In response to an article posted by the American News Report which talked about the remarkable increase in opioid prescriptions, Percy Menzies, President of ARCA and MIRA, followed up with the organization to provide additional insight into the issue. Mr. Menzies was able to point out the differences between variations of the commonly prescribed treatments for detox and rehab for alcoholism and drug addiction focusing on Buprenorphine, Naltrexone, and Suboxone. Available at on the NationalPainReport.com, both articles are posted below.
September 17th, 2013 by Pat Anson, Editor
The prescribing of opioid painkillers by doctors in the United States has nearly doubled over the past decade, according to a large new study that also found the use of safer alternatives for pain treatment was flat or declining.
Researchers at the Johns Hopkins Bloomberg School of Public Health analyzed a nationwide database of outpatient visits to doctors’ offices from 2000 to 2010. About 20% of the visits involved a primary diagnosis of pain.
The overall prevalence of patient-reported pain has not changed during the past decade, although providers’ diagnoses of pain as a primary complaint nearly doubled,” said G. Caleb Alexander, MD, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness.
“Despite greater recognition of pain by providers and a remarkable increase in opioid prescribing, there was no commensurate increase in the prescribing of non-opioid therapies. This is particularly important because of the variety of alternative pharmacologic treatments available to treat nonmalignant pain.”
Researchers found that 11.3% of the visits in 2000 ended with the prescribing of an opioid pain medicine such as OxyContin or hydrocodone. A decade later the prescribing rate for opioids had grown to 19.6% of visits – a 73% increase.
Over the same period, the prescribing rate for non-opioid analgesics such as acetaminophen, aspirin, and non-steroidal anti-inflammatory medicines (NSAIDs) remained flat at about 29% of visits.
For new cases of musculoskeletal pain, the prescribing rate for non-opioid analgesics fell from 38% in 2000 to 29% in 2010.
“Despite large increases in opioid use, there were not similar increases in the prescribing of alternative analgesics, such as NSAIDs, acetaminophen, and other therapies that may serve as alternatives to prescription opioids. These results are important given the epidemic rates of prescription opioid abuse that have occurred in the context of efforts to improve the identification and treatment of nonmalignant pain,” said Alexander.
“There is little evidence to support any greater safety or effectiveness of opioids over many of these alternative analgesics, particularly with respect to functional outcomes and longer term use.”
The study by Alexander and his colleagues is one of the first to focus on trends in pain treatment in outpatient office and clinic visits.
“The majority of pain medications are prescribed by primary care physicians, who treat over half of the chronic pain patients in the United States. Pain specialists only treat a fraction of these patients,” said Matthew Daubresse, MHS, who is lead author of the study being published in the October issue of the journal Medical Care.
About 100 million adult Americans suffer from chronic pain. In recent years there has been a growing awareness in the medical community about the prevalence of pain. That awareness has coincided with a sharp increase in opioid use and abuse. By 2010, over 5 million people aged 12 years and older reported the non-medical use of pain relievers.
“We found that not only have the rates of treated pain not improved, but in many cases, use of safer alternatives to opioids, such as medicines like ibuprofen and acetaminophen, have either stayed flat or declined,” says Alexander. “This suggests that efforts to improve the identification and treatment of pain may have backfired, due to an over-reliance on prescription opioids that have caused incredible morbidity and mortality among patients young and old alike.”
“Policy-makers, professional organizations, and providers should re-evaluate prior efforts to improve the identification, treatment and management of non-malignant pain and promote approaches that adequately reflect the importance of non-opioid and non-pharmacologic treatments.”
September 23rd, 2013 by Pat Anson, Editor, The National Pain Report
A drug increasingly being used to treat opioid addiction may be fueling a new epidemic of diversion, overdose, addiction and death in the United States.
The drug’s name is buprenorphine, but it is more widely known by its brand name – Suboxone – which for many years was sold exclusively by Reckitt-Benckiser, a British pharmaceutical company. Since Reckitt’s patent on Suboxone expired in 2012, several other drug makers have rushed to introduce their own formulations – hoping to grab a share of the $1.5 billion market for Suboxone in the U.S.
Two generic versions of buprenorphine were introduced earlier this year. And this month a Swedish drug maker began selling a menthol flavored tablet – called Zubsolv – that is designed to mask the bitter taste of buprenorphine. Other formulations of the drug include a film strip that dissolves under the tongue and a buprenorphine skin patch. One company is even developing a buprenorphine implant to be inserted under the skin.
“This is insanity,” says Percy Menzies, a pharmacist and addiction expert. “Buprenorphine is one of the most abused pharmaceuticals in the world.”
“We took an abused drug and we said let’s use it to treat addiction to heroin and opiates.”
Last year patients filled about 9 million prescriptions for Suboxone or buprenorphine products, many may not realizing they were taking another opioid to treat their opioid addiction.
Buprenorphine is a narcotic, a powerful and potentially addicting painkiller that was first approved as a treatment for opioid addiction in the U.S. in 2002. When combined with naloxone to make Suboxone, the two drugs can be used to help wean addicts off opioids such as heroin, Vicodin, OxyContin, and hydrocodone.
