Narcotized Elderly America: Diseased, Stoned, or Dealing?

pills-15The Federal Government has been releasing an avalanche of health care utilization data over the past very few years while the rest of use are still trying to figure out how to use the information.  While there exists the potential to use the data to evaluate healthcare quality and safety, to ferret out best medical practices, to more efficiently use increasingly limited healthcare dollars, or to otherwise guide good public policy; the most apparent utility so far is to identify medical fraud. It is easier to justify looking for fraud than to confront entrenched interests dug in deep in this profitable segment of the economy.

Medicare prescription drug cost and utilization data.
One month ago, the Centers for Medicare and Medicaid Services (CMS) published another data-dump. It was the first compilation of all drugs and selected supplies prescribed by physicians and other healthcare professionals to the majority of Medicare patients in 2013.  Included beneficiaries number 35.7 million and include those enrolled in freestanding Medicare Part-D drug plans, or those covered by drug plans that are part of Medicare Part-C (managed care) Advantage plans. These make up about 68% of all Medicare beneficiaries. Medicare fee-for-service patients are not included.  Recall also that a proportion of all Medicare beneficiaries are enrolled because they are disabled, not because they are over 65 years old.   Each provider has a line item for every discrete drug prescribed more than ten times by them (to protect patient privacy) including the number of unique beneficiaries receiving the drug, the number of times times prescribed or renewed, the number of days worth of of drug prescribed, and the total amount paid for the drug by the patient, Medicare, and any third party payers.  In the full data file there are 23,650,520 line items for more than 1 million individual providers prescribing 3449 different drugs or supplies.

How to take the first bite?
This amount of data in the text file of 2.8 GB is too big for a simple spreadsheet program like Excel to handle and beyond the ken of mere mortals to easily analyze (and I include myself in that category).  CMS conveniently provides separate summary files listing every individual drug nationally or by state, and an additional 36 Excel files listing individual providers broken into bite-sized chunks alphabetically by the providers last name. [CMS files available here.] It is my understanding, subject to confirmation, that the summary drug file includes the drugs prescribed fewer than 11 times that are excluded from the individual provider files. To make things more manageable for my readers, and to allow them to help me explore the data, I provide available a spreadsheet (36 MB) containing all the entries for Kentucky providers.  If anyone would like a more specific inquiry at the national or state level, let me know.

First looks by others.
It is the summary reports and charts provided by CMS that garnered the initial attention of the media.  For example, the total drug cost of the “purple pill” for heartburn (Nexium) is the highest for all covered drugs at $2.5 billion– fully 2.4% percent of all Medicare prescription drug expenditures in this population. This is more than for any of the outpatient cancer drugs!  The scandal is that the active ingredient in Nexium is identical to that in generic or over-the-counter omeprazole (Prilosec)!  Generic omeprazole itself is #29 on the most expensive drug list at $0.6 billion.   I had fully intended to base my first look at this data on how much money could be saved if Medicare patients only had to pay generic prices when branded versions were still on the market.  That plan was immediately derailed.  I will address the use of generic drugs and the way the pharmaceutical companies have effectively fended off generic competition in another article. [Hint– combination pills.]

Our love affair with narcotics.
opium-poppy-200Although not entirely surprised, I was blown away by the magnitude of opioid narcotic use in this high-risk elderly patient population.  No wonder the country is awash in prescription drug abuse.  Any kid need only visit his grandparents’ medicine cabinet to score.  For example, if the 3449 different included drugs are ranked by number of unique Medicare beneficiaries taking them, at the top of the list is the combination-pill hydrocodone/ acetaminophen (a.k.a.  Vicodin and Lortab) with 8.1 million unique users. That number represents 23% of all Medicare beneficiaries in these plans!  The next two pills down are the generic forms of the cholesterol-lowering drug simvastin, and the generic blood pressure pill lisinopril with about 7.0 million beneficiaries each. (See chart of top 50 ranked by number of beneficiaries.)  Looked at in another way, more providers prescribed this single narcotic preparation than any other medicine, including common antibiotics.  The number of providers prescribing hydrocodone/acetiminophin was 691,028 compared to the next lower drugs on the list (ciprofloxacin and amoxicillin) which were each prescribed by a mere 550,000 providers or so. [Top 50 by number of providers here.]

