The Painkiller That Saves Money But Costs Lives 385
Hugh Pickens writes "Over 2,000 patients have died since 2003 in Washington State alone by accidentally overdosing on a commonly prescribed narcotic painkiller that costs less than a dollar a dose and the deaths are clustered predominately in places with lower incomes because Washington state has steered people with state-subsidized health care — Medicaid patients, injured workers and state employees — to methadone because the drug is cheap. Methadone belongs to a class of narcotic painkillers, called opioids, that includes OxyContin, fentanyl and morphine. Within that group, methadone accounts for less than 10 percent of the drugs prescribed — but more than half of the deaths and although Methadone works wonders for some patients, relieving chronic pain from throbbing backs to inflamed joints, the drug's unique properties make it unforgiving and sometimes lethal. 'Most painkillers, such as OxyContin, dissipate from the body within hours. Methadone can linger for days, pooling to a toxic reservoir that depresses the respiratory system,' write Michael J. Berens and Ken Armstrong. 'With little warning, patients fall asleep and don't wake up. Doctors call it the silent death.'"
Re:Cynicism (Score:5, Informative)
No perchance, and it was idiotic to even say, since you have easily looked it up and see that its protection was basically stripped from a defeated Germany in 1947. Wikipedia is your friend, laziness is not.
Possible FRAUD Alert (Score:5, Informative)
To me, that article and all the data to which the Slashdot story linked screamed incompetence or fraud. Now that I've read a little of the linked data, I realize the writers are at least partly incompetent. Possibly only whoever started them looking was engaged in fraud to sell more expensive drugs.
I just discovered that I'm not the only one who thinks that. [nwsource.com] Short quotes, read the full comments:
"It does not matter if you switch every body to oxycontin or oxycodone. These drugs are terrible at controlling pain and all are very dangerous."
"... I have an issue with how the Seattle Times is drawing a correlation between poverty and methadone poisoning.
Possibly Methadone is more often given to people who have little education, and who are therefore more likely to overdose because they didn't understand the instructions, or because they have other issues that confuse them.
Re:Accidental overdose? (Score:5, Informative)
Overdose isn't when you take more then prescribed, it's when you take more then what your body can handle.
As such most overdoses are accidental.
Re:Do you have poor reading comprehension? (Score:5, Informative)
Maybe not on your planet, but here on earth, educated people have a much better chance of making money, and people with money are likely to get a better education. People with poor reading skills, or other problems with communication are likely to be on very low incomes all their lives.
I acknowledge that educated people can be poor whether short or long term, but they are not the same boat at all.
Re:it is harder to get high on (Score:5, Informative)
It's prescribed as a painkiller more often than as a treatment. I'm a pharmacist and I go through methadone like mad and not on the prescriptions I fill is for addicition. I spoke to a pain doctor once who told me it was a cheaper alternative to OxyContin, which can run $600/month without insurance. Methadone runs about $30 a month without.
Some patients with insurance won't take OxyContin because their copay is high.
Re:Accidental overdose? (Score:1, Informative)
Here you go, slothbag;
http://www.pharmacy-mistake.com/eight-year-old-sickened-after-pharmacy-refills-prescription-with-methadone-instead-of-ritalin
http://www.wate.com/Global/story.asp?S=3580654
That took 30 seconds. Maybe you could have helpfully posted it yourself in about the same length of time it took to be a prick about it. And being wrong in your implication that it was false.
Asshole.
Re:Accidental overdose? (Score:2, Informative)
You said the kid died. Nobody died.
Re:Do you have poor reading comprehension? (Score:2, Informative)
I just bought a 50-pack of Ibuprofen 600 for 5€ (the same price that every drug costs) and a 30-pack of Omeprazol for 0€ (unless it's free ;), thanks to my health insurance which is paid by a tax going off of my salary.
And if I lose my job, there is a government agency that pays for it no matter how long I'm without a job. (Yes, they push you into getting a job and send you job offers. But there is nothing wrong with that.)
I can go to the doctor or hospital as often as I want and I get what's necessary. It's not perfect, but for a couple of € more a month, I get premium healthcare.
