DEA Plans Further Cuts in Rx Opioid Supply

By Pat Anson, PNN Editor

For the seventh consecutive year, the U.S. Drug Enforcement Administration is planning to cut the supply of prescription opioids, reducing them in 2023 to levels not seen in nearly two decades.

DEA sets production quotas for opioids and other controlled substances annually, after consulting with the CDC, FDA and individual states about their projected medical and research needs. Based on that input, the DEA is lowering the supply of Schedule II opioids such as oxycodone and hydrocodone by about 5 percent next year.

“FDA predicts that levels of medical need for schedule II opioids in the United States in calendar year 2023 will decline on average 5.3 percent from calendar year 2022 levels. These declines are expected to occur across a variety of schedule II opioids including fentanyl, hydrocodone, hydromorphone, oxycodone, and oxymorphone,” the DEA said in a notice published in the Federal Register.   

The production cut in Schedule II opioids is not as steep as in prior years, but continues a trend that began a decade ago. Since their peak in 2013, production quotas have fallen by 65% for oxycodone and 73% for hydrocodone, the two most widely prescribed opioids.

OXYCODONE PRODUCTION QUOTAS (KILOGRAMS)

SOURCE: DEA

The primary goal of the DEA in lowering opioid production is to reduce the risk of diversion, abuse and overdose, but it’s hard to find any evidence the policy is working. Prescription opioid use has fallen by 48% in the last five years, but opioid overdose deaths have climbed to record levels, fueled primarily by street drugs made with illicit fentanyl, a synthetic opioid 50 to 100 times stronger than morphine.

Although DEA is arresting and prosecuting illicit fentanyl dealers, it also continues to actively target doctors who prescribe high doses of opioids. This month it suspended the DEA license of a California doctor for unknown reasons, which led to the death of a chronic pain patient and his wife in a double suicide.

“It’s the end of the road for me with doctors,” Danny Elliott posted on Twitter a few days before his death. Elliott had lived with severe headaches for over two decades and was despondent that he was out of pain medication and unable to find a new doctor.

Low Risk of Diversion    

DEA is required under federal law to estimate the amount of prescription opioids that will be diverted through loss or theft, and then subtract it from the annual production quota. But those estimates reveal just how small the opioid diversion problem actually is.

Using information gathered from prescription drug monitoring programs (PDMPs), pharmacies, hospitals and others in the drug supply chain, DEA estimates that less than one percent of oxycodone (0.3%) and hydrocodone (0.42%) will be diverted for use by someone they were not intended for.

The DEA’s 2023 production quotas are also based on an old recommendation from the CDC that prescribers should “avoid increasing dosages of opioids beyond 90 MME for patients with chronic pain.”  CDC recently revised its opioid guideline to remove the 90 MME dosage threshold. The new guideline is more flexible and encourages doctors to make treatment decisions based on the individual needs of the each pain patient and not on any hard limits.

The DEA is accepting public comments on its production quotas until Thursday, November 17. The public response so far has been muted – only 47 comments as of this writing -- likely because the quotas have received little publicity from the media or the DEA itself.

Most of the comments that have been received are critical of DEA plans to reduce the supply of amphetamines and other stimulants used in treating attention deficit hyperactivity disorder (ADHD).  Some of those drugs are already in short supply, but DEA said it has “grown increasingly concerned” that ADHD medications are being diverted and abused by young adults.

To leave your comment on the DEA’s 2023 production quotas, click here.

Prescription Opioid Use Fell Nearly 7% in 2021

By Pat Anson, PNN Editor

Prescription opioid use in the United States fell by 6.9% in 2021, the tenth consecutive year the volume of opioid pain medication has declined, according to a new report by the IQVIA Institute, a healthcare data tracking firm.

The decline in opioid consumption came even as prescription drug use overall reached record levels in 2021, fueled in part by new COVID-19 vaccines and therapeutics. Spending on medicines rose 12% to $407 billion last year, according to IQVIA, with 194 billion doses of medication dispensed.

While longer opioid prescriptions were written in the early stages of the pandemic to accommodate patients who didn’t see their doctors as often, prescribing quickly returned to its decade-long downward trend.

“Prescription opioid use has fallen by 48% over the past five years and is now at levels last seen in 2000, reflecting efforts by many stakeholders to limit and manage appropriate prescription opioid use,” IQVIA said in its annual report on medicines in the U.S.      

IQVIA tracks opioid prescriptions in morphine milligram equivalents (MMEs). The company estimates that per capita opioid use fell to 309 MME last year (about 0.84 MME per day), down from a peak of nearly 800 MME in 2011.

Some providers have reduced their opioid prescribing more than others. Since 2016, surgeons, anesthesiologists, dentists and general practitioners have cut their opioid prescribing by over 50 percent, while nurse practitioners and physician assistants have reduced their prescribing by 27 percent.

Prescription Opioid Use and by Prescriber Specialty

Opioid consumption by Americans has fallen so sharply in recent years that Canada, Australia and several European countries have overtaken the U.S. and become the highest consumers of opioid medication. A recent study ranks the U.S. as 8th globally in per capita opioid sales.

The decline in U.S. opioid prescribing has failed to stop the surge in overdoses. The CDC estimates that 106,854 people died from drug overdoses in the 12-month period ending November 2021, with drug deaths more than doubling in the last six years. Synthetic opioids – primarily illicit fentanyl – were involved in about two-thirds of fatal overdoses in the past year.

