| May 22, 2012
We've heard statistics again and again - a small percentage of physicians are responsible for a large percentage of prescribing specific drugs. Earlier this month, the Wall Street Journal reported that 15% of NYC prescribers wrote 80% of opioid prescriptions in 2010, and that 1% of prescribers wrote 31% of opioid prescriptions. Among these prescribers, the Journal noted, oxycodone prescriptions rose by 86%.
The popular sentiment appears to be that these prescribers are doing something wrong. But as ASAM Member Michael Miller, MD, pointed out at a lecture during our recent conference, the statistics themselves prove nothing. If we looked, for example, at chemotherapy, it is likely that a very small percentage of prescribers write prescriptions for nearly all the medication prescribed. Prescription numbers may rise because of improved identification of disease that will respond to medication, or because of improved education of physicians as to how to prescribe a given drug.
I'm not arguing that this is the case with the increase in opioid prescriptions over the past years, but I am pointing out the critical nature of our using good science upon which to base our decision-making process. How our country should respond to the over-prescribing of opioid agents should be based on a scientifically sound process; a knee-jerk response that simply bans the prescribing of opioids or limits the prescribing to a fixed number of individuals per physician would result in suffering for those patients who need opioid treatment.
And here is where we get to the interesting part; we haven't seen any significant measures being taken along these lines except for a single drug: buprenorphine/naloxone. For this drug, we've seen limitations being imposed in situation after situation, from federal limits to state limits to insurer limits. Most recently, Kentucky's Medicaid provider, Coventry Cares, informed their members taking Suboxone that it would no longer cover the drug after the current prescription ended. Legal action was threatened and discussions ensued. KYSAM, our Kentucky chapter, was in the midst of it. And fortunately, after a few days, Coventry agreed to continue providing Suboxone coverage.
But we're not out of the woods in Kentucky yet. It still seems probable that some dosing limitations may be imposed as in neighboring West Virginia. In WV, patients on Medicaid are limited to a once per lifetime 60 day 24mg qd dosing, after which their maintenance dose is capped at 16mg. Maine Medicaid also has such a limitation. And in the meantime, we all remain confined to treating only 100 patients with a medication that has demonstrated value.
To recap, we have dozens of opioids and sedative-hypnotics which can be prescribed without any apparent limitation. I can prescribe high dose Vicodin and Klonopin to dozens of patients a day without significant fear of a DEA audit, without any limit to number of patients, and without any dosage limit. So why, when we have a reasonably safe drug which is nearly impossible to overdose on, which has a lower street value than other narcotics, and which is used to deal, in part, with the increasing fallout of overprescribed opioids, does this specific drug keep getting beaten on? I can think of only one reason - discrimination against addicts.
As a result of this discrimination, we have waiting lists that are triple the number of patients that we treat, we have guaranteed unannounced DEA audits in the midst of patient hours, and we have patients who are not allowed to fill their properly prescribed treatment under their insurance program because of economically and politically driven dosing decisions made by non-physicians.
These issues will largely be addressed on a state-by-state basis. ASAM depends upon its state chapters both for early alerts regarding new regulations and procedures impacting addiction treatment, and for response and testimony. Please stay active and in close touch with your state chapter leadership.