"They give away oxycodone like they're Tic Tacs"
That's the mantra. It's repeated so often that no one doubts the veracity of that statement. For those of us who don't take narcotic pain medications, 24 Percocet is "a lot" of narcotics. For someone who's in excruciating pain every day, it's not.
You read the story:
The U.S. attorney charged that Colangelo owned the following clinics that dispensed more than 660,000 dosage units of oxycodone, most of it without a legitimate medical purpose
I was most concerned about the prescriptions that happened allegedly "without a legitimate medical purpose", but to the casual health care consumer, it's the "660,000 dosage units of oxycodone" that catches their eye. Sure, 660,000 doses of anything is a lot of pills, but the story doesn't say if it's 5 mg, 15 mg or 30 mg doses. It doesn't say much of anything factual other than the eye popping 660,000 number. What's more, to the trained medical professional, there's no indication of how much acetaminophen (Tylenol) was bound to the distributed oxycodone and it's the Tylenol that causes most of the permanent liver damage. It's the aspirin in the Percodan that causes the most GI bleeds. It's the Ibuprofen that causes most of the permanent kidney damage. Yet, the average person reading these articles buys into the propaganda that it's the oxycodone that causes the permanent damage.
The public perception fueled by the news media and egged on by the DEA and Attorney Generals of most states is that there's way too much oxycodone prescribed out there. Now, there's just a couple problems with this perception.
The supply of narcotic pain relievers is controlled by the DEA
The amount of narcotic pain medication is controlled by the DEA by awarding allotments to oxycodone manufacturers. The manufacturers in turn ration or limit the quantities they distribute to drug stores. Just about all of these manufacturers or wholesalers have been intimidated into not shipping to physician offices. Any manufacturer or wholesaler that doesn't take a "recommendation" from the DEA seriously; gets shut down. There is no medical assessment, no physician oversight, little if any due process. Just a bunch of cops and lawyers shutting down what they see as an illegal drug operation.
The narcotic supply is limited. In fact, in some areas of the country, there are shortages of narcotics and people with prescriptions can't get them filled. How many pills is too many pills? That's hard to figure.
660,000 pills isn't as much as you think it is
In this article the author presents what they think is convincing, damning evidence that Florida is 100% at fault for the overuse of narcotic pain medications. You see, Florida doctors prescribe 10 times the narcotic pain relievers as doctors in other states do. Is that because doctors in other states under treat pain? Or, is it because Florida doctors over prescribe pain meds? The truth is probably somewhere in the middle.
There's no doubt that there are some opportunistic chronic pain physicians in Florida (and elsewhere for that matter) that need to be shut down; but to use the 660,000 dosage units as justification doesn't pass the sniff test. Here's why.
Say you are a chronic pain management physician. You have normal business hours and see 20-25 severe chronic pain patients a day and you only accept 3-4 new patients per month. Chronic pain patients can have anywhere between 90-180 oxycodone prescribed for them per month depending upon their situation. These could be either 15 mg or 30 mg tablets. Plus, where the patient is in their Suboxone cycle also impacts what is prescribed. Going with the middle of the road, that would be 120-150 per patient per month as our range for this illustration. Under this scenario, the physician would prescribe:
2,400 - 3,750 oxycodone tablets per day.
12,000 - 18,750 oxycodone tablets per week.
51,600 - 80,625 oxycodone tablets per month.
10 chronic pain physicians could and would prescribe 660,000 oxycodone tablets in less than 2 weeks.
Again, 660,000 oxycodone tablets isn't as much as you think it is, which begs the question. How many people really need narcotic medications?
That's hard to figure. Time Magazine reported that about 76 million Americans live in pain every day, but not all of these people take narcotics.
4.2% of the U.S. Adult Population Takes Narcotic Pain Medication on Any Given Day
The CDC Health, United States, 2006 Edition (BIG pdf) featured Pain. Their publication estimated the number of adult Americans taking narcotic pain medications on any given day to be about 4.2%.
To figure out how big a number that is I first went to the Census and found it easiest to pull out the Fact Sheet that shows we have over 227 million adults living in the U.S. today.