Patients Blamed for Diversion 

Despite the historic decline in prescription opioid use, some politicians continue to blame opioid medication, prescribers and even patients for the nation’s overdose epidemic.

In comments recently submitted to the CDC on its revised opioid guideline, West Virginia Attorney General Patrick Morrisey and 10 other state attorneys general said the agency needs to do more to prevent the diversion of prescription opioids.

“Diversion must remain a key consideration of any prescribing guideline,” said Morrisey.

“Although drug dealers and unethical physicians are responsible for much of the opioid diversion nationwide, legitimate prescriptions remain a prime source of diversion, too. Diverted opioids most commonly reach drug abusers through friends and family members who filled a legitimate prescription.

“The amount of opioids prescribed in recent years has been excessive and far beyond the amount necessary to support legitimate medical need.”

— Patrick Morrisey, West Virginia Attorney General

“Indeed, the amount of opioids prescribed in recent years has been excessive and far beyond the amount necessary to support legitimate medical need. And over-prescription allows legitimate prescriptions to fall into the hands of patients’ family and friends.”

How common is it for prescription opioids to be diverted? Not common at all, according to the DEA’s National Drug Threat Assessment, an annual report that estimates less than 1% of legally prescribed opioids are diverted.  “The number of opioid dosage units available on the retail market and opioid thefts and losses reached their lowest levels in nine years,” the DEA’s 2020 report found.

Despite this, Morrisey puts the onus on pain patients to prove that they’re not abusing or selling their prescriptions. He and the other attorneys general called for routine drug testing of pain patients – rejecting evidence that fraud is common is the drug testing industry and that widely used point-of-care urine tests often give false results that lead to patient abandonment.

“The given reasons that toxicology screenings might lead to ‘stigmatization,’ encourage ‘inappropriate termination from care,’ or be ‘misinterpreted’ are unsatisfactory,” Morrisey wrote. “First, what stigma would the patient face? Diagnostic results are private information. The only people who would know that the test is performed are the patient and the prescriber. The prescriber is already familiar with the patient’s prescriptions, so this process would not reveal any new information -- unless, of course, the patient had lied or not followed the prescriber’s directions.”

Remarkably, the 7-page letter from Morrisey never acknowledges that most drug deaths involve street drugs, not prescription opioids, and makes no mention of fentanyl. The most recent overdose data from West Virginia – Morrisey’s home state – indicates nearly 3 out of 4 drug deaths involve fentanyl.    

Morrisey’s letter was co-signed by the attorneys general of Arkansas, Indiana, Kansas, Mississippi,
Nebraska, South Carolina, South Dakota, Utah, Kentucky and Virginia.

How to End the ‘Opioid Paradox’

By Pat Anson, PNN Editor

Three public health and pain management experts are calling for a major shift in strategy to combat the U.S. opioid crisis, one that doesn’t just focus on pill counts and punishing doctors deemed to be “overprescribing” opioids.

In an op/ed recently published online in Anesthesiology, the official journal of the American Society of Anesthesiologists, Editor-in-Chief Evan Kharasch, MD, Editor J. David Clark, MD,  and former U.S. Surgeon General Jerome Adams, MD, said current policies are failing to address what they call the “opioid paradox” --- how opioid overdose deaths have risen to record levels even as opioid prescribing has fallen to 20-year lows.

SOURCE: ANESTHESIOLOGY

“Overall, the nation’s response to the oral opioid crisis has been to tighten patient supplies and impose institutional and practitioner quality indicators based on pill counts. Governments, payers, and pharmacies have assumed authority for limiting opioid prescribing, often in indiscriminate ways, based on misinterpretation of Centers for Disease Control guidelines or based on no real guidance at all,” they wrote.

“Pill counts have become de facto standards employed by healthcare organizations to highlight their success in reducing opioid use, yet there is no discussion of how those reductions are affecting patient outcomes. One crucial problem is that agencies mandating policy restrictions do not measure, nor are they accountable for, patient outcomes. Mandated opioid prescribing limits may be too low to adequately control pain, or too high to reduce oversupply.”

The three authors say more novel and comprehensive approaches are needed to better manage the supply of prescription opioids, prevent diversion and address the opioid paradox.

“It involves immediate action to address opioid use, storage, return, and harm reduction, with a specific focus on patients and communities,” they explained.

Reduce Demand

In recent years, federal and state agencies, healthcare organizations and insurers have created new guidelines for treating pain – many of which take a one-size-fits-all approach to opioid prescribing that doesn’t take into account an individual patient’s needs.   

“Legislative, regulatory, and insurer limitations on opioid prescribing alone have not met their intended goals and are considered unlikely to achieve them. One reason is that they impose tight restrictions on an extremely heterogeneous patient population,” the authors said.

Rather than limiting or withholding opioids after surgery – which has become increasingly common --  Drs. Kharasch, Clark and Adams urge anesthesiologists and surgeons to provide patients with enough opioids for adequate pain relief, because undertreated acute pain can turn into chronic pain and become a risk factor for opioid misuse.

Smaller opioid doses may be effective in treating postoperative pain, the authors said, if they are combined with multimodal strategies that also employ non-opioid medications and therapies. So too may the use of longer-acting opioids such as methadone, which can result in less postoperative pain and relief that lasts for weeks or months after a single dose.

Proper Disposal of Leftover Pills

Hundreds of millions of opioid pills are dispensed to patients but go unused each year, according to the authors. Most leftover pills are kept by patients and few are safely stored. Only a fraction are disposed of properly or returned.

