A twice-daily, extended release, abuse deterrent formulation of oxycodone, to be exact. And just in time, too. I was becoming concerned that FDA's recent commitment to take a new approach to the opioid crisis might have actually been genuine. I guess you can't have too much of a good thing.
The trade name you'll want to look out for is Xtampza ER. And no, I didn't misspell it. Wondering how to pronounce it? Your guess is as good as mine. The pharma industry appears to be running low on catchy, hip drug names with the letters "x" and "z" that play well in the market. Someday soon, we're going to see a drug called Xyz ER. You won't see Xtampza pop up right away - Purdue (makers of Oxycontin) are (predictably) suing Collegium (makers of Xtampza) for patent infringement (because, really, how many extended-release, abuse-deterrent formulations of oxycodone do we need?) But alas, Collegium appears to have a solid case: you can open up Xtampza capsules and sprinkle the oxycodone on your food without sacrificing its abuse deterrent properties. Science!
First, let's talk mandatory physician education. While you probably hadn't yet heard of Xtampza, you can be excused for that lack of awareness given that you likely have neither the authority nor the inclination to prescribe it. But the doctors who can prescribe it are going to learn about it from the sales reps who are pushing it. We can do better than that. We need to do better than that.
And to celebrate the advent of every new abuse-deterrent opioid formulation, I like to remind readers of this blog, both new and returning, that abuse-deterrence is a tool, not a solution. As I have written before, but share again here:
I am 100% supportive of abuse-deterrent formulations of prescription opioids. These formulations are effective in combating abuse and diversion (at least in the short-term - it seems drug addicts often find a way to crack the code of each newly formulated medication. But that doesn't mean we should stop trying, nor does it mean we should eliminate the economic incentive for the pharmaceutical companies to develop such technology).
To me, though, this conversation is a distraction. While eliminating abuse and diversion would be great for the work comp system, these aberrant behaviors are not driving the bulk of the problem. The vast majority of cases in which PRIUM intervenes involve legitimate prescriptions being taken as prescribed. Very little pill crushing. Very little intravenous injections. Very little drug dealing.
The problem as we see it is lack of medical necessity. In most cases, it doesn't matter if the patient's opioid is abuse-deterrent or not. If it's medically unnecessary, if it's leading to loss of function, if it's leading to dependence and addiction... it needs to go away. The doctor will be better educated. The patient will get better. The cost of care will go down. Everyone wins.
Abuse deterrent technology is great, but if we focus on technology over medical necessity, we will have missed the mark and the crisis will continue.
Michael
On Twitter @PRIUM1
Showing posts with label opioid abuse. Show all posts
Showing posts with label opioid abuse. Show all posts
Monday, May 2, 2016
Monday, April 25, 2016
A Wake Up Call for Employers: One-Third of Opioid Scripts Are Being Abused
Castlight, a health benefits platform provider focused on self-insured employers, published a report last week on the opioid crisis. The authors were able to take a unique look at the problem through the lens of current data from self-insured employer clients (vs. latent data from public sources).
Lots of interesting data in the report, but here's the headline:
1 out of every 3 opioid prescriptions is being abused.
I had three reactions, in the following order:
First, I knew that number would seem astronomically large to most people ("Seriously, one-third of all opioid scripts are being abused? How can that be?") Fact is there are more sad opioid statistics than most people realize. It is the disease of not listening. While it makes for admittedly depressing cocktail party conversation, it is a predictable interchange. People know there's an issue... they just don't realize how broad and deep it goes.
Second, I personally thought that number seemed low. While I recognize PRIUM's data is somewhat skewed by our focus on chronic and sub-acute pain (vs. acute pain), our physician consultants conclude that approximately 70% of the the medications we review are not medically necessary based on evidence based guidelines. I recognize that "lack of medical necessity" and "abuse" are two different phenomenon, but when it comes to opioids specifically, the former tends to lead to the latter. So I thought 1/3 was low.
And that led me to my third reaction: How did Castlight define "abuse"? They're looking at de-identified diagnosis and prescription data. I wondered what methodology they used to identify opioid abuse.
Page 12 of the report details their approach:
Excluding cancer diagnoses and hospice care, Castlight defined abuse as meeting both of the following conditions:
Lots of interesting data in the report, but here's the headline:
1 out of every 3 opioid prescriptions is being abused.
I had three reactions, in the following order:
First, I knew that number would seem astronomically large to most people ("Seriously, one-third of all opioid scripts are being abused? How can that be?") Fact is there are more sad opioid statistics than most people realize. It is the disease of not listening. While it makes for admittedly depressing cocktail party conversation, it is a predictable interchange. People know there's an issue... they just don't realize how broad and deep it goes.