It does not seem to be the case that hydrocodone/acetaminophen is only prescribed occasionally as for an acute problem.  If all drugs are ranked by the number of fills and refills, hydrocodone/acetaminophen falls at #4, just below thyroid hormone replacement, a drug that is taken every day!   It is likely that disabled Medicare beneficiaries are disproportionally represented in the group taking narcotic analgesics.

That’s just one drug version.
Of course, in this popular (for patients and providers alike) class of drugs, there are many other brand-name versions, related opiates, and opiate-containing combination pills available for use. To get an estimate on the volume of these alternatives, I extracted from the database all drugs containing the character strings “cod” and “morph.”  Surprisingly, this search yielded only brand-name and generic drugs containing codeine, hydrocodone, oxycodone, morphine, hydromorphone, and the like. I was surprised that no other drug intended for any use contained these letter strings. [See the list of returned drug names here.]

When I added up the number of beneficiaries and the total drug cost, the numbers staggered even me.  Fully 15.1 million beneficiaries took these drugs for a total cost of $2.7 billion, blowing even Nexium out of the water. Recognize that a single beneficiary might well have been prescribed more than one type or brand of opiate such that this number does not represent the overall proportion of beneficiaries taking these specific drugs. On the other hand, I have not yet done an exhaustive search to include all other available narcotics or analgesics subject to abuse, such as Fentanyl [Addendum: see below for such an analysis],  which would increase the proportion of narcotic-takers. (Fentanyl itself is #49 on the most expensive list with 467,471 consumers.)  In terms of cost to the initial user, fully 2.6% of the total $103 billion of private and public monies was spent on these basic opioids alone– this despite the fact that overall, this class of drugs is not very expensive when purchased with a prescription!  Of course once the drugs hit the secondary market, their cost soars in so many ways. [See top 50 drugs by total cost.]

For those already in trouble.
For the sake of interest, nationally the number of beneficiaries taking Methadone was 174,796 for a total cost of $24,794,429 , and taking Suboxone was 51,406 for a total cost of $149,627,043.  Treatment is not inexpensive.

I don’t want my patients to suffer.
I can already hear the justifications that this is an older, sicker, and more pain-endowed segment of our population. Agreed!  However, even 20 years ago when I had access to tallies of drugs taken by a representative employer–based insurance company, various opioids were at or near the top of the list.  When Medicaid used to publish lists of the drugs taken by their intrinsically younger set of beneficiaries, opioids also were similarly among the most frequently taken drugs.  Even 15 years ago when I had access to lists of drugs taken by UofL employees and their dependents (yes, summaries were shared with management), OxyContin was among the top 20 prescribed drugs. Others have pointed out the frankly stupendous use of narcotics by Americans, both legal and illegal.  It should be possible to compare the utilization of narcotics by Medicare patients to other groups of individuals or even break out users by diagnosis.  I cannot do that.

I just cannot understand.
It is from my perspective as a former practicing physician that I am most bewildered by the amounts of narcotics prescribed to patients by healthcare providers.  I am an internist who practiced largely as a rheumatologist, taking care of people with arthritis and others with painful musculoskeletal diseases and symptoms. I am no stranger to the Medicare population– indeed, I are one.  Despite the fact that the majority of my rheumatology patients had chronic musculoskeletal pain that often interfered with, or even limited their daily activities, I cannot recall a single patient for whom I felt it advisable or necessary to prescribe narcotics for pain. In truth, I could never even remember my BNDD (the old Bureau of Narcotics and Dangerous Drugs!) number required to prescribe controlled substances– I had to look it up when needed. The people I learned from and practiced with did not use narcotics either– at least as far as I could tell.

