Medicare Updates Its Prescription Drug Utilization Database.

An improved goldmine of information not otherwise available to the public and a flood of opioids.

On August 18, CMS released the second iteration of its cost-and-utilization database of prescription drugs written for patients covered by Medicare Part-D Medicare which includes beneficiaries in Part-C Managed Care and stand-alone Medicare Part-D Prescription Drug Plans. Compared to the updates of Medicare’s other 2013 public-use healthcare utilization files, this release seemed delayed and I feared the program’s continuing implementation had been quashed by the pharmaceutical industry lobby and its friends as was a 2013 initiative to provide the public with average retail drug prices. The wait was worth it.

Although restricted to the two specific Medicare populations mentioned above comprising some 70% of all Medicare beneficiaries, the database is unique in that the names and other identifying information about individual prescribers are disclosed to the public. Although the drug companies themselves know who is prescribing their products, to my knowledge, this degree of transparency for the public is unique – and therefore doubly valuable. The top 25 opioid prescribers to this population are listed below. Continue reading “Medicare Updates Its Prescription Drug Utilization Database.”

How Did Prince Get His Opioids?

Outlying prescribers of opioids and their drug-dependent patients are easy to find, but it is the standard of medical care in America that is fueling our current epidemic of opioid abuse, diversion, crime, and overdose deaths. These tragedies will not be solved by education, treatment, and law enforcement alone; nor by any amount of money we throw at the problem. The standard of care itself needs to be reassessed by the medical professions and the number and nature of first opioid exposures much reduced.

Long live the Prince.All-Prescribers-TM-62316
He gave us the gift of his music. Might he give us anything else? Is there anything to be learned from his untimely death? As of this writing, there’s no longer any doubt that he died of opioid narcotic poisoning – more specifically of fentanyl overdose. It has also been reported that his addiction to opioids was long-standing, even as it was well hidden from his public. Current popular accounts attribute his opioid addiction to prescription drugs that were begun to treat unspecified injuries related to his vigorous stage performances– as if this somehow automatically legitimizes the use of opioids for musculoskeletal injury or chronic degenerative disease.  A claim that “I can’t live without my opioids,” is in my experience generally a symptom of the opioid dependance itself, not the underlying disorder for which the drug was begun. That is why we use the term addiction. Of course there is a place in medical care for narcotic opioids, but we have strayed far from that place today.

Fentanyl is the new bad boy.
Many other current reported deaths attributed to opioid overdose involve fentanyl, either by itself, or added to preparations of heroin. There has been no evidence reported that Prince was a heroin-user, although the investigation into the circumstances of his death is not over.  Fentanyl is, milligram per milligram, the most powerful opioid available on the market. It is well known that its potency takes some opioid users by surprise with not-infrequent fatal results. (A weekend full of deaths in a given community is commonly the result of a fentanyl-augmented batch of heroin.) It is not yet publicly known how long Prince might have been taking fentanyl.  Did he come by his fentanyl illegally? Was it provided to him unlawfully by friends or supporters who obtained the drug in otherwise legal ways?   Was the unscheduled landing of Prince’s airplane the day he died the result of a fentanyl surprise, or had he not yet been exposed to the drug. Did he acquire the medical disadvantage of being a “special” patient?  I suspect we will find out.  I also suspect that he acquired his fentanyl the same way innumerable other patients do – from their own local healthcare providers.  Often, but certainly not always, the initial exposure to opioids is done with the best of intentions. In Minnesota, there are a few providers who have written colossal numbers of fentanyl prescriptions.  From publicly available data, it does not appear that the physician whose name has most often been associated with Prince’s death is one of those. Continue reading “How Did Prince Get His Opioids?”

Legislative Tinkering With Needle-Exchange Program: Bad Idea.

hep-c-reported-ky-2013I learned today that the Republican-controlled Kentucky Senate passed a bill that would prohibit health facilities that currently run needle-exchange programs from giving out more needles than they receive from the substance-addicted people participating in the program.  Only “one-for-one” exchanges would be allowed. The primary goal of any needle-exchange program is to prevent the spread of hepatitis, HIV, or other blood-borne infection that occurs when iv-injecting drug users share their equipment.  Whether or not a program is successful is measured by changes in new infection rates.  Kentucky could use a little help in that department. As of 2013, for at least the previous 4 years Kentucky led the nation in new reported cases of Hepatitis-C.  That is not a place we want to be, including for reasons I will discuss below. The price we pay in gold and human misery is colossal, whether one abuses drugs or not!  The 2013 data set from the CDC is the most recent available to me.  I must assume that things only got worse since then.

Prohibition and moralizing did not work for alcohol either.
It appears that many if not most of the Senate opponents of needle exchange programs in general are driven by puritanical or judgmental motives.  There are certainly valid reasons to try to remove used needles and syringes from public spaces to avoid accidental injury, but that can and should be an independent initiative. The successful needle-exchange program in Louisville has made great progress in approaching a one-for-one exchange rate.  The last thing we need in Kentucky is to have any of our towns or cities follow Austin, IN into the HIV and hepatitis blasted Hell out of which it will take several generations to climb.

Kentucky’s sons and daughters of families of all political parties are today sharing needles and other bodily fluids with HIV and hepatitis virus-infected individuals. One need not be a committed substance-injecting addict to be exposed.  Healthcare workers are also at risk from needle-sticks. Our goal is to keep as many people healthy as we can through both prevention and treatment.  Neither approach is easy, but that is not a reason not to try.  Austin had the same warning we are being given now, but did little or nothing effective to stave off disaster.  We need to do better. Moralizing will not do the trick.  We must allow public health professionals to exercise their professional opinions based on best available evidence. Continue reading “Legislative Tinkering With Needle-Exchange Program: Bad Idea.”

Per-capita Opioid Prescription to Medicare Part-D Patients in the United States.

Test of Tabloid Public software.

I am still testing software with the capability to map data geographically. This page may change as I manipulate the page layout.

Below is a map of the number of opioid prescriptions written for Medicare Part-D beneficiaries in 2013 divided by the total general population of each state. This version of “per-capita” adjustment corrects somewhat for the large differences in the population amount the states. I have shown earlier that prescriptions of opioids to Medicare patients correlates well with opioid prescription to the general public. It is disappointing to see Kentucky and our neighboring states stand out as hot-spots of prescription opioid drug use. Hover your cursor over the map to interact with the actual data. Here is a link to a full size version.

Peter Hasselbacher, MD
President, KHPI