Rx painkiller supplies, dosages soaring

Supplies of prescription painkillers have increased exponentially since the late 1990s, when regulations governing their use were relaxed.

In Washington, for instance, the volume of methadone distributed from manufacturers to hospitals and pharmacies grew by nearly 975 percent between 1997 and 2004, according to federal Drug Enforcement Administration statistics. Oxycodone supplies surged by nearly 600 percent, state researchers noted.

The methadone figures don’t include use of the drug for rehabilitating addicts in places such as the methadone clinic run by the Spokane Regional Health District. The drugs used there come in a liquid form aimed at thwarting illegal distribution.

In the late 1990s, methadone was approved as a prescription painkiller. Since then, it has become the drug cited most often in opiate-related deaths, noted Jennifer Sabel, an epidemiologist with the Washington state Department of Health.

The increase in drug distribution was driven, in part, by advocates for people with chronic pain, who argued that opiates provided safe, humane treatment with low risk of addiction, said Dr. Gary Franklin, medical director for the Washington state Department of Labor and Industries.

Researchers have discovered, however, that people using opiates for chronic, non-cancer pain have developed growing tolerances for the drugs. Equally alarming, some patients have found that very high doses of opiates actually make them hypersensitive to pain.

Franklin conducted a study of workers’ compensation patients, showing that the average daily dose of the most potent long-acting opiates had increased by 50 percent between 1996 and 2002, to 132 milligrams a day.

Even that figure has been eclipsed, Franklin said recently. The average daily dose for many clients is now up to about 250 milligrams a day, with some users routinely ingesting 400 to 500 milligrams.

“That is absolutely huge,” said Dr. Kim Thorburn, former health officer for the Spokane Regional Health District. “By comparison, in a naïve young woman not used to those drugs, even 10 milligrams can make her really sick.”

One remedy may be a pilot effort, led by Franklin, to provide new opiate guidelines for doctors who treat pain patients through state-run programs.

“The vast majority of people who are getting into trouble with prescriptions are getting into the drugs without any guidance,” he said.

Under a plan scheduled for release in March, doctors will be urged to think twice when daily doses reach 120 milligrams of morphine or its equivalent, and to seek advice from pain management specialists if that level poses a problem.

A second part of the plan offers guidelines to help taper drug dosages that exceed the 120 milligram mark if patients’ pain and function doesn’t improve.

Franklin stressed that the guidelines are an educational effort aimed at preventing new patients from becoming too tolerant to drugs, not a mandate to cut doses for existing clients.

“It is the most practical way to get at this rather than causing a ruckus among people who are already on high dosages,” he noted.

Slowing the skyrocketing number of prescription drug deaths will depend on a number of other actions targeting doctors, patients and the public, experts said.

A prescription monitoring program would provide electronic tracking of patients, doctors and pharmacies to help prevent users from accessing multiple drugs from several sources.

A pharmaceutical “take-back” program that allows people to return unused or outdated drugs to general locations is now in pilot stages in Washington. Current laws require unwanted drugs to be returned only to law enforcement. That encourages people to keep drugs around, where they pose a danger, or to flush them into the sewer, where they contaminate water supplies.

But the biggest effort must center on raising public awareness about the dangers of prescription painkillers, experts said.

Parents need to lock drugs away from their teenagers as well as their toddlers. Patients need to check and double-check their drugs, their dosages and any potential interactions. And they need to take the instructions and warnings seriously.

“People don’t understand the combination with alcohol,” Thorburn said.

Even users popping painkillers for the high need a dose of reality. Unintentional drug poisonings are precisely that, she added.

“This is a preventable death.”