Stymying opioid abuse driving users to heroin

Policymakers must dry up drug sources and heal addicts

A new metric is helping measure progress in America’s efforts to blunt abuse of painkillers and other addictive prescription drugs.

Heroin users.

Ongoing law-enforcement efforts to shut down pill mills are putting a dent in availability. And restrictions imposed on doctors are discouraging more from pushing pills.

One of the most-abused painkillers — OxyContin — also was reformulated to resist abuse. It’s harder to crush or snort. Abuse of the once hyper-addictive pill has dropped dramatically, says a study in the New England Journal of Medicine.

Prescription overdose deaths plummeted 23 percent in Florida between 2010 and 2012, notes a CNN story this week.

Insurers also benefit, because their payouts finance billions of dollars worth of opioid prescriptions a year.

All good, except the lockdown of opioids is driving addicts to heroin. Overdoses are spiking, which is canceling out many of the gains in clamping down on prescription abuse.

Squeezing drug sources — whether doctors, pill mills or heroin dealers — is a worthy though incomplete strategy. If one drug dries up, another will take its place as long as addictive demand remains intact.

Vermont is going after prescription opiate demand. The state has opened five regional drug treatment centers around the state. After addicts “graduate” from a center, they’re treated by doctors and therapists in the addicts’ community.

The centers are overwhelmed by addicts seeking a way out. Convincing local doctors to treat addicts also is difficult. Still, Vermont’s model bears a close look as it evolves.

Policymakers are trying many creative solutions around the U.S. Quashing this scourge requires us to keep looking two ways at once: block the drug sources, and stymie the addictive urge.

About the author: Jim Quiggle is director of communications for the Coalition Against Insurance Fraud.

Latest wave of painkiller addiction may be worst

Silver bullet is development of less-addictive med

“History shows both that it’s possible to overprescribe and misuse powerful narcotics, and that it’s possible to undertreat pain and addiction to them. Balancing the competing needs and risks is a continuing struggle.”

drug imageWhile a bit of simplification, this quote by health economist Austin Frakt nicely sums up the challenge the U.S. faces in curbing mass addiction to prescription painkillers. On one side are pain sufferers and drugmakers. On the other side are insurers, regulators and law enforcement. In the middle are tens of thousands of addicts, black marketeers, fraudsters, and the physicians and pharmacists who enable this crime wave.

Frakt provides a historical snapshot of opioid addiction in a recent column in the New York Times. [link] There have been three major waves of addiction in the US. since opium became the drug of choice in the 1900s. Each time a major public-policy initiative served as a catalyst to end the epidemic.

It likely will take more than a single initiative to end the current wave, considering Americans consume:

• 99 percent of the world’s hydrocodone, the opioid in Vicodin;
• 80 percent of the world’s oxycodone (OxyContin and Percocet); and
• 65 percent of hydromorphone (Dilaudid), Frakt writes.

These three painkillers are killing more Americans than any other drug.

The current wave of drug addiction was spurred in part by naive doctors in the 1980s who touted drugmaker propaganda that these drugs were harmless.

Yet there’s some hope, after thousands of deaths and a price tag in the billions. State drug-monitoring systems and better education of patients and doctors are helping ease drug diversion, as are tougher laws and better treatment and rehab.

Reducing drugmakers’ influence on physicians and policymakers also will help. The magic bullet, though, would be development of an effective non-addictive painkiller.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Medical marijuana as a strategy to reduce prescription drug deaths

New study contains strong evidence that painkiller alternatives can save lives and insurers money

After visiting a medical marijuana outlet in Colorado in May, I wrote about the possibility of medical marijuana replacing addictive opoids to help chronic pain sufferers.

A new study says that states that allow medical marijuana consistently had fewer overdoses than other states.

Medical marijuana states reported an overdose death rate of nearly 25 percent less than states without the laws, according to an analysis of data from the John Hopkins Bloomberg School and the Philadelphia Veterans Affairs Medical Center. The correlation between death rates and the availability of marijuana for medical purposes seems very strong.

