Article by Erik Smith/ Washington State Wire. Published on Thursday, November 19, 2009 EST.

Pain Isn’t All They Kill – Deaths on the Rise

By Erik Smith

Staff writer/ Washington State Wire

OLYMPIA, Nov. 18.—Washington state officials, always proud to point out the areas in which the state leads the country in medical policy, aren’t exactly boastful about one of the state’s rankings: Washington is one of the top states in the country for prescription-drug abuse. And the fact is prompting state officials here to take one of the toughest stances in the nation.

            The state Department of Social and Health Services is implementing a first-in-the-country plan that requires a second opinion when Medicaid patients receive prescriptions for massive doses of painkillers. The move follows an effort by state agency medical directors to establish new painkiller guidelines for patients in public medical programs, and to track individuals’ narcotic usage to prevent “doctor shopping” and multiple prescriptions.

            Meanwhile, the state attorney general’s office has been sounding the alarm publicly and distributing money to agencies from a settlement with painkiller manufacturers.

            It’s a hard line, warranted by an explosion in prescription painkiller use and abuse over the last 10 years, state officials say. According to the national Centers for Disease Control in Atlanta, Washington is one of 16 states in which prescription drug overdoses are the leading cause of injury-related death, beating auto accidents, not to mention heroin, cocaine and methamphetamine combined.

            There’s another statistic, equally disturbing, said Dr. Jeffrey Thompson, chief medical officer for the state’s Medicaid programs. Washington ranks first in the nation for armed robberies in pharmacies, he said. One concern is that prescription narcotics may wind up on the street.

            Under the new DSHS initiative, Medicaid patients who are prescribed more than 1,000 milligrams of morphine or a morphine-equivalent drug must obtain a second opinion from the University of Washington’s pain management clinic. “If they can give us a good justification, we would pay for them,” Thompson said. Cancer patients are exempted.

            First to Require Second Opinions

            About 20,000 patients in state-managed medical programs are on some type of prescription painkiller, Thompson said. 

So far DSHS has identified 200 patients receiving doses of more than 1,000 milligrams, a number that may increase, he said. Second-opinion reviews are being scheduled in those cases, he said. The problem is that patients build up tolerances over time, requiring higher dosages, and there is little agreement about the maximum dosages that may be considered safe. “If there’s not agreement on how high you can go, you’ve got an out-of-control system,” he said.

Meanwhile, he said, about 50 percent of the state’s patients are receiving dosages of between 200 milligrams and 1,000 milligrams daily. To put it in perspective, Thompson said a dose of 1,000 milligrams would be deadly to a person who has not built up a tolerance to pain medication. “To us, we would stop breathing,” he said.

Two years ago the medical directors of Washington state agencies adopted voluntary guidelines for physicians prescribing opiates for patients covered by public medical programs. The best-practice guidelines recommend a second opinion when dosages exceed 120 milligrams daily. Utah also has adopted guidelines, but Washington is the only state with a dosage recommendation, said Dr. Gary Franklin, medical director for the state Department of Labor and Industries.

            Problem is New

The prescription-painkiller problem is relatively recent, Franklin said. Ten years ago, in response to complaints that chronic pain was not being adequately treated, public medical programs in this state and elsewhere began allowing physicians to prescribe “opioid” painkillers in large and increasing dosages.

In this state, Franklin said, officials started seeing a growing number of overdose-related deaths beginning about the year 2000. “It’s been a decade since the deaths started, but the federal government and the states so far have taken little action,” he said. “It’s partly because until the late ’90s, most states didn’t allow or discouraged the use of opioids for chronic pain. There was hardly any usage at all. Now the use is going through the roof, and people are dying.”

The Department of Labor and Industries has noted 100 overdose deaths in its worker-compensation programs since 1999. In the state’s much larger Medicaid programs, about 400 deaths annually are attributed to painkiller overdoses, roughly half the number of painkiller-overdose deaths recorded statewide. It demonstrates that Medicaid patients are at higher risk than the state as a whole — the program covers only about 20 percent of the population.

Last month, the state agencies’ medical staffs pooled their knowledge for a paper in the Morbidity and Mortality Weekly Report, published by the Centers for Disease Control. It is the first article in a major medical journal to call particular attention to the problem in the Medicaid population, Franklin said.

1,668 Deaths in Four Years

The article notes that overdose deaths nationally from prescription painkillers have nearly doubled in the last 10 years, while usage of opioids has increased nearly fourfold. Washington’s death rate is significantly higher than the national average, it said. In the state’s Medicaid programs, between 2004 and 2007, 1,668 patients died as a result of overdoses, about two-thirds involving methadone.

“These findings highlight the prominence of methadone in prescription opioid-related deaths, and indicate that the Medicaid population is at high risk,” the article said. “Efforts to minimize this risk should focus on assessing the patterns of opioid prescribing to Medicaid enrollees and intervening with Medicaid enrollees who appear to be misusing these drugs.”

            Also a Law Enforcement Issue

Washington agencies have been working together on the issue through the state’s Agency Medical Directors’ Group, each focusing on its area of expertise. And some of the interest might not be obvious at first glance. The state Office of the Attorney General, for example, might not be an agency normally associated with medicine, but it has played a major role in financing the effort, distributing money to agencies from a $1.7 million settlement with drug manufacturers.

Over the summer, Attorney General Rob McKenna called attention to the issue in a series of op-ed pieces published in the state’s newspapers, warning parents to guard their medicine cabinets the same way they do their liquor cabinets. In a speech to the state pharmacy association, McKenna noted that the problem is as much a law enforcement issue as it is a medical one. His office has seen a marked increase in the number of pharmacy crimes – forgeries, fake prescriptions and robberies, most of them involving Oxycontin.

“Unfortunately, most people don’t know just how serious this threat is,” he said. “One of the best ways to illustrate the devastating impact these drugs can have on our young people is to talk about a bright young star who became a household name – Heath Ledger.

“In 2007, he was on top of the world. Having been nominated for an Oscar for his role in Brokeback Mountain, he had his pick of challenging and rewarding roles. He’d already appeared in popular films like Ten Things I Hate About You, filmed in part in our state, and of course he had just filmed his role as the Joker in The Dark Knight.

“Heath Ledger was found dead on Jan. 22, 2008. Doctors concluded that the 28-year-old died from a lethal combination of prescription drugs, including oxycodone, hydrocodone and diazepam.”  

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