Second, I personally thought that number seemed low. While I recognize PRIUM's data is somewhat skewed by our focus on chronic and sub-acute pain (vs. acute pain), our physician consultants conclude that approximately 70% of the the medications we review are not medically necessary based on evidence based guidelines. I recognize that "lack of medical necessity" and "abuse" are two different phenomenon, but when it comes to opioids specifically, the former tends to lead to the latter. So I thought 1/3 was low.
And that led me to my third reaction: How did Castlight define "abuse"? They're looking at de-identified diagnosis and prescription data. I wondered what methodology they used to identify opioid abuse.
Page 12 of the report details their approach:
Excluding cancer diagnoses and hospice care, Castlight defined abuse as meeting both of the following conditions:
- Receiving greater than a cumulative 90-day supply of opioids; AND
- Receiving an opioid prescription from four or more providers over the 5 year period between 2011 and 2015.
Let's acknowledge that this is, at best, a proxy for abuse. Might there be patients who are defined as "abusers" in the Castlight data who are not, in fact, opioid abusers? Is it possible that a patient could receive opioid scripts from 4 or more docs over 5 years and not be an abuser? Of course it's possible.
But I think the Castlight approach is actually quite conservative. Using a cut off of 4 prescribers likely leaves out a material number of patients who are abusing opioids but happen to secure their prescriptions regularly from as few as a single provider. By the way, Castlight doesn't capture work comp data. So we know (unfortunately) that 1/3 statistic is low.
A wake up call for self-insured employers? Hopefully.
Michael
On Twitter @PRIUM1
Tuesday, March 29, 2016
President Obama at the National Rx Drug and Heroin Abuse Summit
Imagine getting the chance to hear the President speak in person.
Now imagine he comes to your home town to offer some thoughts on a given topic.
Finally, imagine the topic of his remarks is the very center of your professional life and something you eat, sleep, and breathe every day.
That was my day today.
As my legendary 12th grade English teacher Ross Friedman would say: today was a 9.9 on the groovy scale (note: there are no 10s... so this was clearly a really great day).
President Obama came to Atlanta today to talk about prescription drug and heroin abuse. Rather than give a speech from a prepared text, he sat on a panel moderated by CNN's Dr. Sanjay Gupta along with two recovering addicts and an emergency room doctor who also serves as Baltimore City's Health Commissioner, Dr. Leana Wen (who, by the way, proved to be an incredible advocate for changing the way we view chronic pain and addiction... she issued a standing order in Baltimore so that any citizen in the city can secure a Naloxone prescription - an overdose antidote - under her name. Just walk into any pharmacy in Baltimore and pick it up. Beat that with a stick).
This format enabled President Obama to speak extemporaneously and candidly on a range of topics under the umbrella of prescription drug and heroin abuse. He talked about the Affordable Care Act, mental and behavioral health, criminal justice reform, patient and physician education, addiction prevention, treatment, and recovery. While I'm not supposed to betray my personal politics on the blog (at least according to my PR advisers), most people who know me know that I'm a fan of the president. Despite my admitted admiration for Obama, I expected today to be filled with presidential sounding platitudes like "we need more addiction treatment in this country" and other relatively obvious and safe statements. And he said most of the things I expected him to say along those lines.
But he said more than that. My impression is that President Obama understands both the policy nuance and personal tragedy of this issue at a level I honestly didn't expect. This is a guy fighting multiple battles against an array of terrorist organizations, he's steeped in a Supreme Court nomination fight, he's trying to figure out how and where to weigh in on the circus that has become the 2016 presidential election, and he's dealing with a hundred other issues on a daily basis. But he came to Atlanta today to talk about prescription drug and heroin abuse. And amidst all of the other issues on his desk, it's evident that he gets this. And it shows.
When asked by Sanjay Gupta what brought him to Atlanta this afternoon, President Obama offered this: "When I show up, the cameras usually do, too." He wasn't being arrogant. He was suggesting that his mere presence, regardless of what he said, helps bring needed attention to this critical issue. He was saying that he consciously chose to use the power of his office to shine a light on prescription drug and heroin abuse. And he's right - there certainly were a lot of cameras there today.
He said "we need to think about this [drug abuse issue] as a public health problem, not a criminal justice problem." Many of us close to this issue agree with that statement, but when the President of the United States says it out loud, it reshapes the broader public dialogue and helps further the aims of those of us who have been thinking that way for years. Such a public statement will help reshuffle the priorities of agencies like the FBI, DEA, ATF, CDC, and NIH.
He said he was "shocked to learn how little education medical residents receive in pain management." And as a result, 60 medical schools announced today their intention to significantly enhance pain management training in medical school residency programs. The bully pulpit is real.