Problem, America? :D
Re:it is harder to get high on (Score:5, Informative)
Why not use diamorphine?
Too short of a duration of action. The purpose of using morphine as a replacement for OxyContin is because it's long acting, providing analgesia throughout the day. Diamorphine has a short, intense onset (which is why it's so addictive) and a similarly rapid cessation.
The current regulatory environment in the US, where diamorphine is Schedule I, may also have something to do with it.
(For those who are less pharmaceutically inclined, diamorphine = heroin.)
Re:it is harder to get high on (Score:5, Informative)
It's prescribed as a painkiller more often than as a treatment. I'm a pharmacist and I go through methadone like mad and not on the prescriptions I fill is for addicition.
That's because in order to use methadone to maintain addiction, both the prescriber and the dispensing pharmacy have to be specially licensed. I've never heard of a chain or independent community pharmacy licensed as such. Methadone clinics usually have the prescribers and the dispensary at the same site.
Suboxone and the other buprenorphine-containing compounds have similar restrictions on the prescribers but not on the dispensing pharmacies. That's why you see DEA numbers starting with X on Suboxone scripts . . . it means the prescriber has been specifically licensed to manage opioid dependency.
methadone is very useful in managing chronic pain (Score:5, Informative)
Methadone's pharmacokinetics give it a long half-life, and therefore a long duration of action. This is an asset in managing chronic pain from cancer and some other diseases. Methadone has much less tendency to lose its analgesic effect through habituation. Morphine, for example, while an effective pain reliever due to its action on the mu-opioid receptor, has a metabolite that acutally upregulates perception of pain due to action on the NMDA system. This latter effect probably accounts for most of the often-observed dose escalation needed to maintain effective analgesia in patients treated with morphine. The primary danger of methadone is that physicians who are unaware of its comparitively slow pharmacokinetics overdose their patients because they escalate the dose too fast. It is critical to make changes (either increase or decrease) in methadone dosage *slowly* - when that is done, the drug can provide chronic pain relief with a much better combination of safety and long-term effectiveness than many of the other opiates. As always, ignorance seems to be the most deadly disease.
Re:Is it cost, or painkiller paranoia? (Score:4, Informative)
From the other perspective, my brother is an ER doctor. He sees many drug-seekers every week. They'll come in claiming specious injuries (my neck hurts) and demand Oxycontin. Last week, some guy claimed that he never had Oxycontin before but needed it. A quick check revealed he had eight prescriptions already. And it's not just anecdotal evidence. Countering drug seeking behavior is one of the more important lessons ER doctors have to learn.
What is anecdotal is my brother's disdain for pain management doctors. He calls most of them quacks who are legalized drug pushers. That's not to trivialize your experience or to denigrate your doctor, but apparently many of these dudes are making money pushing Oxycontin.
Re:Both Major Parties' Face of Future Medicine... (Score:3, Informative)
Yes but the policy was put in place during a time when the Republicans controlled 100% of the federal legislative line (House, Senate, Congress) and were screwing with the funding that comes from Medicaid/Medicare, forcing states to try to do precisely this.
And it's not just Washington state, this is happening across the nation. Where I live, public medical care (which my grandmother is on) REFUSES to pay for a prescribed non-generic medication if there is a "generic alternative" available, even if her doctor's specifically prescribed the non-generic due to previous reactions to the generic or the generic not being effective in the patient's case.
So yes, I blame the Republicans. They were in charge federally, they're the ones on the "cut costs cut costs cut costs we don't give a fuck about human lives" bandwagon. You think what Washington State has right now is bad, imagine what it'll be like when these retarded motherfuckers pass something like the "Ryan Plan" where everyone has to hunt for private insurance and hope to god that they don't have a preexisting condition that'll prevent them from getting it.