"The current difficulty of returning prescription opioids contrasts markedly with the ease of obtaining them. This is illogical and unsafe," Drs. Kharasch, Clark and Adams said.

They believe pharmacies that dispense opioids should be required to provide patients with instructions for proper return and disposal; the addresses and telephone numbers of disposal stations; and a pre-addressed, prepaid envelope for returning unused pills. Disposal stations should be available year-round, not just on “Prescription Drug Take Back” days.

Another novel approach would be opioid “buy-back” programs, similar to the gun buy-backs used by law enforcement agencies to get unneeded firearms off the street. One pilot compensation program for opioids found that 30% of surgery patients were willing to participate in buy-backs, selling their leftover opioids for up to $50.

Partial Fills

Kharasch, Clark and Adams also suggest more partial filling of opioid prescriptions. A 2016 federal law allows both patients and clinicians to request partial filling of prescriptions for hydrocodone, oxycodone and other strong Schedule II opioids. Partial filling for schedule III–V weaker opioids has been permitted for decades, but is not widely practiced.

According to one estimate, 36 million postoperative opioid prescriptions could be partially filled each year. One hurdle for partial fills is the extra paperwork and cost to pharmacies, estimated at $15 for each prescription.

“Partial opioid fills could be the single most effective intervention to deplete America’s medicine cabinets of unused prescription opioid pills, shrink the opioid pool, improve the prescription opioid ecosystem, and prevent misuse, diversion, and death,” the authors said. 

Kharasch, Clark and Adams place an emphasis on reducing diversion, even though less than one percent of legally prescribed opioids are diverted, according to the DEA. Partial fills may reduce leftover pills in medicine cabinets, but they won’t do anything to prevent the wholesale theft of opioids from hospitals, pharmacies and the pharmaceutical supply chain.

The authors also buy into the myth that most street drug users start with prescription opioids, and that pain patients denied opioids “switch to illicit drugs” and fentanyl-laced counterfeit pills.

But Kharasch, Clark and Adams do have some interesting ideas about addressing the opioid paradox – chief among them the long overdue recognition that current opioid reduction strategies have been a complete failure.

“Attempts to solve the problem by restricting patient supply alone have not succeeded, and the prescription opioid pool remains large. Additional novel efforts to shrink the pool are needed, both by diminishing demand (reducing pain through better treatment) and by facilitating opioid disposal and return,” they concluded.

More Bad Data on Rx Opioids from Health Canada

By Marvin Ross, PNN Contributor

Canadian health officials are still blaming opioid prescriptions for Canada’s overdose crisis. A new report by the Canadian Institute for Health Information (CIHI) that was funded by Health Canada points out that more than 9,000 people died from opioid-related overdoses between January 2016 and June 2018.

“While many of these harms may be due to the use of illicit opioids, such as heroin or fentanyl, prescription opioids are also contributing to the public health issue,” the CIHI report found.

The data the report presents shows significant declines in opioid prescribing, but no evidence that prescriptions are to blame for the overdoses.

For example, the total quantity of opioids prescribed in Canada between 2016 and 2017 dropped more than 10 percent, while the number of prescriptions fell more than 400,000.

From 2013 to 2018, there was an 8% decrease in the number of people prescribed opioids.

Fewer Canadians are taking opioids long-term and the number on daily doses over 50 MME (morphine milligram equivalent) also declined, which is likely the result of people being tapered.

There were signs of aggressive tapering. The proportion of patients taking over 90 MME fell significantly, from 25.7 percent to 16.6 percent. And more people stopped taking opioids for at least 6 months than ever before.  

But there was no discussion anywhere in the CIHI report of whether these decreases were medically beneficial for the patients involved -- which surely must be a consideration. Healthcare should be about improving care for people, not just cutting them off.  

We do know anecdotally that these changes are making pain care worse. I personally experienced the reluctance to treat pain when I recently cracked a knee cap.

“What about pain control?” I asked the ER doc. Over-the-counter Tylenol was her answer. She said Tylenol 3 – which contains codeine -- would give me constipation, so she would not prescribe it. Anything stronger, she said, would make me fall down and that would not be to my benefit.

The Toradol shot she gave me worked for a few hours. Fortunately, I had some Tylenol 3 at home leftover from a tooth extraction. Thank goodness for dentists, but taking the Tylenol 3 for something other than what it was prescribed for made me an opioid abuser.

Evidence Lacking

As for prescriptions being a significant cause of the crisis, the CIHI report provided a footnote to a report from the Public Health Agency of Canada, which states that illicit fentanyl and its analogues appear to be fueling the crisis. Males between the ages of 30 and 39 were the most prevalent victims of overdose death. Further, 82% of the deaths involved multiple drugs.

What do those figures have to do with chronic pain patients who tend to be older and female?

Here is their proof: In 2016, over 20 million prescriptions for opioids were dispensed, which is equivalent to nearly one prescription for every adult over the age of 18, making Canada the second-largest consumer of prescription opioids in the world after the United States.

That’s an interesting fact, but it does not show that prescribing to people who need analgesics has fueled the increase in overdose deaths. It only means there are a lot of Canadian adults in pain.

They also cite a 2015 survey, which found only 2% of those who had a prescription for opioids misused them. A more recent 2017 survey found that nearly a third of people who used opioid medication did not have a prescription. That proportion increased to almost 50% for teens under the age of 18, and 88% of those were illegal drug users.

