Here - Arkansas

¡ “Darkness cannot drive out
darkness, only light can do that.
Hate cannot drive out hate, only
love can do that.”
Stephen Loyd, M.D.
Arkansas Prescription Drug Abuse Summit
Little Rock, Arkansas
September 9-10, 2014
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Receives no commercial support, in any form, from pharmaceutical companies or anyone else
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Associate Professor, Department of Internal Medicine, Quillen College of Medicine, East Tennessee State
University; Chief of Medicine and Associate Chief of Staff for Education, Mountain Home VA Medical Center in
Johnson City, Tennessee
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Expert witness, U.S. Attorney, TBI, FBI, DEA, IRS, Commonwealth Attorney Virginia and Kentucky, Virginia State
Police, Tennessee Board of Medical Specialties
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Member, Greene County Drug Court, Judge Kenneth Bailey and member of the National Association of Drug
Court Professionals
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Speaker, Proper Prescribing of Controlled Substances
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Founding Partner and Chairman, Board of Directors, High Point Clinic, a non-profit clinic in Johnson City,
Tennessee, with an interest in opiate addicted pregnant women
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Recovering from addiction to opiates, benzodiazepines and alcohol since July 2004
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Advocate for Proposition 46 in the state of California
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2014 Advocate for Action, Office of National Drug Control Policy, Executive Office of the President of the United
States
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Tennessee Volunteer Fan and Alum and Father to Heath and Hayley and husband of 24 years to Karen
Understand the neurobiological basis of
addictive disease
¡ Overview of prescription drug abuse
¡ Understand why proper prescribing of
controlled substances matters
¡ Over-prescribing case review and potential
for cooperation between law enforcement,
the judiciary and the medical profession
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Retain faith that you will
prevail in the end,
regardless of the
difficulties.
AND at the
same time
Confront the most
brutal facts of your
current reality,
whatever they
might be,
Admiral Jim Stockdale
Collins, J. Good to Great. HarperCollins
Publishers, New York, 2001
¡ “Here is the solution to the American
drug problem suggested by the wife
of our President: “Just Say No.””
Kurt Vonnegut
“How about treatment that works instead of
ridiculous 12-Step AA/NA cult “Higher Power”
nonsense that has a 100% failure rate?”
¡ “Pain management specialist are hard to
come by and not covered by my insurance.
My physicians will not treat my pain properly
and threaten me with no medication.”
¡ “99% of addicts are personality disordered.
They are mentally retarded.”
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Dependence- once the drug is stopped, a
predictable physiological withdrawal
syndrome occurs
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Addiction- the compulsive use, loss of
control and continued use despite adverse
consequences
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Missed opportunity to help patients
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Impact on Healthcare System
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Impact on Criminal Justice System
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Major cause for increasing incidence of heroin
use
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Estimated cost in the United States from nonmedical use of prescription opioids for 2006
$53.4 billion
$42 billion- lost productivity
$8.2 billion- criminal justice costs
$2.2 billion- treatment costs
$944 million- medical complications
Five drugs- Oxycontin, oxycodone,
hydrocodone, propxyphene, and methadone
accounted for 2/3 of the economic burden
▪ Source: Clinical Journal of Pain, December 2010
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From 1999-2009, drug overdose deaths due to
prescription painkillers increased 400%
Overdose fatalities are now the leading cause of
accidental deaths in America, nudging out motor
vehicle crashes
In 2010, about 12 million Americans (age 12 or
older) reported non-medical use of prescription
painkillers in the past year
The United States represents < 5% of the world’s
population but consumes approximately 80% of
the world’s opioid supply
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Healthcare providers wrote 259 million
prescriptions for opioid painkillers in 2012
Highest painkiller prescriptions per person:
Alabama, Tennessee, West Virginia
Highest prescribing states were in the South,
can’t be explained by underlying health status of
the population
“Improving how opioids are prescribed will help us
prevent the 46 prescription painkiller overdose
deaths that occur each day in the United States.”
Daniel Sosin, M.D., Acting Director of CDC’s
National Center for Injury Prevention
Data source: CDC National Center for Injury Prevention and Control ‘Preventing Prescription Painkiller Overdoses’ fact sheet .