Hopefully, this new evidence will spur Congress to allow researchers to test of efficacy of marijuana as pain medication. Good studies are lacking because of current law outlawing the possession of pot makes it nearly impossible for researchers to conducted this needed study.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Should marijuana replace addictive opioids?

Studies still needed, but insurers must solve prescription-drug pandemic

Could marijuana replace OxyContin as the painkiller of choice?

As legal pot spreads across America, insurers might want to consider this alternative.

I had the honor last Friday of serving as keynote speaker for the annual conference of the Rocky Mountain chapter of IASIU held just outside of Denver. It was a well-attended meeting with good speakers and interesting topics — including one on the impact of legal marijuana on insurance.

With a few hours to kill before my plane departed, I decided to check out Colorado’s latest burgeoning industry and visit a marijuana dispensary to satisfy my curiosity (and impress my hip friends back home).

The dispensary in Boulder is called The Farm. It was a medical marijuana retailer before the state legalized recreational pot for adults on January 1. Entering the store, ID was required and scanned for validation.

“You wouldn’t believe how many underage kids try to use fake IDs to get in here,” the young woman behind the counter told me. After validation, she handed me a plastic chip with a number on it. She encouraged me to look around while waiting for my number to be called.

The store’s main section looked like a traditional jewelry store with several showcases of shiny merchandise. Instead of diamonds, glass bongs were featured. It was certainly more upscale — and expensive — than the head shops I recall from the 1960s and 70s.

A locked side room contained the featured merchandise on display. Only perhaps a half-dozen customers at a time were allowed in the room, where marijuana products were displayed along the walls and underneath glass display cabinets.

If more studies conclude marijuana is effective and relatively safe for pain relief, then insurers and government programs should consider getting out front to replace the widely destructive — and expensive — use of opiods.

I told the clerk I wasn’t buying but wanted to see what was available and just look around. He was accommodating and knowledgable of the many products available, from dozens of varieties of marijuana to edibles to oils.

As I wandered around, I noticed the clientele wasn’t anything like I imagined. One guy looked like a corporate middle manager. Another could’ve been a truck driver, and a middle-class, middle-aged woman also perused. None looked like the potheads I’d expected. Overhearing their conversations, I learned that all sought relief for some ache or pain. One had back problems and another customer had arthritis.The corporate guy was picking up a package I surmised was for a family member, perhaps wife or parent, who had cancer.

Different types and strains of marijuana are suggested for different ailments, the clerk told me. Some marijuana even is sold without the key ingredient that gets users high — and his clients attest that it’s still effective.

I’d always thought that medical marijuana was more of an excuse for stoners to get high legally, but new evidence out this week challenges that assumption.

If more studies conclude marijuana is effective and relatively safe for pain relief, then insurers and government programs should consider getting out front to replace the widely destructive — and expensive — use of opiods. Prescription abuse kills Americans by the thousands, and is creating the largest generation of heroin users this country has seen. Prescription drug diversion also imposes a huge dollar drain on insurers and government health programs.

Twenty-one states and DC now allow marijuana for medical use. I’d love to see a group of insurers or a state Medicaid program conduct a pilot program in one state to test pot vs. opiods such as the painkiller oxycodone..

I’m still not sold on the idea of legal recreational marijuana, but medical marijuana might help curb one of our nation’s most pressing problems of prescription drug abuse.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Best practices aim to best drug diversion

Lawmakers gaining tool to review state efforts

State legislators now have a useful best-practices blueprint to help close gaps in dealing with the scourge of prescription abuse. This national epidemic wrecks lives and costs insurers billions of dollars annually.

The National Conference of Insurance Legislators released a report on best practices  at its summer meeting this month in Philadelphia. The valuable document will reinforce how states deal with this national epidemic.

Legislators can compare their state’s actions to the Best Practices report to see where new laws might fill gaps in the state’s enforcement efforts. This also might uncover best practices to add to the NCOIL document. This was the Coalition’s message to the assembled legislators in working with legislators on a report that will be out in the fall.