As for the source of these unprescribed drugs, the Public Health Agency states:

“There are many routes that allow for prescription opioids to be diverted for nonmedical use, including sharing with family members, ‘double doctoring,’ prescription fraud and forgery, street drug markets, thefts and robberies and Internet purchases, making it difficult to estimate the proportion diverted. Through its surveys, Health Canada found that the most common source of opioids used without a prescription was a family member.”

They have no idea how these drugs get out there and admit there are many routes, but conclude that most come from family members who have a prescription for them.

What proof do they put forth? This is the reference they provide in a footnote to prove something that is contentious and disputed:

“Health Canada. Baseline survey on opioid awareness, knowledge and behaviours for public education research report. Ottawa (ON): Prepared by Earnscliffe Strategy Group for Health Canada; 2017. Unpublished report.”

When they say unpublished, I assume that this report was never submitted to a peer reviewed journal. Or if it was, then it was rejected. Scientific research should be published in peer reviewed journals where a panel of experts in both methodology and subject matter determine if the study is any good and will add to our collective knowledge of the topic. That is how science is advanced.

Regardless, the Earnscliffe report is buried on a government website and they tell us it cost almost $100,000. The report is largely based on an online survey with self-selected participation. Because of this, “no estimates of sampling error can be calculated, and the results cannot be described as statistically projectable to the target population.”

In other words, they cannot claim that any of their findings are valid. Just saying that opioid prescriptions are diverted from family members does not make it true. As the report indicates, even the teens who participated in the survey were conflicted about where illicit prescription opioids come from:

“The most common way of obtaining opioids illegally was from a friend or relative with a prescription, and the most common reason for taking them was pain relief. When teens were asked where they thought people their age get illegal opioids, the most common source was a drug dealer or other stranger.”

So much for the alleged proof that the illegal market is mostly comprised of drugs diverted from legal prescriptions. The findings here are similar to my experience, where I used a prescription given for tooth pain for a knee fracture. If I did not have the pills leftover, I would have obtained what I needed from a relative.

The initial published report went on to disprove their own hypothesis on the role of opioid prescriptions by saying that about 2% of Canadians used illegal drugs in 2015, including the “use of crack, cocaine, ecstasy, speed or methamphetamines, hallucinogens or heroin and therefore was not specific to opioids.”

The Canadian government is simply blowing smoke when it comes to proof that prescribing is fueling opioid overdoses. Canadians can only hope that after the federal election we get a new health minister who is a bit more logical. But I am not holding my breath.

Marvin Ross is a medical writer and publisher in Dundas, Ontario. He is a regular contributor to the Huffington Post.

The information in this column is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Report: DEA ‘Slow to Respond’ to Opioid Crisis

By Pat Anson, PNN Editor

DEA investigators should get easier access to prescription drug databases and electronic prescribing should be required for all opioids and other controlled substances, according to a new report from the Justice Department’s Office of Inspector General (OIG).

The 77-page report is sharply critical of the Drug Enforcement Administration for its slow response to the opioid crisis and said the agency was “ill-equipped” to monitor suspicious orders and prevent diversion of prescription opioids.

“We found that DEA was slow to respond to the significant increase in the use and diversion of opioids since 2000. We also found that DEA did not use its available resources, including its data systems and strongest administrative enforcement tools, to detect and regulate diversion effectively. Further, we found that DEA policies and regulations did not adequately hold registrants accountable or prevent the diversion of pharmaceutical opioids,” the report found.

The OIG report focused exclusively on prescription opioids and did not evaluate the significant role that illicit fentanyl, heroin and other street drugs play in the opioid crisis. About two-thirds of opioid overdoses involve illicit drugs.

The report also contains some factual errors, such as the misleading but often repeated claim that “nearly 80 percent of people who began abusing illicit opioids during the 2000s started by abusing a prescription opioid.”

Less than one percent of legally prescribed opioids are diverted, but the report claims the “pervasive nature of prescription fraud” is so rampant that paper prescriptions for opioids should be prohibited. Instead, electronic prescribing should be mandated nationwide to prevent fraud and allow for better tracking of opioid prescriptions.

‘Puzzling’ Restrictions on Opioid Databases

The report also calls for greater law enforcement access to state run prescription drug monitoring programs (PDMPs). To protect patient privacy, several states require a subpoena or search warrant before giving DEA investigators access to their databases. The report calls the requirement “puzzling” and said it creates “significant challenges” for DEA investigators “who should be able to receive PDMP data and information.”

“We believe that the Department and DEA should continue to work with states to reach agreements that will enable DEA to have timely access to PDMP prescription data as needed… while also ensuring adequate protections for the important healthcare privacy interests of patients,” the report said.

Other recommendations from the report:

• DEA should develop a national prescription opioid enforcement strategy

• Require criminal background checks for all new prescribers and registrants

• Re-establish a nationwide early warning network to identify emerging trends in drug abuse   

• Expand DOJ opioid fraud units to additional U.S. Attorney’s Offices

In its response to the OIG, the DEA said the report “rightly identifies areas of improvement,” but said the agency has taken a number of steps to reduce the supply and diversion of prescription opioids.

The DEA said “only a minute fraction” of the more than 1.8 million registrants are involved in illegal activity. The agency said it had revoked about 900 registrations annually over the past eight years and reduced the supply of prescription opioids by 45 percent since 2017. Additional cuts in the opioid supply are proposed for 2020.

Opioid Hysteria and the Demonizing of Dsuvia

By John Burke, Guest Columnist

Recently the FDA approved a new sublingual formulation of sufentanil -- called Dsuvia -- for the management of moderate to severe acute pain in hospital-like settings. This would include surgical centers and emergency departments.

