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Prescription for Abuse: The Progression of Prescribing Opiates in Washington State

JAN. 27, 2012
ByEthan Morris
KCTS 9 Executive Producer of Public Affairs

Ethan Morris

Insiders in the health and medical community refer to it as “The Change.”

In the mid-1990s, the State Medical Quality Assurance Board issued a new directive. Doctors, they said, were under-treating pain. They urged physicians to begin using opioids – semi-synthetic forms of opium such as hydrocodone (Vicodin) and oxycodone (OxyContin) – which, up until then, had only been used for the most severe types of pain associated with cancer and end-of-life. Now, doctors were encouraged to use them for chronic and acute pain too.

The medical community responded. “Dramatic, dramatic increases,” says Caleb Banta-Green, an epidemiologist with the University of Washington’s Alcohol and Drug Abuse Institute. “In Washington state, we’ve gone from about 10 million daily doses of hydrocodone – Vicodin – to about 45 million daily doses of that one medicine, just in Washington state, so there are enormous increases in the medication being prescribed and used.”

Those enormous increases have had an unintended result. More prescriptions has meant more people using. More people using has meant more people abusing. More people abusing has meant more overdoses. More overdoses and more deaths. In 2008, more than 500 people died of a prescription pain medication overdose – more than died in car accidents.

“Prescription opiates are quite widely available and accessible. One in five adults is prescribed an opiate every year in the United States. One in ten adolescents is prescribed an opiate every year in the United States. So there’s just a lot of these meds out there and in the community.”

A Clear Direction

To help health professionals, policy makers, and the public understand what is happening, Banta-Green and his collegues at ADAI created a series of maps based on data they have collected from across the state.

The first map gives a snapshot of prescription drug use in 2000. It’s based on amounts of prescription drugs confiscated by police and sent to the State Crime Lab for testing. “A conservative estimate of drug arrests,” Banta-Green says. The areas in green show where there was some drug activity. The darker the green, the more activity. In 2000, most counties had little to no prescription drug use.

But by 2009, the picture has changed dramatically. There’s evidence of heavier prescription drug use in nearly every county in the state. “The directionality’s pretty clear,” Caleb says. “For the prescription type opiates there was basically none in 2000 and in 2010 it’s everywhere.”

Heroin use follows the same trend. In 2000, heroin use is widespread, but the rates are relatively low, fewer than 25 people for every 100,000.

Eight years later, heroin is in all but four counties, with higher rates in rural counties such as Whatcom, Skagit and Grays Harbor. “If you look at 2000, we had heroin up and down I-5 and along I-90 and that was about it,” says Caleb. “In 2010, it’s really expanded. Not everywhere, but it’s expanded into some of the mid-sized cities, places like Port Angeles and Grey’s Harbor and Bellingham.”

Another way Banta-Green looked at the problem is through treatment rates. In 1999, almost no one was being treated for prescription drug addiction in Washington.

But by 2010, all of the counties in dark blue reported major increases in the number of people seeking treatment for opioid dependence.

Two People a Day

By far, the grimmest picture is the comparison of overdose deaths. This map shows the rate of overdose deaths from 2000 to 2002 from either prescription opioids or heroin.

By 2009, the overall number of opiate deaths has doubled.

Caleb Banta-Green: “So what we’re seeing in Washington state, if you look at all opiate drugs, heroin and prescription, we had about 344 [deaths] in 2000, and we had about 722 in 2009. So we’re more than doubling. That’s more than two people a day who are dying with some form of opiate in their system.”

A Lot of Vigilance

Caleb Banta-Green and others at ADAI hope the data they’ve compiled will help bring increased awareness to the prescription drug problem – not just on the part of doctors and regulators, but the public at large.

“You think about the vigilance, all of the tools, all of the devices we have for traffic safety. Everybody locks their kid up in a car seat, everybody puts their kid in a seatbelt, adults have to wear seatbelts, there’s all these requirements to prevent this type of injury. And there are all sorts of laws built around that. And it’s just part of our concept. It’s not something we really even question anymore. But we don’t have the same types of interventions in place for medications.”

Special thanks to Caleb Banta-Green, Meg Brunner, Nancy Sutherland, and everyone at ADAI.


There are 6 Comments

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I am a family physician in practice in Washington for 28 years. I find it ironic that the new legislation requires physicians to refer narcotic-dependant patients to "pain specialist" physicians.
"Pain Specialists" were the Pied Pipers of the escalation of narcotic prescribing in the 1990s. I went to lectures where physicians were told that we were cruel and insensitive if we did not prescribe narcotics whenever patients complained of pain. Nurses and Nurse Practitioners were even more likely to become enmeshed and co-dependant with difficult patients. There was never any more science behind it than there was to blood-letting or applying leeches. WA MQAC should be ashamed of its role.
Now "Pain Specialists" are teaching us that we should be saying "opiods" instead of "narcotics". Why? Patients SHOULD know that Oxycontin IS heroin.
Safe prescribing depends on knowing your patients and watching them closely.

Most PM Doctors know much less than the GP.
I'm 52 with many health issues and my recoveries have always been faster and better with access to higher levels of pain control.
You should always try to fix the source of your pain and ONE doctor with a Patient Advocate as a case manager should be prescribing ALL medications.
There is reason why someone is required to have a prescription for some drugs, my Uncle nearly from died from Prescriptions from multiple Doctors.
Remember Doctors want to, and in most cases should make money. If someone OD's from a doctor's script he could be screwed. But if a Doctor denies Pain Killers to someone with a urgent need of pain control and he walks out the door then has a massive heart attack and stroke as he drives home and kills 5 people, the Doctor is better of as long as no drugs or alcohol is found in his patient





Why is there NO MAP showing how many severe needlessly due to lack of pain control. This is propaganda, without showing the negative side of this issue.
NOW that may upset those getting rich by the suffering and pain of others.


Reply to Ed Champagne--

This is very complicated. Every patient is different. Pain is always "real", but in different ways. Narcotics are always dangerous.

I think that you already identified the best solution - which is long-term experience with a knowledgeable physician who cares about you and will work hard for you.

Sadly, the value of longitudinal care is lost in the current move to practice "by statute" and by MQAC regulation, both of which wave in the current political and cultural winds.

Calling OxyContin the same as heroin is just plain wrong. OxyContin is a legally prescribed medication that is given under careful and constant observation by a doctor trained in treating the patient who finds themself suffering from pain so severe they are unable to work, unable to live a productive life before the pain became the focus of their live's. Heroin is a street drug that varies in strength, varies in adulterants used to make it up, and varies in size of each 'dose' sold. There is no follow up by the dealer, no concern for the well-being of the user, and sold only for the money it brings in. OxyContin is made using strict observation, under tight controls assuring each dose contains the same amount of the active ingredient, tablet after tablet, pill after pill. The same cannot be said about heroin- a street drug that is used only for those wanting an illegal, illicit high. The risk is taking a drug that may not be what it is said to be, as well as contributing to the profits from these illicit drugs going to gangs, cartels and terrorists, both here in the USA as well as overseas. These are vastly different substances; and confusing a public hungry for knowledge is wrong to do.