Thursday, June 5, 2008

Tough pill to swallow: Most overdose deaths involve prescription drugs

Data released last week show 154 people died in Maine from drug overdoses in 2007, and 86 percent of those deaths involved pharmaceuticals — many obtained with a legitimate prescription often paid for by Medicaid or private insurance and taken improperly or turned around for cash.

At the same time, the Prescription Monitoring Program approved by the Legislature in 2003 is being “grossly underutilized,” according to Maine’s U.S. Attorney Paula Silsby, and opportunities are being missed to prevent abuse, including fraud of the Medicaid system.

Adding to the problem is the fact Maine doctors and other providers write more prescriptions per capita for narcotic painkillers than in most other states.

Methadone was the leading killer, involved in 58 of the deaths last year, followed by oxycodone, involved in 38 deaths, and, benzodiazepine or prescription tranquilizers, involved in 36 deaths, according to statistics presented last week at the Maine Medical Association’s annual education seminar.

Heroin or morphine was also found in the blood stream of 25 who died, and the culprit could have been either, since heroin breaks down into morphine after death. Cocaine, an illegal drug becoming popular once again, was cited in 30 deaths. The drugs are often taken in combination and used with alcohol.

Marcella Sorg, director of the Rural Drug and Alcohol Research program at the Margaret Chase Smith Policy Center at the University of Maine, said more than 50 percent of those who died from oxycodone, which includes the infamous OxyContin, had a prescription for the drug, as did those who died from benzodiazepine.

The bulk of methadone deaths, however, appear to come from methadone tablets resold on the street and most likely initially prescribed as pain killers. Methadone is now used to treat pain more often than OxyContin because it is cheaper and relatively less controversial.

“It’s not the clinics,” providing the drugs on the street, Sorg said, separating the methadone given out by clinics in liquid form to treat narcotic addiction from the now prevalent tablets prescribed for pain.

While the death toll in 2007 is slightly better than 2006, when 167 people died from drug overdoses, the numbers have more than quadrupled since 1997 when 34 people in Maine died from overdoses.

Yet the state-run Prescription Monitoring Program set up in 2004 to help prevent prescription drug abuse and illegal resale by tracking how many controlled substances are being prescribed to an individual is only being used by 28 percent of eligible providers, according to Silsby.

“The very system that was developed to address this issue is simply not being used by the overwhelming majority of prescribers and pharmacists, and for me, that’s a problem,” said Silsby, who spoke last week along with Sorg to doctors gathered at the Augusta Civic Center.

That system lists all the controlled substances sold by pharmacists to an individual and would allow a doctor to see what a patient already has been prescribed. It helps prevent “doctor shopping,” where a patient goes to multiple physicians to get drugs.

Silsby also believes it could help raise some red flags on abuse of the state’s Medicaid system, which she said is a big part of the problem.

“A substantial amount of prescription drug abuse is associated with the Medicaid community,” Silsby said. “If they don’t pay for them with cash, then they’re all paid for by Medicaid, and then they can turn around and have 100-percent profit.”

Sorg said her research doesn’t show how many of the drugs that killed people were issued through the Medicaid program, but common sense shows it is part of the problem.

“We’re talking about rural poor people,” she said, who could sell just part of their prescription and make money, while still having enough pills to treat themselves.

In Maine, nearly 20 percent of the population is on Medicaid, so the sheer size of the program also assures it has a part in prescription drug abuse.

Roy McKinney, head of the Maine Drug Enforcement Agency, said whether it’s public or private insurance that buys the drugs, money is the motivator.

“Money is the root of it,” McKinney said, because drugs like OxyContin sell for $1 per milligram, making a 30-day supply of 40 milligram tablets worth $1,200 on the street.

Overmedicated Maine?

Sorg said the broader issue is more narcotics are being prescribed to treat pain nationwide, and Maine providers write more prescriptions than most.

According to the federal drug data base that tracks prescriptions of controlled substances, Maine ranked sixth in the country for morphine and methadone, and eighth for oxycodone.

Sorg said it is indicative of Maine’s aging population, and that the state has many manual laborers in dangerous jobs like wood harvesting. “We’re old, with a high number of laborers, who have a high number of injuries,” she said.

The typical overdose fatality is not a young person, although teenage abuse of pharmaceutical drugs has surpassed marijuana, according to McKinney.

Rather, the average victim is a male between 38 and 40 years old, whose body has been depleted through years of drug and alcohol abuse and the chronic diseases that go along with that behavior. “They’re not trying to recreationally get high,” Sorg said. “They’re addicted, and they absolutely have to have the drug.”

Gordon Smith, executive vice president of the Maine Medical Association, invited Sorg and Silsby as presenters at this year’s education seminar to raise awareness about the problem, and the use of the Prescription Monitoring Program.

“We’ve done a lot of education, but it is a difficult audience to get to,” Smith said. “They’re too busy and they can’t delegate this to their practice manager. They have to do this themselves.”

“In my opinion, the Board of Medicine and U.S. Attorney and DEA are going to come down quite hard on those, who after three years, are not utilizing this information,” he said.

Silsby agreed it’s hard for doctors. “In the medical profession, it’s ‘Do no harm. Do no harm.’ And now they find themselves having to be vigilant that they are not being scammed by their patients,” she said.