When the FDA announced this approval, several so-called experts claimed that Dsuvia – which is a potent opioid – would worsen the already out of control opioid problem. They said it would quickly find its way to the streets of America and kill even more of our citizens addicted to opioids. They can’t imagine why the FDA would approve such a killer drug!

Dsuvia was originally developed by AcelRx Pharmaceuticals, in cooperation with the U.S. Department of Defense, to treat battlefield wounds. The single dose formulation is designed to enter your body and provide pain relief faster than the traditional intramuscular injections that are now standard in treating traumatic injuries.

I can only imagine the horrendous wounds that are present on the battlefield. Offering faster pain relief seems like a great option, to say the least!  

ACELRX PHARMACEUTICALS

Dsuvia will also be used in our nation’s emergency departments and other healthcare facilities to offer faster pain relief to patients who suffer traumatic injuries. The drug will not be available in retail pharmacies or for most prescribers to order up for a patient. Doctor shoppers, script scammers and others that prey on retail pharmacies will have no access to this pain reliever. Those involved in armed robberies or burglaries of retail pharmacies will also have zero access.

Who will have access to Dsuvia are healthcare employees -- nurses, doctors and other medical professionals who already have access to a whole host of opioid drugs. There is no question that Dsuvia could potentially be a target of a small group of professionals who suffer from addiction problems. However, the illegal diversion and sale of this specific medication seems less likely in healthcare facilities.

Dsuvia will be more easily identified when it is diverted due to its limited availability and usage. Addicted healthcare employees will likely opt for more commonly used opioids like morphine and hydromorphone rather than a rarely used medication that will be easily missed when diverted.

The other part of this equation, that was either not considered by critics or didn’t suit their narrative, is that diversion inside healthcare facilities virtually always involves self-addiction. This means that even if an opioid is stolen by an employee inside one of these facilities, it will rarely make it to the street and cause more deaths.  

AcelRx has already developed a Risk Evaluation and Mitigation Strategy (REMS) involving RADARS, a nationwide drug abuse surveillance system, to monitor any diversion of Dsuvia and provide quarterly reports to law enforcement. In the interest of full disclosure, I am on the Scientific Advisory Board of RADARS.

Dsuvia has great potential to provide quick relief to trauma patients in a focused setting. Its diversion potential, especially to the public, is almost nil. Demonizing a drug without any real knowledge of its legal distribution and potential for diversion is irresponsible to say the least.

The drug problem in America primarily involves street drugs such as heroin, illicit fentanyl, and more recently crystal methamphetamine and cocaine. Even as the prescribing of opioids has dropped over 30% in recent years, drug deaths continued to rise. The reason is the increased supply of street drugs supplied by cartels that continue to profit from our nation’s addiction.

Put the blame where it belongs, and don’t ostracize a legitimate new pain drug that any of us might need in an emergency.

John Burke spent nearly 50 years in drug and law enforcement in southwestern Ohio. John is a former president of the National Association of Drug Diversion Investigators and is the president and founder of the International Health Facility Diversion Association, a non-profit devoted to the issues surrounding the diversion of controlled substances from healthcare facilities.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Cutting Rx Opioid Supply Is Not Stopping Diversion

By Roger Chriss, PNN Columnist

Drug diversion is an increasingly important factor in the opioid overdose crisis. A new report from Protenus found that 18.7 million pills, valued at around $164 million, were lost due to drug diversion in the United States during the first half of 2018. This represents a vast increase over 2017, when 20.9 million pills were diverted during the entire year.

As we’ve described previously, drug diversion in the supply chain is a vast, complex and old phenomenon. And it is rapidly worsening.

According to the textbook, “Prescription Drug Diversion and Pain,” drug thefts from hospitals “have increased significantly within the past decade as street prices have climbed sharply for diverted prescription opioids and benzodiazepines.”

In other words, the steep cuts in opioid production that began in 2017 aren’t working. And Attorney General Jeff Sessions was wrong when he said, "The more a drug is diverted, the more its production should be limited." A tightening supply has actually resulted in more diversion.

Drug diversion can be broadly divided into three categories: clinical diversion, personal diversion and industrial diversion. The first, according to Protenus, is drug diversion by healthcare workers. The second is the sale or transfer by a patient who received a legitimate prescription to a third party. And the third is everything else, from diversion by employees at manufacturing facilities to theft in distribution centers or pharmacies.

Personal diversion has gotten substantial attention in recent years. Prescription drug monitoring databases, pain agreements, and urine drug testing are all intended to help prevent such diversion.

Clinical drug diversion is a long-standing problem in healthcare that has garnered more interest recently. The bipartisan opioid bill recently passed by Congress includes a provision that allows hospice workers to destroy opioid medication that has expired or is no longer needed by a patient. The National Institutes of Health has also awarded a grant to further expand efforts to detect opioid and other drug theft in hospital systems.

Industrial diversion is less well known, but appears to be a longstanding problem. In the book “Dopesick,” journalist Beth Macy writes that as early as 2001 the DEA was investigating lax security standards at Purdue Pharma manufacturing plants after the arrest of two Purdue employees accused of trying to steal thousands of pills.

Between 2009 and 2012, over 63,000 thefts of opioids and other controlled substances were reported to the DEA. Pharmacies (66%) and hospitals (19%) accounted for the vast majority of those drug thefts.

And in 2007, an audit of CMS Medicare Part D payments identified 228,000 prescription payments with invalid prescriber identifications for Schedule II drugs.