Naloxone blocks opioid receptors in the brain and will trigger sudden withdrawal symptoms when injected. It is added as deterrent to prevent addicts from injecting Suboxone. When taken as a pill, naloxone is not absorbed into the body.
Over three million Americans with opioid dependence have been treated with Suboxone. Although praised by addiction experts as a tool to wean addicts off opioids, some are fearful the drug is overprescribed and misused.
A report by the Substance Abuse and Mental Health Services Administration (SAMHSA) found a ten-fold increase in the number of emergency room visits involving buprenorphine. Over half of the 30,000 hospitalizations in 2010 were for non-medical use of buprenorphine.
How many died from buprenorphine overdoses is unknown, because medical examiners and coroners do not routinely test for the drug.
“Suboxone is a fantastic detox agent. But you have to use it with great caution as a long term maintenance medication. In my clinic we use a lot of Suboxone, but only for detox,” says Menzies, who is president of Assisted Recovery Centers of America, which operates four addiction treatment centers in the St. Louis, Missouri area.
The problem with Suboxone, according to Menzies, is that many addicts have learned they can use the medication, not to treat their addiction, but to maintain it. Suboxone won’t get them “high” but it will help them smooth out withdrawal symptoms between highs.
“For a drug addict, the most uncomfortable, painful problem of their addiction is withdrawal. If I can somehow control my withdrawal, then I have complete freedom to use heroin,” Menzies toldNational Pain Report.
“It’s a perfect formula for drug addiction. They have very little interest in getting off the drug. Suboxone, in my estimation, has allowed a very significant number of people to maintain their addiction.”
“This was great drug for its intended use,” says Charlie Cichon, executive director of the National Association of Drug Diversion Investigators, a non-profit that educates health care providers about drug abuse and diversion.
“But the abusers found out that this was another drug that they liked. It’s not a drug that gets them on that high plain like the other drugs that they abuse. But if they can’t get that drug that they like, Suboxone is readily available and it keeps them at this mellow stage until they can get the next drug.”
Suboxone is so popular with addicts that it has turned into a street drug – to be bartered or exchanged for money, heroin or other illegal drugs. According to one estimate, about half of the buprenorphine obtained through legitimate prescriptions is either being diverted or used illicitly.
“We joke that there’s more Suboxone on the street than in pharmacies. Most of the heroin dealers are diversified now. They offer you a choice of Suboxone and heroin. And now with all these generic forms coming out, that is going to explode,” says Menzies.
“My concern is that, just as what happened with chronic pain, we had an explosion of generic oxycodone and hydrocodone being introduced. And look at the mess we had. We’re going to see the same thing happen with Suboxone and buprenorphine generic preparations.”
Drug makers are well aware of the potential for diversion and tampering. Orexo, the maker of menthol flavored Zubsolv, is selling the tablets in single dose “blister” packaging designed to reduce accidental ingestion by children.
And Reckitt-Benckiser, which took its Suboxone tablets off the U.S. market last year, now only sells Suboxone in individually wrapped film strips.
But experts say no amount of preparation and packaging can outsmart a determined drug abuser.
“When they had the pills available, the abusers would crush the Suboxone pills and make a yellow paste out of it,” says Chicon, explaining that the “paste” was sometimes smuggled into prisons after it was smeared on the pages of children’s coloring books.
“They’d have their little kids color in Mickey Mouse with crayons and they’d send the coloring book to prison to daddy or mommy. Daddy or mommy would know the pages that the Suboxone paste is on and they’d suck it or they’d sell it into the prison system,” Chicon told National Pain Report.
“Now they’re taking the yellow strips and they’re just taping them onto the pages as yellow squares or rectangles and then coloring around it. I have a coloring book page that has these strips on it that they’re getting into the prison systems. The abusers are always another step ahead of law enforcement.”
But the potential for abuse and diversion is no reason to stop treating addicts with buprenorphine, according to a commentary published in the journal JAMA Internal Medicine that calls for a “balanced approach” to the drug.
“Buprenorphine can and does cause harm, but those harms are outweighed by the serious health consequences and fatalities associated with opioid addiction itself,” wrote Robin E. Clark, PhD, and Jeffrey D. Baxter, MD, of the University of Massachusetts Medical School.
“Rather than overreacting to reports of buprenorphine diversion, policymakers should consider the actual harms that diversion may cause. Placing buprenorphine in the same category with more addictive and risky opioids distorts public policy and impedes effective treatment. Better education of prescribers and patients about the dangers of accidental ingestion by children, continued improvements in packaging and formulation of buprenorphine, and careful monitoring by prescribers and policymakers are all essential.”
Over 20,000 physicians in the U.S. are certified to prescribe buprenorphine. Percy Menzies wonders how many really understand the risks posed by buprenorphine.
“The Suboxone doctors, many of them have been very irresponsible, because they have no training in addiction,” Menzies says, explaining that the training often only amounts to a few hours of online education.
“It is shocking in this day and age that physicians are so incredibly ignorant about the pharmacology of buprenorphine preparations.”