Blog | Friday, September 13, 2013

Liquid gold

Barry Meier is a journalist for the New York Times. [That’s one of those newspaper thingies that people of a certain age still read.] He recently wrote an e-book about abuse of prescription drugs called A World of Hurt: Fixing Pain Medicine’s Biggest Mistake. It seems to be selling well.

His reporting and his book highlight the growing U.S. death rate from overdose of prescription pain medicine. He’s definitely entered the fray—some people applaud him as identifying a systemic problem (with some egregious bad actors); others view him as having muddled the issues and assigning blame without enough in-depth analysis. One negative reviewer summed up his disappointment with the book this way: “What I got was a jeremiad against the doctors and pharmaceutical companies that was loosely based on a couple of research studies with very specific data that had little general application despite the author’s attempt to do so.” Ouch.

In spite of some loud criticism, Meier stays on the beat. He recently wrote an article with some interesting information; namely, that in the last two decades, the U.S. market for urine drug testing has more than doubled, to over $2 billion dollars annually.

The rise mirrors the growth in the prescribing and availability of opioid (morphine-like) prescription pain medication. Why so much money in urine drug testing?

Doctors use urine drug testing for at least two reasons:

1) To assure “good behavior.” Many offices and clinics that prescribe narcotics seek to make sure that patients are not taking illicit (or non-prescribed) substances. Doing so can result in dismissal from such clinics for ‘aberrant behavior.’

2) To assess adherence: If you prescribe narcotic pain medication, you want to be sure that your patient is actually taking the medication as prescribed. If I prescribe Oxycontin for someone but there’s no evidence of it in their system, how do I know they’re not selling it on the street (what’s known in the trade as diversion)?

All of that aside, shouldn’t we simply trust our patients when they tell us they’re in pain, and let the authorities handle the law enforcement side of things? No one likes to be swindled, but is it really the doctor’s role to patrol for potential criminal behavior?

I will say this. I know that I’ve had patients for whom I’ve prescribed opioids divert them. I would never do it knowingly. But the economy’s bad. Selling controlled prescription drugs is a source of income for people without employment or marketable skills. In the fancy world, it’s called arbitrage. If I’m lucky enough to have insurance (e.g. Medicaid) pay for all or 95% of my monthly narcotic prescription, then I can go out and sell the pills for cash. Easy money. Even if I pay full price at the pharmacy, I can still get a markup on the street.

I’d love to see conclusive research on how many of the patients who obtain chronic narcotic prescriptions divert them. We have estimates, but really no clear idea. I’m guessing it’s a much bigger problem than we know of or that anyone would care to admit.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.