In other words, tens of thousands of drug thefts and hundreds of thousands of fraudulent prescriptions are occurring annually, leading to millions of prescription pills entering the illegal market. This may help explain how OxyContin entered the black market so quickly and completely.

As Beth Macy writes: “The town pharmacist on the other line was incredulous: “Man, we only got it a month or two ago. And you’re telling me it’s already on the street?””

The National Association of Drug Diversion Investigators and the DEA Diversion Control Division are attempting to address industrial diversion. But available evidence suggests there is much more work needed to secure the entire prescription drug supply chain.

As the opioid overdose crisis continues to evolve toward poly-drug substance abuse, drug diversion will play an increasingly significant role in the illegal supply of prescription pharmaceuticals unless the entire supply chain is secured. This will require far more than the easy tasks of checking a prescription database or legislating pill counts. The hard part of reducing drug diversion remains to be done.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Lessons from ‘Prescription Drug Diversion and Pain’

By Roger Chriss, PNN Columnist

The new book "Prescription Drug Diversion and Pain" is a textbook treatment of pain management and drug policy amid the opioid crisis. Written and edited by experts, the book is a scholarly, rigorous and evenhanded examination of the benefits and burdens of opioid pain medication.

Each chapter is written by specialists who address a particular aspect of the opioid crisis, with extensive footnotes justifying every statistic and claim. Much of that data, however, is admittedly flawed.

“As we show in this book, essential data about opioid abuse, morbidity, and mortality are lacking and what little data we have are derived from flawed and obsolete government databases,” the authors note in the preface.

“Yet, these resources are relied upon for public policy development, resource allocation, and lawmaking. In the absence of sound data, ingrained cultural feelings about addiction can become a powerful driver of attitudes, even among pain specialists who, despite their professional training and experience, may be influenced by such bias in their prescribing practices.”

The first chapters look at the history, regulation and monitoring of opioid prescriptions, and attempts to defuse the bias often associated with them:

"These medications are neither good nor bad absent context, despite the public tendency to oversimplify their use and mischaracterize their utility."

The origins of the opioid crisis are given due consideration. Rising rates of opioid prescribing are recognized as one factor, but drug diversion in the supply chain is also acknowledged:

“There is evidence that thefts from hospital and pharmacy drug supplies, as well as in-transit thefts from manufacturers and distributors, may also be a significant source of diverted opioids.”

Close attention is given to the issue of overprescribing and doctors who are “careless, corrupt, and compromised by impairment.”

But the book is also critical of the theory – expounded by the CDC opioid guideline – that reducing the number of prescriptions will help solve the opioid crisis:

“One might expect… that a decline in sales would produce a corresponding decline in overdose deaths. This has not occurred, casting doubt on the CDC’s original hypothesis. Several explanations are possible for this and may involve the recent increase in the use of street opioids like heroin and fentanyl analogs.

“Government databases for tracking nonmedical drug use and related health consequences are obsolete and lack the sensitivity to show which drugs, by chemical name and product formulation, licit or illicit, are responsible for the increasing overdose deaths.”

Later chapters explore opioid prescribing in detail and echo many of the themes of the CDC guideline:

“Not every patient who complains of pain needs an opioid or is a candidate for opioid therapy. Opioids should be prescribed only when the benefit outweighs the risks. Functional improvement should be a primary goal, along with improved sleep and mood, regardless of the therapy used.”

Indeed, the book goes to great lengths to discuss the risks associated with long-term opioid therapy, not just addiction but endocrinopathy, sedation, delirium, and bone loss. Many alternatives, from non-steroidal anti-inflammatory drugs and tricyclic antidepressants to cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) are also described in detail.

The book laments the loss of interdisciplinary pain management programs, starting in the 1980s. These programs provided “a safer and clinically more effective alternative to opioids [and] have also been empirically associated with reducing patients’ reliance on opioids.” But the programs were costly to insurers and not profitable for medical facilities. Their disappearance “should be considered a contributory factor in the crisis of diversion and abuse and the associated destruction of lives.”

The book challenges areas of pain management and prescribing practice. A whole chapter is given over to the subject of urine drug testing, which is described as “an important element of an overall opioid-compliance program.” Because misuse of prescription drugs and use of illicit drugs is not uncommon among chronic pain patients, such monitoring is recommended. But the book cautions: “Other clinical indicators are needed before determining if a patient is nonadherent.”

The book concludes with its key idea, that there are no easy solutions:

"Given the complexity of the practice of pain management, the ‘opioid crisis’ cannot be solved, nor can conditions for pain patients be improved, using only simple and direct approaches: one medication, one regulatory policy, one law, or one injection will not be the answer for our chronic pain patients.

The government’s crackdown on drug companies and others in the pharmaceutical industry has had a negligible effect on reducing the morbidity and mortality resulting from the abuse of opioids.”

In other words, the opioid crisis and pain management are sufficiently complex that simple approaches are bound to fail. We need smart approaches. This book does an excellent job outlining the current state of knowledge to inform such approaches.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Rescheduling Hydrocodone May Have Increased Abuse

By Pat Anson, Editor

Four years ago that the U.S. Drug Enforcement Administration ordered the rescheduling of hydrocodone from a Schedule III controlled substance to the more restrictive category of Schedule II.  The move was intended to reduce the diversion and abuse of hydrocodone, which at one time was the most widely prescribed drug in the United States.

It turns out the rescheduling may have had the unintended effect of increasing the diversion and abuse of opioid medication by elderly Americans.