Among the Coalition’s recommendations that NCOIL adopted:

  • Enhanced interstate data-sharing among state prescription drug monitoring programs (PDMP):
  • Greater access to authorized users of the PDMPs;
  • Mandated use of PDMPs by medical providers and pharmacies;
  • Real-time reporting of prescriptions;
  • Regulation of pill mills; and
  • Proper funding of state PDMPs.

Auto, workers compensation and health insurers are defrauded by illicit prescriptions for painkillers, muscle relaxers and other narcotic prescription meds. Drug diversion steals tens of billions of dollars a year through insurance scams. Insurance fraud thus is a major financier of this crime.

Addicted doctor shoppers ply pharmacies with false prescriptions. Shady pain clinics dole out thousands of pills to addicts, and pharmacies often are complicit in a thriving black market for the insurer-paid drugs.

Several insurers — including auto and workers comp carriers — also gave presentations about the need to combat drug diversion, and applauded NCOIL’s efforts.

The report clearly had the attention of one state legislator. The best practices create a prime opening to instruct states looking for thoughtful solutions to this complex and costly problem. The report is unique in its comprehensive approach. This was the message of Vermont state Rep. Bill Botzow during the workers compensation committee discussions at the meeting.

A prosecutor also also sees the report’s value. Prescription abuse is a critical issue in his suburban Philadelphia county, he said.

We’ve seen efforts to strengthen state laws and regulations targeting diversion of addictive prescription narcotics. But, this is the first time that legislators can weigh in with a sweeping review of their own state’s efforts. This new legislative weapon comes none too soon.

About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.

An overdose of problems, a trickle of solutions

A multifaceted approach is needed to fix N.Y’s prescription epidemic


Overdoses of addictive prescription painkillers have increased sevenfold in New York City, says a recent study by Columbia University.

The prescription abuse epidemic is spreading throughout the state. People of all ages, income levels and races are getting addicted.

The New York Alliance Against Insurance Fraud this week called for a multifaceted approach to tackle the problem. The NYAAIF works to increase public awareness about insurance fraud and its consequences.

Corrupt doctors prescribe painkillers for addicted patients, fraudulently billing insurance companies for the unneeded medicine and doctor visits. Demand for painkillers has boosted the drugs’ street price, attracting organized criminals and growing the black market. Healthy patients become addicted to painkillers by careless doctors who overprescribe, or by people taking a friend’s pills without a prescription, thinking that medicine won’t harm them. Prescription abuse is killing people — sometimes teenagers — with overdoses.

New Yorkers aren’t waiting.

Last January, legislation enacted created a statewide database to track prescriptions and prevent doctor-shopping.

The surge in addictions has led to increased pharmacy robberies, thefts, shoplifting and healthcare fraud schemes. So NYPD is placing GPS chips in pill bottles to track stolen inventories. Physicians also must be educated to recognize drug dependency. Consumers need better information to recognize the signs of drug abuse in the home, workplace and schools.

But the road is long and reducing prescription abuse will take many weapons. This problem can’t wait, prescription overdoses are taking lives.

About the author: Jennifer Tchinnosian is communications specialist for the Coalition Against Insurance Fraud.

Drug diversion and the poor

BLOG_prescriptionBabiesLast week I participated in an expert panel meeting at the Centers for Disease Control & Prevention on the issue of prescription drug abuse and its impact on Medicaid programs.

The new director of the CDC has deemed drug diversion one of six public-health issues that CDC has embraced for study and action in 2012. The meeting included some very smart people from CDC, mostly medical experts, plus representatives from a handful of state Medicaid programs and a few private payers.

Drug diversion is a huge problem for Medicaid. A third to a half of all prescription drug deaths in the U.S. are Medicaid recipients. Eighty percent of babies born addicted to prescription drugs are born to mothers on Medicaid. The prescription rate among patients on Medicaid is more than twice that of the private sector. No doubt many of those pills end up on the street.

