Calif. Counties Declare a Different "War on Drugs"

Drug overdose is the leading cause of injury-related death among Americans. While a portion of overdose deaths result from recreational drug use, a growing body of research points to prescription drugs--particularly opioids-- as an equally significant culprit.

Treatment of pharmaceutical overdoses places a major financial strain on the American health care system.

Two California counties recently moved to address this rising problem by attacking it at the source: they sued six opioid manufacturers for deceptively promoting opioids to practitioners and to vulnerable patient populations.

Filed last May by the Orange County District Attorney and the Santa Clara County Counsel, the new lawsuit targets nine opioid pharmaceutical manufacturers, arguing that the companies encourage opioid treatment for conditions outside the drugs' FDA-approved use, and that the companies' marketing programs deliberately downplay the risk of addiction and overdose.

Originally intended for pain management in cancer and end-of-life care, the use of opioids has since expanded into a significantly larger market of chronic pain patients.

Awash in Opioids

Due to drug manufacturers' aggressive marketing tactics, the suit claims, the US is now "awash in opioids."

OpioidMapOpioidMapIt notes that, "in 2010, 254 million prescriptions for opioids were filled in the US – enough to medicate every adult in America around the clock for a month. Twenty percent of all doctors' visits result in the prescription of an opioid (nearly double the rate in 2000). Opioids – once a niche drug – are now the most prescribed class of drugs – more than blood pressure, cholesterol, or anxiety drugs."

It also calls attention to the fact that "in 2009, there were more than twice as many deaths from prescription opioid overdoses (15,597) than from cocaine (4,350) and heroin (3,278) put together."

According to the lawsuit, the drug companies "created campaigns – including literature, websites, community groups, and programs – related to chronic non-cancer pain from illnesses such as low back pain, shingles, migraines, osteoarthritis, phantom limb pain, fibromyalgia and multiple sclerosis."

It alleges that the pharmaceutical companies knowingly disseminated misleading information both to practitioners such as family doctors, as well as to vulnerable patient populations, including veterans and the elderly. The manufacturers' marketing efforts reportedly promoted opioids as a safe, effective treatment for chronic pain, while minimizing their risk of addiction.

It's not exactly news that America has an opioid overuse problem, but the ravages it is causing in cities and towns across the nation are starting to come to light.

The use of opioid analgesics for chronic non-cancer pain has increased dramatically over the past 25 years in North America. Today, the US opioid market exceeds $10 billion annually. And as the use of pharmaceutical pain relievers has increased, so too have the rates of opioid addiction and death due to overdose (Juurlink & Dhalla. J Med Toxicol. 2012; 8(4): 393-9).

The CDC reports that in 2013, out of 43,982 drug overdose deaths in the United States, 22,767 (51.8%) were related to prescription pharmaceuticals. An overwhelming majority of those were attributed to opioid pain relievers. Among the 22,767 prescription-related deaths, 16,235 (71.3%) involved opioid analgesics, while 6,973 (30.6%) involved benzodiazepines. A small number of deaths were linked to more than one type of drug.

In a study published in December 2014 in JAMA Internal Medicine, a team of researchers examined the specific subtypes of opioid overdose that commonly lead to emergency room visits. Michael A. Yokell, Sc.B., and colleagues, of the Stanford University School of Medicine, analyzed 135,971 ER visits for opioid overdose in 2010 using the Nationwide Emergency Department Sample.

They found that prescription opioids, including methadone, were involved in a striking 67.8% of overdose cases. The remaining cases were linked to heroin (16.1% of cases), unspecified opioids (13.4%), and multiple opioid types (2.7%). Of all overdose patients, 50.6% were admitted for inpatient treatment (Yokell et al. JAMA Intern Med. 2014; 174(12): 2034-7).

The study also revealed high rates of several comorbidities within the sample population. In addition to substance use, 33.9% of overdose patients presented with chronic mental illness, 29.1% with circulatory disorders, and 25.6% with respiratory disease.

Of the prescription overdoses evaluated, the greatest proportion occurred in urban areasOxycontin (84.1%), in the South (40.2%), and among women (53%). The researchers observed "marked regional variation in overdose patterns, with the highest burdens of prescription overdose found in the South and West."

In the Stanford study, inpatient and emergency room charges for overdose patients totaled almost $2.3 billion. Its authors argue that opioid overdose, "exacts a significant financial and health care utilization burden."

Prescriber Responsibility

The California lawsuit is just one example of a growing national attention to opioid dependence and overdose as significant public health concerns.

Noting that the majority of patients in their sample overdosed on pharmaceuticals, the authors of the Stanford opioid study described the phenomenon as a "prescription opioid overdose epidemic." They concluded that "strategies to reduce morbidity and mortality resulting from overdose are urgently needed."

First and foremost, healthcare practitioners need to understand the signs of opioid dependence and advise all patients about the risks of addiction and overdose when prescribing opioid drugs.

Expanded access to effective addiction treatment programs must also be part of a national plan to address the overdose epidemic.

Additionally, because acute benzodiazepine intoxication was identified in 22.2% of all overdose patients, Yokell and colleagues suggest that practitioners exercise great caution when prescribing opioids in conjunction with other sedating medications. Similarly, take great care when providing opioid painkillers to patients with other coexisting conditions.

The dangers of prescription drug dependence are well established and can be reduced in large part through responsible prescribing. On a larger scale, others may be encouraged by California's example to enact plans that minimize opioid use at local or statewide levels.