Kristen Mascia’s January 28, 2013 article in People Magazine, One Death Every 24 Minutes (Deadly Pills: A National Epidemic) although factual, is variously lopsided to healthcare providers that routinely treat chronic pain. After speaking with Ms. Mascia, it seems that her intent was not to sensationalize a serious problem that might breed fear in community and feed ammunition to media-starving politicians. Instead, I’m convinced her heart was in the right place to share a message that if not taken as directed, any drug could kill. That intent is admirable, although I believe was lacking in a recent Wall Street Journal article reviewed in a paindr.com blog, PROMPT Position Remains Unchanged.
True enough, prescription drug abuse is a serious problem that needs to be addressed. Panic, fear, and politics are counterproductive to addressing the problem − that only serves to fuel a fire which spreads across the field to innocent bystanders. The innocent that get burned are legitimate pain patients.
Let’s start with these three important take home points:
It is not okay to;
…drink alcohol with opioids.
…use someone else’s medication.
…take more medication than instructed.
The in-print and online versions of Deadly Pills: A National Epidemic includes 2/3 of one page outlining some “painkiller pill” (opioid) statistics and related deaths. But, it does not go far enough to objectively outline the whole [complex] problem. Five of the remaining pages include large color pictures of families that survived the deaths of their loved ones from opioid overdoses. I would have liked to see a few pictures of live patients writhing in pain and withdrawal because they were unable to obtain their opioids. I would have liked to hear about how families are destroyed because of poorly controlled pain that has caused job loss and failed marriages.
A follow-up article addressing much needed pain education among healthcare providers, the importance of stratifying risk in patients that are considered for chronic opioids, the harm to patients (and their families) that find themselves in withdrawal because they are unable to obtain an opioid refill for various reasons, the financial, psycho-social impact of poorly treated pain on patients, their families, and society, the absurdity of 20-40 Lortabs following a dental procedure (when NSAIDs work better and the Lortab ends up in a medicine chest someplace later to be confiscated by a teen), the black market that exists and what practitioners (and patients) must deal with in clinics to monitor patients (urine screens, serum analysis, and more), etc.
The article plays on emotions of the reader laying blame on the drugs. All three deaths discussed in the article are a direct result of behavior that is explicitly proscripted on the part of the deceased. I truly feel horrible for the families of these victims, as they are living with the tragic outcomes of their loved ones. I personally cannot imagine losing a son, daughter, or spouse to a drug overdose. I also suspect that if this blog finds its way to any of the families that interviewed for Ms. Mascia’s article, the truth herein will be quite hurtful; for that I am sorry.
Tragedies like this provide an opportunity to say that we (all of us, journalists, healthcare providers, patients, law enforcement, etc.) have a role in helping make sure we are doing everything we can to help make pain management safer.
Three cases given by People Magazine’s author Kristen Mascia;
1. A young woman (previously an athlete), age 28 recently married and pregnant. She took Lexapro, hydrocodone, and was “excessively drinking”. She died. [Drugs and Alcohol: There is a warning on all opioid prescription bottles that includes some permutation of, “CAUTION: Do not drink alcohol, drive or operate heavy machinery”].
2. A high school senior football player, 150 pound athlete, took 2 methadone tablets from his grandmother’s medicine cabinet. He died. [Although I don’t know for sure, I suspect the methadone tablet strength was no more than 10mg based on grandma’s diagnosis. A total dose of 20mg is high for an opioid naïve patient, but it strains credulity to believe that this didn’t involve more than two tablets and/or other substances in an otherwise healthy 150 pound male athlete. Also, taking someone else’s medication! All opioid bottles state, “Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed.” I think taking your grandmother’s drugs is covered by this.]
3. Forty year old firefighter post-injury now on prescribed Dilaudid and Celexa. He died of an “accidental overdose”. [I’m not sure what that means. Did he accidentally take a handful instead of the prescribed amount? This is where education comes in for the prescriber and patient; although we can’t prevent 100% of adverse outcomes, risk stratification in terms of co-morbid depression and other mental health disorders before and during opioid therapy is important and underappreciated].
