Plenty of drugs to go around!
Louisville Magazine’s August issue included an excellent extended piece profiling the impact of narcotic addiction in Austin (Scott County) Indiana. The sensitive and insightful article by senior writer, Anne Marshall with the collaboration of photographer William DeShazer, is titled, “The Craving.” The article deserves a wide readership and I recommend it to you. [Not all browsers may open on-line version of the story available here.] The title would be appropriate for a late-night horror show, but in real-life, the story is even more scary. This tiny town is ground-zero nationally for epidemics of opioid addiction, HIV and hepatitis, and the other medical and social side-effects of this class of drugs.
Based on visits and extensive interviews, the article makes clear the enormous cost of opioid addiction on entire communities. It is not just the users that pay the price. Legal or otherwise, the presence of opioid narcotics in communities exacerbates the poverty and social isolation that provide an important foothold for drug addiction and accelerates its grasp on communities large and small. By no means, however, is opioid addiction limited to the poor. To believe otherwise is to to hide out heads in the sand and allow this horror to grow. Some accounts of the epidemics in Scott County worry that the problem might spread to Louisville. Bad news folks! I am reliably told it is already abundantly here. This story could have been written about hundreds of towns and cities, large and small all over the nation, including Louisville.
Admittedly hard to fix– Why tie our hands?
In addition to accounts of human heartbreak, the article highlights longstanding political and institutional barriers to most effectively confront a problem that has always been with us. Detox and treatment options are subject to limitations of both effectiveness and availability. Relapse rates are high. The cost of medical treatment is also high and treatment itself is subject to both provider and patient abuse. Hard to swallow is the ideologically driven political foolishness that ties the hands of those offering effective support like needle exchanges, or playing games with the funding of Planned Parenthood which was providing HIV screening to citizens of Scott County. Perhaps when it is acknowledged that opioid abuse is not limited to the poor, to minorities, or other socially marginalized people, we will hear both the public and their elected representatives singing a different song and making resources other than more prisons available. Sad to think that is what it might take! [Read today’s story in the Lexington Herald Leader about a new federal prison in Eastern-Kentucky promoted as an economic development issue and weep!]
I had initially assumed that much of the narcotic addiction in Scott County and adjacent areas as in Clark County was driven by the easy availability heroin in our part of the country, facilitated by its lower cost compared to prescription narcotics and the innovative marketing of Mexican black-tar heroin in small and medium-sized cities and towns. (Get your heroin delivered like pizza!) I learned from Ms. Marshall however that the prescription drug Opana remains the drug of choice in Austin. This long-acting pill is broken up, dissolved and injected intravenously. So how do the citizens of Austin get their Opana? Certainly they are obtaining some from out-of-state or other distant sources. However, as I have reported earlier, free-market Opana flows abundantly right here in the region.
Narcotics for the aged like me.
Medicare makes available a database of all drugs prescribed for Medicare Part-D patients in 2013. For providers who write prescriptions for a given drug to more than 10 patients in a year, the prescriber is identified by name, place, and specialty. In this provider-identified subset, I surveyed prescriptions for Opana-ER (the brand name for extended-release oxymorphone) to Medicare patients for all of Indiana.
Opana runneth over.
Given the spotlight on Scott County, I was not especially surprised to note that much Opana enters the marketplace in several small towns and cities of Southern Indiana. Of 72 Indiana cities listed in descending number of prescriptions, New Albany and Seymour had the 3d and 4th highest number. Jeffersonville was number 8. All three of these small cities are within 40 miles of Austin/Scottsburg. Is there any possible reason on earth why tiny Seymour should prescribe so much Opana– or New Albany or Jeffersonville for that matter? Help me. These numbers reflect Part-D Medicare patients only but there is no reason not to generalize to Medicaid and other patient groups. Here are the top 15. [The complete lists will be available at the end of this article]
|Indiana City||# Rx Opana|
Including generic oxymorphone.
Opana is a brand name for oxymorphone. I redid the count of Opana prescriptions to include the generic forms, oxymorphone and oxymorphone HCL. Thus, of 79 Indiana cities, New Albany had the fourth, Seymour the 6th and Jeffersonville the 9th highest number or prescriptions written for oxymorphone. [Table available below.]
How about Kentucky?
It goes without saying that opioids are also available to Hoosers right across the river. For comparison, here are the number of prescriptions for Opana written in Kentucky extracted from the same federal database. It is interesting, that given its population, Louisville is not #1. Is it worth a look to try to understand why? Is Opana being used appropriately throughout Kentucky?
|Kentucky City||# Rx Opana|
Many other opioids available in Indiana!
For perspective, I rounded out the survey of the geographical distribution of prescriptions to include all brand and generic forms of opioids available and listed by Medicare. To inspection, it appears that for the size of their populations, New Albany, Seymour and Jeffersonville are hotspots for opioid narcotic prescription in general. Tiny Austin itself ranks #160 out of 318 cities for number opioid prescriptions to Medicare patients. I have not yet adjusted Opana prescriptions for the populations of the towns or the specialty of the prescribers. That is an important next step.
|Indiana City||# Rx Opioids|
Who is doing all this prescribing?
If all prescriptions for oxymorphone, including those by prescribers to 10 or fewer unique Medicare patients, then in Indiana 10,509 prescriptions were written for some 1827 patients by some 787 providers at a cost of $5.7 million. [Because some unique patients may have received both generic and brand-name oxymorphone from the same provider, the exact numbers of prescribers and patients are not easily disentangled. The total number of prescriptions and cost are exact however.] For comparison, in Kentucky, 6514 prescriptions for oxymorphone were written for some 1320 patients by some 495 providers at a cost of $3.1 million. That’s about $2400 per patient before possible markup on the street!
For the 217 Indiana providers identified by name because they prescribed to more than 10 patients, 9112 prescriptions for Opana and its generic forms were prescribed to individual Indiana Part-D Medicare patients in 2013 at a total cost of $4.9 million.
To disclose names or not to disclose?
As might be predicted, a relative handful of prescribers wrote the vast number of prescriptions for oxymorphone. The top Indiana prescriber wrote 415 such prescriptions for Medicare patients alone. The next lowest wrote 276, and only 22 prescribers wrote more than 100 prescriptions each. The Medicare database identifies these providers by name. Anyone with a computer and a spreadsheet program can know them. I have such lists but I am still debating on whether I should make them public in articles like this without the prior screening that someone needs very much to make. The traditional objection to identifying hospitals and providers with respect to their volume of service, quality of care, or amount of their bills has already been lost in the debate. More transparency is in my opinion a good thing albeit often painful in the current environment. One can reasonably debate whether or not we are revealing the right things in a meaningful way. I have already expressed an opinion that many of the Hospital Quality Compare items being published are not quite ready for prime time. What is your opinion?
No more secrets?
Nonetheless, it also seems to me that without identifying who is actually prescribing these truckloads– indeed trainloads of narcotics– we will never get a handle on the problem of prescription drug abuse and diversion. Certainly “education” alone as was the earlier prescription offered to providers is not doing the job. Some over-prescribers will rightly think twice about the appropriateness of their practice style when they see they are far-outliers compared to their peers. (So may some low volume prescribers.) As a physician, I would want to know how free with narcotics a physician was before I referred my patients for help. In the end however, there is no denying that some physicians and other prescribers are participants in criminal schemes to profit from pushing controlled substances. I do not believe as a professional or a patient that any physician or other provider worth seeing will withhold legitimate treatment because they are unwilling to stand by their actions. If someone has a better idea of how to identify bad actors or inappropriate prescribers without identifying them personally, please share it with us below.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
Aug 17, 2016