According to a new study by researchers at the University of Texas Medical Branch (UTMB), hydrocodone prescriptions for Medicare beneficiaries declined after the rescheduling, but opioid-related hospitalization of elderly patients increased for those who did not have a prescription for opioids.

"The 2014 federal hydrocodone rescheduling policy was associated with decreased opiate use among the elderly," said lead author Yong-Fang Kuo, PhD, a professor of Preventive Medicine and Community Health at UTMB.

"However, we also observed a 24 percent increase in opioid-related hospitalizations in Medicare patients without documented opioid prescriptions, which may represent an increase in illegal use."

Kuo and her colleagues say Medicare beneficiaries are among the largest consumers of prescription opioids. They speculated that opioid abuse by the elderly may be a coping mechanism to deal with poor health and depression, and that opioid diversion may be a sign of drug dealing.

“An economic purpose may relate to monetary gains from the diversion and sale to others,” Kuo wrote. “It is important for prescribers to understand that their elderly Medicare beneficiaries might be obtaining opioids from sources that are not documented in their medical records. There is a need for additional research on why, where, and how these Medicare enrollees are obtaining opioids.”

The UTMB research team analyzed a large sample of Medicare Part D enrollment and claims data from 2012 through 2015. Their study was published in the Journal of the American Geriatrics Society.

The reclassification of hydrocodone to a Schedule II controlled substance limited patients to an initial 90-day supply and required them to see a doctor for a new prescription each time they need a 30-day refill. Prescriptions for Schedule II drugs also cannot be phoned or faxed in by physicians.

In 2012, over 135 million prescriptions were written in the U.S. for hydrocodone products such as Vicodin, Lortab and Norco.  That fell to 90 million prescriptions by 2016.

Overall Opioid Prescribing Down

Hydrocodone isn't the only opioid medication to see steep declines in prescribing. The volume of opioid prescriptions filled last year dropped by 12 percent, the largest decline in 25 years according to a new report by the IQVIA Institute.  Opioid prescriptions have been falling since 2011, while dispensing of addiction treatment drugs like buprenorphine (Suboxone) and methadone have risen sharply.

“The U.S. opioid epidemic is one of the most challenging public health crises we face as a nation," said Murray Aitken, IQVIA senior vice president and executive director of the IQVIA Institute for Human Data Science.

“Our research and analytics revealed that 2017 saw new therapy starts for prescription opioids in pain management decline nearly 8 percent, with a near doubling of medication-assisted therapies (MATs) for opioid use dependence to 82,000 prescriptions per month. This suggests that healthcare professionals are prescribing opioids less often for pain treatment, but they are actively prescribing MATs to address opioid addiction."

All 50 states and Washington DC had declines in opioid prescribing of 5 percent or more in 2017, with some of the states hardest hit by the opioid crisis -- like West Virginia and Pennsylvania --  showing declines of over 10 percent. Nevertheless, the number of Americans overdosing continues to rise due to increased use of black market drugs like illicit fentanyl, heroin and cocaine, which now account for about two-thirds of all drug deaths.

Painkillers Stolen from Dying Patients

By Melissa Bailey, Kaiser Health News

Nothing seemed to help the patient — and hospice staff didn’t know why.

They sent home more painkillers for weeks. But the elderly woman, who had severe dementia and incurable breast cancer, kept calling out in pain.

The answer came when the woman’s daughter, who was taking care of her at home, showed up in the emergency room with a life-threatening overdose of morphine and oxycodone. It turned out she was high on her mother’s medications, stolen from the hospice-issued stash.

Dr. Leslie Blackhall handled that case and two others at the University of Virginia’s palliative care clinic, and uncovered a wider problem: As more people die at home on hospice, some of the powerful, addictive drugs they are prescribed are ending up in the wrong hands.

Hospices have largely been exempt from the national crackdown on opioid prescriptions because dying people may need high doses of opioids. But as the nation’s opioid epidemic continues, some experts say hospices aren’t doing enough to identify families and staff who might be stealing pills.

And now, amid urgent cries for action over rising overdose deaths, several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.

Blackhall first sounded the alarm about drug diversion in 2013, when she found that most Virginia hospices she surveyed didn’t have mandatory training and policies on the misuse and theft of drugs. Her study spurred the Virginia Association for Hospices and Palliative Care to create new guidelines, and prompted national discussion.

Most hospice patients receive care in the place they call home. These settings can be hard to monitor, but a Kaiser Health News review of government inspection records sheds light on what can go wrong. According to these reports:

• In Mobile, Ala., a hospice nurse found a man at home in tears, holding his abdomen, complaining of pain at the top of a 10-point scale. The patient was dying of cancer, and his neighbors were stealing his opioid painkillers, day after day.
• In Monroe, Mich., parents kept “losing” medications for a child dying at home of brain cancer, including a bottle of the painkiller methadone.
• In Clinton, Mo., a woman at home on hospice began vomiting from anxiety from a tense family conflict: Her son had to physically fight off her daughter, who was stealing her medications. Her son implored the hospice to move his mom to a nursing home to escape the situation.

In other cases, paid caregivers or hospice workers, who work largely unsupervised in the home, steal patients’ pills. In June, a former hospice nurse in Albuquerque, N.M., pleaded guilty to diverting oxycodone pills first by recommending prescriptions for hospice patients who didn’t need them and then intercepting the packages with the intention of selling the drugs herself.

Hospice, available to patients who are expected to die within six months, is seeing a dramatic rise in enrollment as more patients choose to focus on comfort, instead of a cure, at the end of life.