Although prescription bottles are labeled with warnings and transfer is prohibited, we also know that folks typically don’t pay attention, are distracted, and don’t read all the labels. Is that all the patient’s fault? Pharmacies that rely on printouts to provide important drug information are copping out. Prescribers who don’t assess patients for alcohol and other drug use are dropping the ball.
Are opioids dangerous if taken other than as directed? You bet they are!
Dr. Scott Strassels said it well; “The challenge to policy makers, health care providers, patients, and law enforcement officials is to balance the need for appropriate pain management with efforts to reduce abuse and misuse, and to do so without resorting to fear or emotion.”1 His commentary was written in rebuttal to “Danger in your pill bottle” on the Cable News Network (CNN) Web site. (Seppala MD). The approach by Seppala was similar to what we saw in People Magazine.
Considering the numerous evidence-based pain practice guidelines in place, legitimate patients continue to suffer needlessly, outcomes overall are poor, and society pays a high price figuratively and practically because of suboptimal pain treatment strategies, resultant clinic and emergency room visits, hospital admissions, and readmissions.
Any real answer to this problem is multifaceted and needs to include education for healthcare providers, lawmakers, and consumers.
Articles such as the one that appeared in People Magazine could have a negative [fear factor] impact on patient care. “Pill Mills” are problematic and need to be squelched. Criminals involved in such activities need to be brought to justice, but patients have suffered needlessly because of knee-jerk reactions by lawmakers in various states. (See Dancing to the Pharmacy Crawl for Opioids and Kentucky’s Pharmacy Crawl. In some cases, we see sensationalized statements from politicians such as Senator Chuck Schumer speaking on an extended release formulation of hydrocodone: “It’s tremendously concerning that at the same time policymakers and law enforcement professionals are waging a war on the growing prescription drug crisis, new super-drugs could well be on their way, flooding the market… The FDA needs to grab the reins and slow down the stampede to introduce these powerful narcotics.” This blog on paindr.com addresses that well, [Hydrocodone: Potency, Popularity, Politics, & Practicality], as hydrocodone surely is not a “super drug” of any sort.
Here are some facts to balance out Mascia’s People Magazine article.
More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined.2,3 I don’t see anyone rushing to take cigarettes off the market, limit the number of cigarettes that one can purchase, or limit the nicotine intake from any consumers! But, this is on the table for opioids.
Every day, almost 30 people in the United States die in motor vehicle crashes that involve an alcohol-impaired driver. This amounts to one death every 48 minutes and the annual cost of alcohol-related crashes totals more than $51 billion.4
And finally with regard to opioids, see Policy Impact: Prescription Painkiller Overdoses. About one-half of prescription painkiller deaths involve at least one other drug, including benzodiazepines, cocaine, and heroin. Alcohol is also involved in many overdose deaths.5 In 2010, 2 million people reported using prescription painkillers nonmedically for the first time within the last year—nearly 5,500 a day.6
So there you have it. Isolated Police State politics and narrow-minded, draconian policy changes, across more and more states, is not the answer. Instead, it may fuel a black market or increase more dangerous activities such as injecting heroin as outlined in Pain Pills Wane – Heroin Moves In.
Telling the whole truth is less sexy media, may be limited by space constraints, and calls less attention to readers and magazine sales. Journalists – you are in a position to help or hurt. Publish the whole story fairly, even if it requires sequential articles, so that we can all work together for some reasonable solutions rather than pointing fingers. Let’s not blame the ground on a faulty parachute; instead let’s repair the equipment together.
- Danger in Your Pill Bottle? (Journal of Pain & Palliative Care Pharmacotherapy, Vol. 23(4), 2009.
- Centers for Disease Control and Prevention. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Morbidity and Mortality Weekly Report 2008;57(45):1226–8.
- McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of American Medical Association 1993;270:2207–12.
- Blincoe L, Seay A, Zaloshnja E, Miller T, Romano E, Luchter S, et al. Injury Prevention & Control: Motor Vehicle Safety
- CDC. Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006.
- Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2011.