PUCKETT: UPDATED: Hey, look! The AP says everyone is on drugs!

UPDATED: Based on Katie's comments, I poked around and did some more research. According to the FDA's congressional testimony about rogue Internet pharmacies, it looks like my initial numbers were - although not exactly accurate - not nearly as wildly off-base as I feared. While Katie is clearly correct in noting that, for example, a hydrocodone tablet only contains 5 milligrams of narcotics, Joseph T. Rannazzisi, the Deputy Assistant Administrator for the DEA's Office of Diversion Control referred to "dosage units of hydrocodone combination-products" ... specifically, 98,566,711 units prescribed by rogue Internet pharmacies in 2006. When multiplied by 505 (the total milligrams in a single dose of hydrocodone, including the anti-inflammatory and narcotic components) and then divided by 302,665,263, the result is 164 mg per person in the U.S. Based on these statistics, I stand by my original comments, considering that brick and mortar pharmacies continued their strictly controlled disbursement of narcotics, even according to the DEA's own information [PowerPoint].

Now, I would really like to see the report that the AP based its story on because the DEA's Congressional testimony seems to support my rough calculations while, if Katie's point is true, 300+ mg of narcotics for every American calculating ONLY the narcotic component of a "combination-product" means that my grossly over-simplified title is far more true than not (to the tune of more than 151 million one-month prescriptions, using the math of 300 mg multiplied by the U.S. population, then divided by 5 mg and divided again by 120 doses, a typical one-month supply or, if you divided by 12 to get a number for a full year, 12.6 million full-year supplies of narcotics), and that's way too much junkie business.

So we clearly have a discrepancy here with only a very few explanations:

1. Someone screwed up their math.
2. We're seriously fucked up and might as well turn our offices into shooting galleries.
3. Your best guess goes here because I'm fresh out of anything reasonable.

Many thanks to Katie for raising the question that prompted this additional research. On with the original story.

I'd like to begin with something pithy, but I can't think of any humorous anecdotes which don't involve Brenda Spencer today.

I woke up this morning, went to physical therapy and then went to my soon-to-be-stepdaughter's first day of school. My spinal cord stimulator was on for most of it and I still came home and took a painkiller.

Then I sat down to check email and found this lovely news item:

AP: Pain Medicine Use Has Nearly Doubled

Apparently, enough pain medication has been prescribed during the most recent recorded year of DEA statistics to give every American more than 300 milligrams of painkillers. In practical, everyday terms, think of that as slightly more than half a tablet of Vicodin. I'm more concerned about alcohol consumption and text messaging while driving
than what amounts to 1.5 million one-month prescriptions of Vicodin (estimated at 500 mg per tablet with an average of 300 million citizens and 4 tablets of Vicodin for a 6 hour dosage interval for 30 days). Basically, those numbers are misleading because - using very rough numbers here - it means approximately one-half of one percent of the population of the U.S. received a prescription for painkillers in the DEA's most recent statistics. Of course, the DEA isn't providing information about how many surgeons used an invasive procedure to remedy a patient's health concern during the same time, nor is the DEA providing any information about the number of terminal cancer cases treated during that time (UPDATE: More than 550,000 U.S. citizens died from cancer in 2007 alone), so it's difficult to gain any idea of how many truly questionable prescriptions were written, but gosh, 300 milligrams per person sure sounds like a lot, Wally!

For those of you who remember Quantum Leap, "Oh boy."

Or, perhaps more accurately (and certainly more appropriately), "There are three kinds of lies: lies, damned lies, and statistics."

Sure, there are some doctors out there who over-prescribe painkillers, but the problem is that most articles about this issue give the impression that the problem is more significant than it is; that there are hordes of doctors out there turning good American citizens into zombie addicts when really, the number of doctors who improperly prescribe pain medication is quite small and the patients who become addicted were abusing their medication instead of taking the recommended dosage at the recommended intervals purely for the purpose of alleviating breakthrough or otherwise unmanageable pain.

However, this perception has a number of ripple effects:

1. As noted in the article, some pain management doctors are so concerned about possible DEA investigations that they refuse to prescribe pain medication of any sort. While every pain management clinic that I've been to has prescribed pain medication, every one that has been willing to prescribe narcotics has also required me to sign a contract stating that I will not seek or accept any sort of narcotic relief from any other source. Earlier this year, that resulted in me sitting in an emergency room at midnight on a weekend getting injections of non-narcotic pain relievers to deal with breakthrough pain and calling my doctor on Monday morning to let him know what happened and why. I can't argue with the contract - it makes it much easier to detect drug-seeking behavior and the potential for abuse.

2. Patients in areas without a doctor willing to take effective steps to manage chronic pain may have to travel extensively to find a doctor willing to treat them appropriately, as the case of Sean Greenwood illustrated. This may look like drug-seeking behavior, but what else is a patient with intractable pain supposed to do? I'll grit my teeth and suffer because I have the larger goal of being able to advocate for pain management reform from a position of moral, ethical and legal credibility in mind; I don't expect anyone else to take that course of action, nor do I expect people who care about a patient suffering from chronic pain to stand by and do nothing. As medical science progresses, more conditions are identified and these conditions, such as fibromyalgia, are not always accompanied by clear-cut diagnoses supported by hard medical evidence. This doesn't mean that the pain isn't real or that the patient isn't suffering - just that a doctor can't point to a lesion on an MRI or report from a biopsy to explain why a patient is in pain and prove it conclusively. When you also account for variables in quantifying pain levels due to the self-reported nature of pain surveys and the spectrum of potential responses (and the inherently qualitative nature of those responses due to varying degrees of pain tolerance), things get very fuzzy and it's difficult to tell which patients are in desperate need and which are exaggerating the severity of their condition, contributing to federal efforts to marginalize pain management practice.

3. It encourages off-label use of other medications. It also encourages pharmaceutical companies to conduct clinical trials to determine whether a given medication can be considered effective in the treatment of other conditions. It's easy to understand why pain management practitioners would welcome additional pharmacological options - after all, I'm not aware of the DEA prosecuting anyone for prescribing Cymbalta, Elavil or Lyrica, among just a few options that I've been prescribed and that are commonly used as non-narcotic treatments for chronic pain. Unfortunately, medications such as Cymbalta do not have nearly the body of clinical knowledge around long-term effects that more traditional opioid agonists do. The simple fact of the matter is that medications like Cymbalta, Lyrica and so forth haven't been around for sufficient time to let us know what the long-term effects may be. By comparison, codeine, morphine and semi-synthethic opiates like hydrocodone have been around long enough for us to understand exactly what the long-term risks of ongoing use are. In essence, the fear of DEA prosecution is encouraging doctors to forgo tried and true methods which present a limited set of known and clearly understood risks in favor of newer methods which present an as-yet unknown set of emergent risks that extend far beyond dependency and into potentially permanent physical and psychological problems.

For a patient who is already suffering from chronic pain, what could be worse than medication prescribed to treat a condition working instead to expand the set of problems that they suffer from?

And yet this, for all practical purposes, is what pain management has been like for some years.

Simply put, it's a mess.

I'm lucky in that I have MRIs which show at least part of the cause of my pain, a doctor who conducts clinical research studies and is willing to try alternative treatments, and a medical jacket which shows that I have tried non-narcotic means of alleviating pain for more than a year with limited success before returning to narcotics. Not everyone has those advantages when trying to treat their chronic pain.

Some people have more or less credulous doctors, more or less documentable pain, and so forth.

I don't think I've put it quite this bluntly, but I feel very fortunate.

Posted by Puckett at August 21, 2007 08:59 PM
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