I don't buy it (Score:5, Informative)
In terms of pharmacodynamics, methadone is a garden variety opiate. It has two major distinctions: it has good oral bioavailability, and it is long-acting (i.e. it has slow pharmacokinetics). These are major advantages for people with chronic pain. Morphine has poor oral activity, and also wears off fast. This makes it good for intravenous infusion in a hospital setting, but terrible for patients with severe chronic pain. One aspect of opiate analgesia is that once the pain "breaks through," it is hard to knock it down again. Opiates work best for pain relief if blood levels are kept reasonably constant. So with a short acting opiate, patients have to be constantly popping pills. A long-acting opiate makes it possible for a patient with chronic pain to live something approaching a normal life.
Respiratory depression by opiates tracks very well with pain relief, so it is not plausible that the respiratory depression would greatly outlast the pain relief, as claimed in the article. Moreover, we have a huge amount of experience with methadone, because it is widely used for opiate maintenance in opiate addicts. Opiate addicts take methadone under supervision, so they can't escalate their doses. So we know that when methadone is taken as prescribed on a regular basis, it is safe and effective, and toxic levels do not build up in the body.
I think that this is a problem of poor patient and physician education and poor choices by physicians in prescribing a long-acting drug to patients who don't really understand what that means. The average patient has no experience with long-acting pain relievers, because all of the commonly used medications such as hydrocodone are short-acting. The pain relief of a long-acting opiate lasts a long time, but it is also slow in onset. This is an unavoidable aspect of the pharmacokinetics of long-acting drugs. That means that you can't wait until you start hurting, then take a methadone pill and expect the pain to go away in under an hour, as with short-acting drugs. It will take days for the pain relief from methadone to build up to its full level. A patient who doesn't understand this is likely to think, "It isn't working," and take more than the prescribed dose--and then when it does build up, they end up in respiratory depression.
There is no way to have a long acting opiate pain killer drug that does not carry the same risk as methadone. The same hazards apply to oxycontin (which is a time-release formulation of a short-acting opiate, oxycodone).
So the patient needs to be told in no uncertain terms, "This isn't a drug where you can wait until you start hurting and then take a pill. It won't work, and it is dangerous to take it that way. You must take it on schedule, every day. You can't take extra even if you are hurting. If you miss a pill, don't take extra to make up. If you take more than the prescribed dose, or take it more often than prescribed, you may DIE." And the doctor needs to be absolutely certain that the patient understands this and is capable of complying. If not (or if there is not a reliable care-giver capable of controlling dosing), then the patient should be prescribed a short-acting narcotic (although this carries its own, different risks).
Re:it is harder to get high on (Score:4, Informative)
I do not frequently prescribe methadone (I am a physician) because it's not often I have patients on chronic opioid medicine who I consider responsible enough to use it safely. And, I have seen inexperienced staff at pain specialty clinics nearly kill people a few times. But, if your drug plan won't cover sustained-release oxycodone or morphine (common until a few years ago in the US when morphine SR finally went generic) it's a viable alternative.
For a list of "worst" opioid agonists in terms of effectiveness for pain, consider codeine and propoxyphene (as in Darvocet in the US), both of which don't seem to be more effective than acetaminophen/paracetamol.
Re:Both Major Parties' Face of Future Medicine... (Score:2, Informative)
Therefore, it's a giveaway of tax money to large corporations--a Republican specialty. However, do you hear Democrats calling them out on it loud and clear? No? Why not? Everyone needs to start asking questions like that.
The largest giveaway to large corporations in the history of the world was signed into United States law with a Democrat House, a Democrat Senate, and a Democrat President. Only a single Republican, in both House and Senate combined, had voted for the bill.
It was called the Patient Protection and Affordable Care Act, a name that appeals to emotion.
The Republicans do call out corporate give-aways, but the heart-string yanking Democrats have bamboozled everyone into believing that the Republicans are the #1 offenders, and oh.. they are rich racists too. More than one Republican tried to stop the government-funded housing bubble years before it exploded.. they (such as McCain and Paul) were called racists right there on the floors of both House and Senate by Democrats (such as Frank and Waters) when they tried.
If the obscene buying of Democrat votes as the Health Care bill ballooned into thousands of pages didn't convince you, nothing fucking will.