The fast-growing industry serves more than 1.6 million people a year. Most of hospice care is covered by Medicare, which pays for hospices to send nurses, aides, social workers and chaplains, as well as hospital beds, oxygen machines and medications to the home.

There’s no national data on how frequently these medications go missing. But “problems related to abuse of, diversion of or addiction to prescription medications are very common in the hospice population, as they are in other populations,” said Dr. Joe Rotella, chief medical officer of the American Academy of Hospice and Palliative Medicine, a professional association for hospice workers.

“It’s an everyday problem that hospice teams address,” Rotella said. In many cases, opioid painkillers or other controlled substances are the best treatment for these patients, he said. Hospice patients, about half of whom sign up within two weeks of death, often face significant pain, shortness of breath, broken bones, or aching joints from lying in bed, he said. “These are the sickest of the sick.”

Earlier this year in Missouri, government investigators installed a hidden camera in a 95-year-old hospice patient’s kitchen to investigate suspected theft. A personal care aide was charged with stealing the patient’s hydrocodone pills, opiate painkillers, and replacing them with acetaminophen, the active ingredient in Tylenol. Hospice nurses in Louisiana and Massachusetts also have been charged in recent years with stealing medication from patients’ homes.

But many suspected thefts don’t get caught on hidden cameras, or even reported.

In Oxnard, Calif., in 2015, a person claiming to be a hospice employee entered the homes of five patients and tried to steal their morphine, succeeding twice. The state cited the hospice for failing to report the incidents.

In Norwich, Vt., in 2013, a family looked for morphine to ease a dying patient’s shortness of breath. But the bottle was missing from the hospice-issued comfort care kit. The family suspected that an aide, who no longer worked in the home, had stolen the drug, but they had no proof. State inspectors cited the hospice, Bayada Home Health Care, for failing to investigate.

David Totaro, spokesman for Bayada Home Health Care, told KHN that situations like that are “very rare” at the hospice, which takes precautions, such as limiting medication supply, to prevent misuse.

There is no publicly available national data on the volume of opioids hospices prescribe.  But OnePoint Patient Care, a national hospice-focused pharmacy, estimates that 25 to 30 percent of the medications it delivers to hospice patients are controlled substances, according to Erik Jung, a vice president of pharmacy operations.

Jung said company drivers deliver medications in unmarked cars to prevent attempted robberies, which have happened on occasion.

Little Oversight of Hospice Medication

Two recent studies suggest hospice doctors and social workers across the country are not prepared to screen patients and families for drug misuse, nor to address the theft of pain medication.

For family members struggling with addiction, bottles of pills lying around the house can be hard to resist. Sarah B., a 43-year-old construction worker in Vancouver, Wash., said when her father entered hospice care at his home in Oregon, she was addicted to opioids, stemming from a hydrocodone prescription for sciatica.

After he died, hundreds of pills were left on his bedside table. She took them all, enough Norco, oxycodone and morphine to last a month.

“I have some shame about it,” said Sarah, who declined to give her full last name because of the nature of her actions.

Sarah, who was one of her father’s primary caretakers, said the hospice “didn’t talk about addiction or ask if any one of us were addicts or any of that.”

“No one gave us instructions on how to dispose of all the medications that were left,” she added.

Medicare requires hospices to establish a safe way to administer drugs to each patient — by identifying a reliable caregiver, staff member or volunteer to manage the drugs or, if need be, relocating the patient. And it requires hospices to set policies, and talk to families, about how to safely manage and dispose of medications.

But there’s little oversight: Unlike nursing homes, hospices may go years without inspection, and even when they are cited for noncompliance, they rarely face any consequence except coming up with a plan to improve.

And in most states, hospices have little control over the pills after a patient dies. The U.S. Drug Enforcement Administration encourages hospice staff to help families destroy leftover medications, but forbids staff from destroying the meds themselves unless allowed by state law. Leftover pills belong to the family, which has no legal obligation to destroy them or give them up.

However, some states are taking action. In the past three years, Ohio, Delaware, New Jersey and South Carolina have passed laws giving hospice staff authority to destroy unused drugs after patients die. Similar bills moved forward in Illinois, Wisconsin and Georgia this year.

In Massachusetts, one of the states hit hardest by drug overdose deaths, VNA Care Hospice and Palliative Care advises families to empty leftover pills into kitty litter or coffee grounds before disposal — a common practice to prevent reuse, since flushing them down the toilet is now considered environmentally hazardous.

But families “don’t have to comply,” said VNA Care medical director Dr. Joel Bauman. “Our experience is maybe only half do. We don’t know what happens to these medications. And we have no right, really, to further inquire.”

Hospices across the country told KHN they take precautions, including counting pills when nurses visit the homes, limiting the volume of each drug delivery, giving families locked boxes for medication and giving patients random urine tests. They also said they prescribe medications that are harder to misuse, such as methadone.

Some, like VNA Care, have also started screening families of patients for history of drug addiction, and writing up agreements with families outlining the consequences if drugs go missing.

But “there’s so much moral distress” about punishing dying patients for family members’ actions, said Bauman. He said he tries to avoid doing that: “Why should we fire a patient for having inappropriate pill counts, when it may not be their fault in the first place?”

Though Blackhall helped spark a national discussion about hospice drug diversion, she said she’s also worried about restricting access to painkillers. Hospices must strike a balance, she said.

“It’s important to treat the horrible suffering that people have from cancer,” said Blackhall. But substance abuse is another form of suffering which is “horrible for anyone in the family or community that might end up getting those medications.”

Kaiser Health News (KHN), a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.