One of the most effective tools Medicaid programs have to curb diversion is requiring patients to use only one physician and one pharmacist for their prescriptions. Such “lock-in” requirements help stem doctor shopping.

But there are two problems with such programs. First, they don’t exist in many states because doctors and pharmacists sometimes don’t like them and their lobbies help to either kill lock-in legislation or weakened the bills.

Second, lock-in programs don’t catch Medicaid patients who intentionally avoid detection by paying for their illicit prescriptions in cash. Prescription monitoring programs (PMPs) — in which doctors and pharmacists log prescription activity into a state database — can catch such transactions.

But surprisingly, all but one state Medicaid program are denied access to PMP data mostly because of privacy concerns. That’s a huge missed opportunity to catch drug abusers early, and save taxpayer dollars and perhaps a few lives.

PMPs, health regulators and state legislators need to consider giving Medicaid programs access to drug data so they can become full partners in combating fraud and abuse involving prescription drugs.

About the author: Dennis Jay is executive director for the Coalition Against Insurance Fraud.

Model for fighting fraud

heroin oxycodone Inside a glass case lies a corpse covered by white fabric. Across the room, a glassy brown medicine bottle labeled ‘Heroin” offers to cure cough, with one or two tablets every two or three hours. The Drug Enforcement Agency’s museum’s exhibit, Good Medicine Bad Behavior describes the national epidemic of prescription addiction and will be open through 2012 in our Nation’s Capital.

A few miles away, Karen Kelly from the Kentucky-based Operation UNITE talks at a meeting on Capitol Hill about beating the medicine cabinet epidemic. Kentucky has been fighting drug diversion for the past 10 years, and Kelly has been instrumental in organizing the addiction-prevention efforts. She has seen addiction devastate entire neighborhoods, leaving 50 percent of children in some districts to grow up without parents. As the epidemic  continues spreading across the nation, we asked Kelly a few questions.

Kentucky may be the precursor to the rest of the nation in terms of prescription abuse. You‘ve been fighting it for a decade. How did this program get started?

Operation UNITE was launched in April 2003 by U.S. Congressman Hal Rogers, who called people together to brainstorm a way to fight the prescription abuse. He called judges, social workers, parents who’d lost kids, police officers and educators, and they came up with the UNITE plan. We got a call from a grandmother raising her grandkids, and she asked if we’d come visit, so we did. She had three grandkids and she couldn’t let them play in the yard because of the drug dealer next door would offer them pills and needles, often throwing them into the yard.We spent most of 2003 just getting access to funding and hiring people, then we kicked off in 2004. We started strong in newspapers with a law-enforcement front. We started organizing one of the biggest drug roundups, and arrested 200 people in one day. We didn’t want to jam up the court system, so we began creating treatment programs to give addicts the choice of rehab. Now we have at least one drug court in every single county. So if people are arrested, they have the option of drug court, where they’re drug tested regularly, they meet with a judge, and with a treatment counselor for 18 to 20 months. From there we started our hotline, town hall meetings, building a community of volunteers.

What advice would you give to other states thinking of implementing similar programs?

First, go out of your way to educate the medical profession. Most prescribers want to do the right thing but they’re not educated about addiction. We have some volunteers on the medical advisory counsel who say, “Every 10 years I get HIV training, and I haven’t seen one HIV patient yet, but today 80 addicts walked through my door and I can’t tell who’s who.”

Second, even if you can’t organize law enforcement and education, convene a meeting and to see where you can forge key alliances, to see how these different groups can work together. For example, the largest insurer in our state offers volunteers for our drug-free summer camp, that’s a tremendous resource, they also donated lock boxes for medication.

