and federal drug-enforcement agencies; the regulatory oversight and monitoring of those medications; and fear of penalties imposed by state and federal agencies.
Pharmacists who reported a low demand for opioids or expressed concern about their disposal were most likely to be in predominantly nonwhite neighborhoods.
"The movement to educate health care professionals on providing appropriate pain and palliative care for patients has made tremendous strides over the past few years, " said Morrison. "However, our efforts are thwarted when access to and availability of the services and therapies we prescribe are denied."
Increased opioid analgesic not a prescription for abuse
Conventional wisdom that drugs used for relief of severe pain — such as morphine — are widely abused was challenged by a recent study published in Journal of the American Medical Association.
The study looked at the use of opioids in the early 1990s and their rate of abuse. It also compared the rate of abuse of opioids to the abuse of illicit drugs. The study, which was published in the April 5 issue, was done by the Pain & Policy Studies Group (PPSG) of the University of Wisconsin Comprehensive Cancer Center.
Researchers examined data from two government-sponsored sources — the Drug Enforcement Agency’s medical use data from the Automation of Reports and Consolidated Orders System, which collects information on the national distribution of selected drugs to pharmacies and hospitals; and abuse data from the Drug Abuse Warning Network, which collects data about drug overdoses from a nationally representative sample of general hospital emergency departments.
Small part of national drug problem
The study found that from 1990 to 1996, there was a significant increase in the incidence of opioids being prescribed by physicians in the United States. "Although there are many ways to treat pain, the increased medical use of opioids is a strong indicator that we are making progress to improve pain management," said David E. Joranson, lead author and PPSG director.
The study also found that abuse of opioids was low and stable, accounting for a small part (less than 5%) of the national drug abuse problem, as measured by drug overdoses. From 1990 to 1996, abuse of opioids increased 6.6% in contrast to the abuse of the category illicit drugs, including cocaine and heroin, which increased by 109%.
"At a time when abuse of illicit drugs continues to increase, it is reassuring that abuse of opioid pain medications is a small part of the U.S. drug problem," said Joranson.
One of the reasons for inadequate pain management is that health professionals fear that opioid medications will be abused. "This study suggests that increased use of opioid pain medications resulting in abuse may be based more on myth than reality," said co-author Karen Ryan, chief policy analyst for the PPSG. "This is exceptionally good news for pain patients and for public health officials."
Joranson added that the danger for abuse should not be taken lightly. "[] we must continue to exercise caution with opioids, since there is an illicit demand for these drugs. Health care professionals and patients should continue to exercise appropriate care to avoid diversion and abuse of pain medications."
According to Ryan, "These results indicate that the United States could be a model for how to achieve a balanced controlled substances policy, that is, one which can improve the availability of opioids for medical purposes while limiting abuse."
Mt. Sinai creates national pain care center
The Mount Sinai School of Medicine in New York City has created a national center to promote pain management. The Center to Advance Palliative Care was established thanks in large part to a four-year, $4.7-million grant from The Robert Wood Johnson Foundation.
"The world is changing," says Rosemary Gibson, Senior Program Officer at the Foundation. "People are learning to expect more from the care they get at the end of life.
"Young doctors are learning that technical medical care isn’t enough, that pain and suffering have to be addressed, too," she said. "We need hospital environments that support these changes, and I can easily see the day when providing good palliative care [will] become the standard of care for every hospital in our country. Today, a hospital wouldn’t dream of not having an infection control program. In a few years, they won’t imagine not providing good, palliative care of the seriously ill, as well as the dying."
Specifically, the Center will offer the following products and services:
• a how-to manual on establishing a hospital-based palliative care program;
• a national directory of palliative care programs;
•case studies on ways to institutionalize palliative care programs in hospitals and health systems;
• a comprehensive Web site at www.capcmssm. org;
• a speakers’ bureau;
• policy papers on financing and other issues affecting palliative care;
• referral to fellowship and other training opportunities for physicians and nurses;
• a national educational conference;
• other services identified by collaborating hospitals and health networks.
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