The discrepancy between how I practiced and what I see happening in the community has always confounded and even troubled me.  Was I being a bad doctor?  Was I ignoring important needs of my patients? Did they go elsewhere? No one in my medical training had told me to do differently. My patients seemed to like me and stuck by me.  I had enough conversations with other physicians that I felt comfortable I was doing the right things in my disease management strategies. I had many alternatives.  This is what I taught a hundred rheumatology trainees and thousands of students and residents.  It was not that I categorically refused on principle to prescribe controlled substances for chronic arthritis, back pain or similar conditions– it just never seemed to come up!  I must have thought it was not necessary. I must have concluded that the adverse effects of narcotics in this population outweighed their potential benefit. Why switch one bad condition for a worse one?  Narcotics can offer needed comfort, but they are also a leading cause of individual and societal misery. It is no secret that many if not a majority or prescription drug abusers got their start in their doctor’s offices. I observed several started down that path even by the supposedly benign drug Darvon.  Narcotics have universal and often gruesome side effects.  Older folks like me are especially vulnerable to some of them. We get confused.  We fall down a lot.

Is this really new news?
In the past few years as the explosion of  awareness of prescription drug abuse has happened (I do not think the abuse itself was particularly new) I wanted to write about the issue, but did not know what to say, and indeed, was reluctant or even afraid to say what I truly believed.  I certainly do not contest the fact that narcotics are an important group of drugs for some individuals with some conditions. I would not want to die without access to morphine. If I had cancer in my bones that was intolerable despite other analgesic approaches, I would want to have narcotics available to me.  But that is not how we are prescribing these drugs.  I was sick to my soul when patients with fibromyalgia or related conditions would come to me dependent on narcotics others had prescribed– one condition exchanged for a worse one.  In my opinion, the simple fact is that we physicians as a group prescribe too many narcotics for no justifiable medical reason.  There– I have said it!  We as a profession must shoulder the blame for much of the distress these drugs inflict on individual of our patients, and on the community as a whole.

How has this happened?
Has it always been thus?  Have we providers been convinced, brainwashed, or perhaps bullied by accreditors into accepting that we have been undertreating pain and that narcotics are the right answer?  How low do we have to push mandatory perceived pain scores to get a 5-star rating for our hospitals or practices?  Is the patient unquestionably always right? (Of course not– otherwise might as well sell narcotics over-the-counter.)  Given that pain has always been a major, if not the major reason patients come to doctors, has the emersion of stand-alone “pain clinics” and pain doctors fueled the rise of narcotic use or made it easier for unscrupulous physicians to dispense.

There is no doubt that some physicians abuse our privilege as gatekeepers and simply hand out narcotics for money to anyone who asks.  We all understand the term “pill mills.” It is hard to believe a physician would go so low.  Is there a continuum of behavior between criminal intent and convenient inattention?  Drug detail people used to tell me of waiting rooms in rural Kentucky full of patients they perceived as simply waiting to get their narcotic prescriptions filled.  Perhaps some of these needed their pills, but I know of no more reliable way to keep your waiting room full, and to get patients in and out more quickly than by accommodating their requests for narcotics.  How much of the narcotic use by Medicare beneficiaries is unnecessary, abusive, or worse– I do not know.

You broke it, you fix it.
Because it is we as physicians who control the flow of controlled substances into the legitimate and ultimately the illegitimate market, it is our responsibility to aggressively try to fix our mess.  Governor Beshear asked the Kentucky Medical Licensure Board and the Kentucky Medical Association (KMA) (they are almost the same thing) for help in combating the epidemic of prescription drug abuse.  The most apparent response of the Board to me was a series of seminars around the state that seemed to emphasize how to make a patient’s chart bulletproof against an audit. I attended one. No doubt going through the logic of having to justify the administration of narcotics to a patient might actually cause a physician not to use the drug, but in my view at the time, the Board was actually facilitating if not enabling physicians who could and should be prescribing fewer narcotics.

A second state-wide initiative that took on the force of law was for all Kentucky physicians to demonstrate that they had completed several hours of “continuing medical education” on proper prescribing of controlled substances and recognition of the signs of drug abuse in their patients.  I fulfilled this requirement for licensure– the KMA made it easy to do at home.  I had to purchase a small book about substance abuse and take an online quiz.  I confess I did not read the book, and suggest that even an average high school student would have also passed the common-sense test as I did without preparation.  Recognizing the drug dependent or drug abusing patient is not rocket science.  I doubt that the CME requirement is going to change anything but it is something that our legislature and professional organization can point to as having done something.