Third, get law enforcement and treatment to start working together with education; it takes all three working together to tackle this. Law enforcement runs into a lot of addicts who need help, and they refer them for treatment. Education means using creative ways to reach the public. Ask the dry cleaners to put short anti-fraud messages on coat hangers, go to civic clubs and talk to people about locking up drugs, and know the signs that your kids are starting to struggle. We go region by region targeting the biggest employers in each county, and offering free anti-fraud training lunches. We say, “Have your employees bring lunch we can spend an hour teaching them how to recognize addiction in their kids or colleagues.” Volunteers teach that class; they want to do it because they’ve been affected by the problem somehow. You have to use all your resources.

If you could go back and change something, what would you change, or warn others against?

I wish we’d gotten our healthcare providers onboard before we made a show of law enforcement, because after that happened, the doctors didn’t trust us to talk. A lot of doctors didn’t feel a need to get involved with the issue until a doctor was killed by an addicted patient.

The prescription-drug epidemic  is escalating. What would you attribute this to?

Ease of access, and pill mills. Kentucky recently passed legislation to stop pill mills. Doctors will be educated in Kentucky. New clinics will have to be doctor-owned. The problem is not socioeconomic at all; it’s affecting every family in our region no matter what their background. Prescription abuse also is a different type of investigation,― anybody could be a drug dealer, and we have many that are wearing white coats.

You got corporate funding for some of the programs, like the summer camp sponsored by Toyota. How would you advise that other states to get funding like this?

I would say don’t give up. A lot of employers have been impacted by the problem, so our state sees it as a really good benefit for its dollars because  it  costs more money to ignore the problem. Also leave no stone unturned. Even insurers are recognizing how big a deal this is, so they’ve decided to help us fund our initiatives. Even if its not their mission, it still impacts that family or that company or that organization. And there are government dollars; we had a CDC grant to implement wellness programs. Most states get CDC funds, but don’t use them to stop prescription abuse.

What can be done about the problem nationwide?

As Florida has gotten stricter on its pill mills, people are turning to Georgia and Nashville for meds. We need a pill-mill crackdown act on the federal level, because we know that what Florida did has had an impact. Kentucky and Ohio have passed laws, but how long is it going to take for every state to get onboard? There really aren’t any good reasons to have cash-only pain clinics, with bouncers, for example. We need to  educate doctors. Everybody also has a responsibility to know what they are being prescribed, and parents have a responsibility for their children, to know where they are and who they’re with. A lot of addicted teens call us and say that if they drank alcohol, their parents could smell it. So our parents have got to be educated. We have parent trainings where kids tell the parents, “This is how I duped my parents.” Many times the parents are stunned. Then we did focus groups to find out what parents wanted to learn, and made it part of the curriculum. We warn caretakers not to wait until they have evidence or proof of the problem to address it, because by that time, these kids are so far gone that we can’t get them back.

A brief history of analgesic’s holy grail

holygrail75 Americans will die today from a prescription drug overdose. In fact, prescription drug overdose is rated as the second most frequent cause of accidental death. It’s not just a problem for adults — every hour a baby is born in the U.S. with symptoms of withdrawal from opiates — meaning 13,500 babies a year.

How did we get here?

Nowadays, almost all prescription drugs that are misused come from doctors’ prescriptions, and end up in the wrong hands through theft or sale. Insurance companies often pay for prescriptions.

But painkillers have existed long before prescriptions or insurance companies have. In 5000 B.C., Sumerian tablets named opium poppies HulGil, or “joy plant”. Egyptian Papyrus from 1550 B.C, archives instructions on using grains of poppy plant as medicine.

With pain relief came the drug’s euphoric feelings, and an onset of steady addiction. Non-addictive painkillers became the holy grail of chemists, who set about toying with molecular structures of opioids to get the perfect combination of maximum benefit with minimum risk. In time, they developed several close calls.

Codeine (1830), heroin (1874), and oxycodone (1916) were all advertised immediately after their discoveries as the perfect painkillers, noted for their ‘non-addictive’ properties, and ability to replace their antecedents in the painkiller world.

Morphine, developed in the early 1800s, remains the gold standard for treating severe pain, and is given to cancer patients to this day. The first civil war (1861 – 1865) in America largely depended on the availability of morphine, with one general quoted saying “You can’t fight wars without morphine.”