4.2% of 227 million is over 9.5 million people taking narcotic pain medication on any given day.
ok, doing the math....that's
9,545,718 times 4 pills = 38,182,872 dosage units of narcotic pain medication per day.
And we thought 660,000 was the eye popping number. Again, I'm not saying if these are 5 mg, 15 mg or 30 mg tablets, but 38,000,000+ is the daily number of narcotic pain relievers throughout the U.S. That 38 million covers the kid who just had their wisdom teeth removed (about 24 - 5 mg tablets to be used over the following week) to the car crash survivor who had their leg reattached (about 180 - 30 mg renewed every 30 days).
That's a lot of pills that is difficult to oversee.
You cannot feel someone else's pain
Florida's State Attorney Pam Bondi has decided that she can determine who really is in pain and who isn't. The DEA also believes they have a reliable painometer as does our current Sheriff in Broward County, Nick Lamberti. Like any good policy maker you would emphasize the statistics that illustrate your point and down play or ignore the inconvenient truths. That's what we get every 6 months when the Florida Medical Examiner's report is released (another BIG pdf).
The opening statement is:
The Florida Department of Heath, Office of Vital Statistics has recorded that approximately 89,800 deaths occurred in Florida during January through June
2010. Of these, the medical examiners reported on 4,150 drug-related deaths (whether the cause of death or merely present) through toxicology reports
submitted to the Medical Examiners Commission. In order for a death to be considered “drug-related” there must be at least one drug identified in the decedent, which is a drug occurrence. The vast majority of these 4,150 cases involved more than one drug listed in the report.
Of the 89,800 deaths, 4,150 were determined to be drug related. That means 4.6% of Florida deaths are drug related. Or slightly fewer than 1 out of 20 deaths. Tobacco is excluded from this report or it would be much higher.
Seven Floridians a day is not as many as you think it is
The Headlines continue. The latest stat is that 7 Floridians die every day due to prescription overdoses. That would be just over 2,500 people out of the estimated 180,000 total Floridian deaths every year. Another way to look at it is 7 out of the 500 daily Floridian deaths are due to prescription drugs.
That's all prescriptions, which can include blood thinners, anti-neoplastics, anti-biotics - any prescription. What we're interested in, however, is controls which is what this graphic illustrates.
Please note that alcohol and tranquilizers are nearly twice the problem of Oxycodone.
And, if I zero in on Oxycodone:
Medical Examiner Report on
Oxycodone Deaths
Tot Dths w/Oxycodone Dths w/Oxy Only Dths w/Oxy Comb w/Otr Drgs
Total Cause Pres Total Cause Pres Total Cause Pres
Statewide Tots 1,117 715 402 95 38 57 1,022 677 345
38 deaths out of 89,800 (over 6 months) is attributed to the sole cause of Oxycodone. That doesn't make for a big headline, so we cast the net further and focus on the Total deaths with Oxycodone present. 1,117 deaths? Now, we're talking. Oh, we'll just down play that it's 1,117 out of 89,800. We'll go with 7 Floridians a day. ...and call it a day.
Even one preventable death is worth preventing, so don't think I'm saying we don't have a prescription drug problem in Florida. That isn't my point. The question should be,
How do we get the right amount of narcotics to the people who need them and prevent narcotics from going to people who don't need them?
Any way I look at this problem, I see the need for a Drug monitoring data base at the very least. Any reputable Chronic Pain Physician is on board with a Nationwide Drug monitoring Data Base, but there's a problem with going nationwide, so we'll have to content ourselves with a State-Wide Drug Monitoring Data Base.
The best solution? That one is still a little out of our reach. The best way to go would be a cradle to grave, all encompassing single payer health program that would appropriately track the pain patient from the onset of their pain. That would prevent losing track from people changing insurers or moving around to avoid detection.
Unfortunately, my approach isn't all that sensational. It's just some simple looking at some statistics and doing some basic math. My heart goes out to the family and friends of patients who died taking these drugs inappropriately. My heart also goes out to the patients in pain who can't get relief because the medical establishment can't address their needs. What we need is a Pain Management solution based upon medical facts and efficacious treatment guidelines; not a political tool of a new AG with aspirations of becoming Florida's first woman Governor. It must be hell to be part of a political football game.