Exercise of peer review and professional judgment.
We need as a profession to be willing to get our hands dirty and actually ask prescribers to justify what they are doing or not doing.  We missed a big opportunity when Kentucky All Schedule Prescription Electronic Reporting (KASPER) was first introduced several years ago.  A database was established requiring drugstores to keep track of who was prescribing what controlled substances to whom.  The main purpose as I understood it was to enable physicians to check to see if their patients were receiving narcotics from other professionals. In legislative wisdom, and with the lobbying advice of professional medical societies, the initial law prohibited state authorities or law enforcement to look at patterns of use or possible abuse prospectively.  All this in the respect of privacy. This was back in the day when I was mapping small area variation in medical practice.  I visited Kentucky’s KASPER office to suggest that a more prospective approach was to start by looking at narcotic utilization in the top 10 zip codes, towns, pharmacies, or providers; or the top ten patient outliers to determine what was happening.  I predicted (correctly) that examples of frank criminal activity would be found, or that aberrant patterns of unnecessary or inappropriate medical utilization would be identified.  Once the top tens were reviewed, the next tens could be observed. The review would be done principally by health professionals. Today I would add that underutilization should also be considered.  What if I were the only rheumatologist not using narcotics for patients with rheumatoid arthritis? The underlying philosophy of small area of practice variation is that it makes no initial judgment about right or wrong. It can both root out fraud and encourage best medical practices. For these reasons, I am in agreement with the release of the increasing amounts of medical utilization and cost information being released by the government and by private organizations. The cat is already out of the bag.  We need to take advantage of it.

Enough for now.
This is surely a can of worms and I have only just pierced the lid.  Many heartfelt opinions will differ from mine and I am sure I will agree in part with most of them.  What I am confident is that we cannot continue to do what we are doing and expect anything to change.  If we physicians do not take charge, to exercise peer review, or to serve as an active partner willing to do hard and unpopular things, then we have lost our right to complain when others do what we should have. The hospice or palliative-care care physician or oncologist who uses more narcotics than the rest of us has nothing to fear.  The rheumatologist who never uses narcotics may have something to learn.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
June 3, 2015

Addendum June 5, 2015:
I ran a search for other opioid derivatives on lists of abused narcotics– tramadol, fentanyl, and meperidine. Tramadol (Ultram) was approved by the FDA as an analgesic but not as a controlled substance. Failure to restrict this very addicting drug represented a triumph of lobbying over common sense. Fentanyl is the stuff of patches and drug lollypops.  It is both very potent and very expensive. Meperidine was sold as Demerol in the old days but is now much less often used.

These three drugs combined are given to numbers of beneficiaries similar to acetaminophen/codeine but at almost 20 times the cost. The various versions of all three drugs combined were prescribed for 941,699 beneficiaries by 335,980 prescribers, at a cost of $611,939,690.  [I aded some calculated fields to the table such as claims per beneficiary, cost per claim (i.e. per prescription), and cost per beneficiary.]  Reference to the separate provider tables reveals that a few individual physicians are prescribing millions of dollars worth of these drugs to very few patients. The lollypops or lozenges of fentanyl in particular are extraordinarily expensive– if the data are to be believed, thousands of dollars per prescription.

Grand Total.
If f these three opioid derivatives are combined with the traditional opioid narcotics, then 16,103,700 mostly elderly Americans are taking $3,322,090,728 worth of the most highly addictive drugs in the world. These figures do not even include the third of Medicare patients not covered by a drug plan, who do not get the cost savings of negotiated or discounted prices, and have no one looking over the shoulder of their prescriber to offer even simple consumer protections that, alas, seem absolutely necessary. Patients covered by other health insurance plans or the uninsured are not included in the analysis above.  I believe findings from these groups would be the same, and probably more troubling.   In the spirit of the article above, why should state medical licensure boards, public health officials, or law enforcement officials not be looking at lists such as these if for no other reason than to check their accuracy?

Link to list of prescription drug utilization by all Kentucky providers is provided.