As the problem of addiction became a growing concern, the Bureau of Social Hygiene created a Committee on Drug Addiction. In 1929, the committee decided upon a research plan that involved three components — chemical, pharmacological, and clinical. After the first decade of research, 500 compounds were ready for testing in animals. Three were tested on humans for pain relief and dependence liability.

Seeking to help existing addicts and understand the root of the problem, the narcotic farm (U.S. Public Health Service Hospital) in Lexington, Ky. was opened in 1935. Prisons that had been flooded with addicts now sent drug-addicted criminals to Lexington for treatment. The Addiction Research Center (ARC) inside the farm was open until 1970 and is today known for accomplishing many of the landmark studies in the field of drug abuse.

Hundreds of prisoners were recruited to volunteer in the ARC as guinea pigs for groundbreaking drug experiments. Scientists would administer heroin, morphine, and other drugs, and take note of what effects it had on the addict. In other experiments, they abruptly stopped dispensing heroin to cause withdrawal symptoms, and then introduce dan experimental drug to see if it would effectively relieve withdrawal symptoms.

Then, Analgesic Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) was established as a “public-private partnership with the United States Food and Drug Administration (FDA) to identify, prioritize, sponsor, coordinate, and promote innovative activities — with a special interest in optimizing clinical trials — that will expedite the discovery and development of improved analgesic treatments for the benefit of the public health.”

In the 1940s, the opiate program at the National Institutes of Health (NIH) began, and has resulted in more than 750 research papers and patents. Some 59 drugs identified as painkillers were introduced from 1960 to 2009, and remain in use today. From 1960 to 2009, pain-related publications grew exponentially: The number of articles almost tripled during the first and second decades, and then doubled during each of the next three decades until 2009. Intensive research has produced thousands of publications, but none of these efforts has yielded new painkillers that can significantly change the scope of the opioid addiction problem.

Today, various laboratories are synthesizing different molecules in hope of finding the perfect cure. Though progress has been made, the answer has not yet been found. It will take a national database where researchers can share their results, more funding, and certainly more time before we may ever reach painkillers’ holy grail.

About the author: Jennifer Tchinnosian is communications specialist for the Coalition Against Insurance Fraud.

The novel idea of a non-addictive painkiller

BLOG_nonaddictiveMore than 600 people gathered in Orlando last week for an inaugural summit on prescription drug abuse. There were high-level government officials (including the surgeon general, congressmen and administration officials). There also were lots of medical types with impressive credentials, a bevy of vendors selling anti-drug wares, and a few stoic parents who had lost sons and daughters to drug overdoses.

Only a couple of insurers attended, even though the general consensus of attendees was that much of the illicit use of painkillers is insurer-paid.

What was evident from the week-long conference is that prescription drug abuse and fraud in the U.S. is a huge, complex problem with many facets. And the problem likely is still growing. It touches the urban core, suburban bedroom communities and rural America. Drug diversion is an equal opportunity scam perpetrated by druggies, honor society high schoolers, soccer moms, celebrities, physicians, pharmacists, and increasingly, organized criminal enterprises. The power of addiction plus high profit makes this incarnation of drug abuse perhaps the most sweeping ever.

I was asked to speak about the high cost of drug diversion — specifically painkillers — on employers and insurers. There’s a strong need for more anti-fraud measures, including prescription monitoring programs (PMPs) in states and general awareness all around, I noted. Organizations attending the conference also must get more involved in the political process to enact stronger anti-drug diversion legislation.

Then I threw out perhaps a not-novel and even naive idea: The government, medical community and insurance industry should launch a Manhattan Project to develop an effective non-addictive painkiller. It would take the profit motive out of drug diversion — yet still help those who are in pain obtain relief. Plus it might save a lot of lives.

I asked the audience, which numbered in the hundreds, if anyone was working on such an effort. One person raised her hand. Others shrugged. Perhaps it’s not such a naive idea after all.