Finally, he said "we medicate... self-medicate... a lot of problems in this country." I was floored when he said that. We know that's true, he knows that's true, but for the president to say it out loud is to acknowledge the fundamental need for cultural change necessary to truly stem the tide of prescription drug and heroin abuse. Perhaps the most deeply rooted of all the root cause issues behind prescription drug abuse is the notion that Americans expect to be pain free, stress free, anxiety free. Opioids aren't ragingly popular simply because they help manage pain. Opioids also have psychoactive attributes that make the slings and arrows of our difficult and complicated lives seem easier to handle. And President Obama said it. And that matters.
Today was a great day for me, personally and professionally. I think today might also turn out to be a great day in the broader fight against prescription drug misuse and abuse. And that's a great day for all of us.
Michael
On Twitter @PRIUM1
Now imagine he comes to your home town to offer some thoughts on a given topic.
Finally, imagine the topic of his remarks is the very center of your professional life and something you eat, sleep, and breathe every day.
That was my day today.
As my legendary 12th grade English teacher Ross Friedman would say: today was a 9.9 on the groovy scale (note: there are no 10s... so this was clearly a really great day).
President Obama came to Atlanta today to talk about prescription drug and heroin abuse. Rather than give a speech from a prepared text, he sat on a panel moderated by CNN's Dr. Sanjay Gupta along with two recovering addicts and an emergency room doctor who also serves as Baltimore City's Health Commissioner, Dr. Leana Wen (who, by the way, proved to be an incredible advocate for changing the way we view chronic pain and addiction... she issued a standing order in Baltimore so that any citizen in the city can secure a Naloxone prescription - an overdose antidote - under her name. Just walk into any pharmacy in Baltimore and pick it up. Beat that with a stick).
This format enabled President Obama to speak extemporaneously and candidly on a range of topics under the umbrella of prescription drug and heroin abuse. He talked about the Affordable Care Act, mental and behavioral health, criminal justice reform, patient and physician education, addiction prevention, treatment, and recovery. While I'm not supposed to betray my personal politics on the blog (at least according to my PR advisers), most people who know me know that I'm a fan of the president. Despite my admitted admiration for Obama, I expected today to be filled with presidential sounding platitudes like "we need more addiction treatment in this country" and other relatively obvious and safe statements. And he said most of the things I expected him to say along those lines.
But he said more than that. My impression is that President Obama understands both the policy nuance and personal tragedy of this issue at a level I honestly didn't expect. This is a guy fighting multiple battles against an array of terrorist organizations, he's steeped in a Supreme Court nomination fight, he's trying to figure out how and where to weigh in on the circus that has become the 2016 presidential election, and he's dealing with a hundred other issues on a daily basis. But he came to Atlanta today to talk about prescription drug and heroin abuse. And amidst all of the other issues on his desk, it's evident that he gets this. And it shows.
When asked by Sanjay Gupta what brought him to Atlanta this afternoon, President Obama offered this: "When I show up, the cameras usually do, too." He wasn't being arrogant. He was suggesting that his mere presence, regardless of what he said, helps bring needed attention to this critical issue. He was saying that he consciously chose to use the power of his office to shine a light on prescription drug and heroin abuse. And he's right - there certainly were a lot of cameras there today.
He said "we need to think about this [drug abuse issue] as a public health problem, not a criminal justice problem." Many of us close to this issue agree with that statement, but when the President of the United States says it out loud, it reshapes the broader public dialogue and helps further the aims of those of us who have been thinking that way for years. Such a public statement will help reshuffle the priorities of agencies like the FBI, DEA, ATF, CDC, and NIH.
He said he was "shocked to learn how little education medical residents receive in pain management." And as a result, 60 medical schools announced today their intention to significantly enhance pain management training in medical school residency programs. The bully pulpit is real.
Finally, he said "we medicate... self-medicate... a lot of problems in this country." I was floored when he said that. We know that's true, he knows that's true, but for the president to say it out loud is to acknowledge the fundamental need for cultural change necessary to truly stem the tide of prescription drug and heroin abuse. Perhaps the most deeply rooted of all the root cause issues behind prescription drug abuse is the notion that Americans expect to be pain free, stress free, anxiety free. Opioids aren't ragingly popular simply because they help manage pain. Opioids also have psychoactive attributes that make the slings and arrows of our difficult and complicated lives seem easier to handle. And President Obama said it. And that matters.
Today was a great day for me, personally and professionally. I think today might also turn out to be a great day in the broader fight against prescription drug misuse and abuse. And that's a great day for all of us.
Michael
On Twitter @PRIUM1
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