Accessed November 2012 at http://www.cdc.gov/injury/pdfs/NCIPC_Overview_FactSheet_PPO-a.pdf
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An estimated 4.25% Tennessee adults (or 201,000 people) used
pain relievers non-medically in the past year. Almost 12% of 18-25
year olds (or about 77,000 people) abused pain relievers
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Tennessee ranks third in the nation for number of prescriptions
written at 17.6 per capita. Prescribing practices in 2010 resulted in
51 pills of hydrocodone, 22 pills of Xanax and 21 pills of oxycodone
for every Tennessean above age 12
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There were 887 prescription drug overdose deaths in Tennessee in
2010, up from 301 deaths in 2001
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Currently losing 3 Tennesseans/day to unintentional drug overdose
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926 babies born with NAS in 2013
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Consider ways to increase the use of prescription
drug monitoring programs
Consider laws and regulation relating to pain
clinics to reduce prescribing practices that are
risky to patients
States need to evaluate their own data and
programs (Medicaid and Worker’s Comp) to
detect and address inappropriate prescribing of
painkillers
Identify opportunities to increase access to
substance abuse treatment and consider first
responder access to naloxone
Patients- addicts; legitimate pain patients
Doctors- no training on pain control,
prescribing narcotics or addictive disease;
conflicts between the medical specialties
(Primary Care vs. ObGyn)
¡ Law Enforcement- pill mills; deaths; conflicts
with the medical profession
¡ Pharmacy- frustration is palpable
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9/06- 26 year old female presents to a Family
Medicine Clinic
Previously seen in another city , where she
lives, for a diagnosis of chronic pyelonephritis
Chief Complaint: “My back hurts”
PE: RLQ, LLQ and suprapubic pain
No urine drug screen was ordered
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Past Medical History: acute pyelonephritis
Social History: married with multiple marital
problems
§ Husband beat her
§ Now separated, single mom with 2 children, 6 & 8
§ Husband skipping child support
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Employment History: CNA, pharmacy tech
Previous Imaging: U/S kidneys- normal
Current meds: oxycontin 40mg TID, Percocet
10 mg QID, Roxicet 30 mg QID
Multiple requests for increases in pain meds
Requested meds by nameoxycontin/percocet
¡ April- she reports increasing anxiety
¡ Neck pain- 10/10, no imaging ordered
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§ 1 month later- neck pain worse??
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July- crying daily, “life is in complete
disarray”
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Same July- UDS was negative for
hydromorphone (Dilaudid)
She was prescribed dilaudid 8 mg, #370 per
month, 12 pills per day
Detection time for lab- 2-4 days for
hydromorphone
She had to have skipped 24-48 pills
Her prescriptions continued monthly without
investigation for possible diversion
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Ambien 10 mg #30
SOMA 350mg #60
Oxycontin 80 mg #300
Roxicodone 30mg #400
Dilaudid 8mg #370
Xanax 2mg #120
Mepergan fortis (Demerol) #60 (with a note
that says: “try not to use”)
§ 1340 pills/month, 44 pills/day
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Oxycontin 80 mg #300
Roxicodone 30 mg #400
Dilaudid 8 mg #370
Demerol 25 mg #60
Xanax 2 mg #120
$24,000.00
$12,000.00
$37,000.00
$1,500.00
$240.00
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Assuming $1.oo/mg- conservative street
value= $74,740.00/month
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May and June 1 year later- pill counts came
up short
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July- office could not reach patient for a pill
count and when they did reach her, she was
on her way to Florida and couldn’t come in.
(all of these were in violation of the informed
consent that she had signed)
June, 1 year later- Office Note: “Her
appearance was very strange today. Wearing
blonde wig with her natural hair sticking out
everywhere. Wearing dark sunglasses.
Wearing a long men’s shirt with tears in it and
doesn’t appear to have on anything under it.”
“Her pill count came up short today.”
Really?!!??!! Shocker!!!
¡ How does the doctor’s office respond?
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Oxycontin 80 mg #360
Roxicodone 30 mg #450
Xanax 2 mg #120
Demerol 100 mg #40
970 pills of high potency narcotics
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No UDS
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Prescribed controlled substances in
quantities and frequency inappropriate for
her complaint or illness
Hard to determine what her source of pain
was
She had obvious behavioral problems
She was being abused
She had a dramatic and compelling but vague
complaint (10/10 pain)
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Pressured her doctor for increases in her
medication
She had a crescendo pattern of drug use with
progression to multiple drugs
She asked for drugs by name
She worked in healthcare (CNA, pharm tech)
UDS’s were inconsistent
Pill counts were short- either selling them or
taking more than prescribed
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The controlled substances prescribed in this
case were outside the scope of accepted
medical practice and were not for a
legitimate medical purpose.
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Enforce REMS requirements for prescribing
controlled substances (Federal and State)
Utilize the Prescription Databases (Example
in Virginia)
Adhere to proper prescribing legislation
already in place
Prosecute CRIME!
Cooperation between state boards of medical
examiners and state and federal law
enforcement
DEA Office of Diversion Control
http://www.deadiversion.usdoj.gov/
¡ National Association of Drug Diversion
Investigators http://www.naddi.org/
¡ DEA Practitioner Manual
http://www.deadiversion.usdoj.gov/pubs/ma
nuals/pract/pract_manual012508.pdf
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Stephen Loyd, M.D.
Chief of Medicine
Associate Chief of Staff of Education
Mountain Home VA Medical Center
Associate Professor of Medicine
Quillen College of Medicine
East Tennessee State University
loydpd@me.com
Stephen.loyd@va.gov
Cell phone #423-557-4601