What's an emergency?

"emergency warning" issued after 2,173 deaths

In May of 2004 Washington State's preferred drug list took effect the only preferred drugs on it for long term chronic pain were methadone and morphine.  For years afterwards the rising death toll was a topic of discussion and debate at the monthly Pharmacy and Therapeutics Committee meetings without any definitive corrective action being taken.


Two years and nine months after the Feb. 18, 2009 meeting of the P&;T committee, during which it was stated that the deaths due to methadone overdose were continuing to occur; it was also stated that this 'issue' had been a regular topic for 3-4 years by then.  AFTER the death toll was publicized by the Seattle Times on December 10, 2011, the State of Washington's Medicaid program announced that it was issuing an EMERGENCY WARNING---Issuing a warning after two thousand people have died, is kind of like teaching your child about fire after they have burned your house down playing with matches... 

Strictly speaking, issuing a warning years after the State P&T committee members were aware, (and after over 2,000 deaths!) is not really much of a warning...it's obvious the situation wasn't considered an EMERGENCY---it seems as if it was issued because the deaths were publicized.


here are some excerpts from that 2009 meeting

WASHINGTON STATE PHARMACY AND THERAPEUTICS COMMITTEE MEETING
February 18, 2009

"So I mean…I can’t remember if it’s sixth or third, but the bottom line is Medicaid is almost 50% of all prescription related deaths in the State of Washington and growing. And so we’re just now doing the 2007 runs where we actually load DOH’s death certificate data into our claim system, and so we’ll be able to feedback and see, you know, are we now 50+% of the deaths. And I just think, you know, this is something I’m hopeful the state could start taking on a little bit stronger, because I think this is a distinction that we don’t want, and it just keeps growing. And quite frankly, I’m at a loss of what to do.

"The issue is not just opiates. The issue is who are getting these opiates? And then this is a slide that shows the ratio…or the percent of clients who have a psychiatric dose…or psychiatric diagnoses as it relates to the deaths. And basically, it says that at less than 120 mg of morphine equivalent, you know, a little less than 60% of the people have a mental health diagnosis. What is a sad fact is as we increase the amount of morphine that goes into our clients, the more likely we’re treating also a person that has a mental health issue.

"So we are giving our most vulnerable clients in the State of Washington huge doses of narcotics, and so that’s the first face. The next face applies to substance abuse, so that the more you get in a morphine equivalent, the more likely you are to have a substance abuse issue.

"And when you consider that on top of this we’re treating some of our bi-polar clients and schizophrenic clients and other, now, children who are getting some of these other medications, including the atypical antipsychotics as well as the antidepressants…I mean, the…we just compound the issue.

"And then I think the sad fact is now we’re creeping down into the teenagers. So these are teenage deaths with narcotics that are prescribed to the teenagers who have a coroner or a death certificate data that state on a more likely than not basis that the death was related to a narcotic. (emphasis mine)

"And so what is the distribution by prescribers? Well, you can see that in over 1,000 milliequivalents per day, we have about 35 providers that prescribe in these doses.

"in the 35, it includes the University of Washington, Harborview as well as some very reputable pain specialists as well as some solo practice, ARNPs, and family practice, etc., etc.

"there’s no agreement on how high you can go, and it is a number of small providers that believe that you can go up several thousands of milligrams a day. I think our highest is up to 7,000 or 8,000 milligrams of morphine a day.

"And then again, I think methadone is an issue. I mean, we would hope that these 35 prescribers actually know about the issues with methadone and its depo effect and that small genomic class of clients who might actually have the unfortunate gene history to actually have increased amounts of this. But methadone is not our only high use, it includes hydromorphine as well as fentanyl, and so some of that fentanyl is actually even being used at nursing homes. I mean, that’s a very frequent event where fentanyl is used in lieu of multiple dosing through the day to save some nursing time. But I would stipulate that it’s all the drugs; and just eliminating methadone alone from the preferred drug list is not, I think, the solution. Next slide.

"You know, and again, when we work together…and I think Siri’s come up with a really nice in the original 320 group that were 10 or more prescriptions per month, which we found out was not 100% sensitive and specific for abuse or misuse, that when we notified the prescribers, we saw an instant 25% reduction because of the poly-prescribing issue." Jeff Thompson

"The prescriber got the client into this issue. I’m going to be really…I’m going to be firm. On the 1,000 mg, it is a prescriber issue. It’s not a client issue, because the majority of these clients are getting them from just one prescriber. Out of the 800, there’s about 200 that are getting it from more than one prescriber. So this is a prescriber issue, not a client issue. I’m sorry, these are, but I really…I think that we’ve gotten ourselves into this problem as medical professionals. It’s not the client’s problem. unnamed man

"Jeff, this is Carol Cordy. It sounds like you’ve spoken with some of these 35 prescribers personally
Jeff: Yeah.
Carol Cordy: You have?
Jeff: Yeah.
Carol Cordy: And do they…I mean do you get the sense that they don’t want to be in that position  not to be prescribing all that narcotic?
Jeff: They typically don’t see the problem.
Carol Cordy: They don’t? So there is the problem."
here the discussion about pain killers begins on pg 86

In 2010 Senator Charles Grassley asked for information on the top prescribers of pain medications and neuroleptic drugs because of the rampant illegal marketing, and Medicaid fraud. What is interesting is an email from the Governor's Office:

Why wouldn't  Washington State respond?

 Then there is this:

A top prescriber who accounted for 1-2% of the entire Rx budget but the problem is considered resolved when SHE closes her office---

via The Seattle Times

State plans emergency warning on risks of methadone

Washington state will issue a public health advisory that singles out the unique risks of methadone, a commonly prescribed pain medicine that's linked to the most accidental overdose deaths.

By Michael J. Berens and Ken Armstrong

12-21-2011

A few excerpts:

"To save money, the state steers Medicaid patients, workers' compensation recipients and state employees toward methadone, a long-acting painkiller that costs less than a dollar a dose. Since 2003, at least 2,173 people in Washington have died from unintended overdoses linked to the drug, The Times found.

"Committee Chairwoman Karen Keiser, D-Kent, became frustrated with Dr. Gary Franklin, medical director for the Department of Labor & Industries, which handles workers' compensation.

"Keiser asked Franklin — a principal defender of the state's decision to designate methadone as a preferred drug — if the painkiller is more difficult to manage than other long-acting narcotics. When Franklin responded by discussing the toll of long-acting opioids in general, Keiser said: "Dr. Franklin, answer the question about methadone."

"She later told him: "That's something I'd like to get a straight answer on. And I'm not getting a straight answer."

"Franklin told lawmakers that methadone is not at the heart of the state's struggle with painkiller overdoses. "It's dose, not a specific opioid," he said.

"Almost no one dies from a single opioid. When you look at death certificates, and I've reviewed many of these at L&I, you never see just methadone or just OxyContin or just fentanyl listed," he told the committee.

"Coroners, in fact, will not ever say on a death certificate that this death is from methadone. It is always a combination of multiple opioids plus other drugs."

"But a Seattle Times analysis of death certificates turned up 443 cases since 2003 in which methadone was the only drug listed when someone fatally overdosed. And this was using a conservative sift, excluding cases where the deceased had so much as a history of alcoholism.

emphasis mine)

"Sen. Cheryl Pflug, R-Maple Valley, told Franklin that she was troubled even by those cases in which methadone had combined with other drugs to cause a fatal overdose.

"I don't really care that the coroner isn't willing to say this was caused by methadone," she said. "If the person has a toxic level, and they were taking methadone and other drugs known to have a synergistic, respiratory depressive effect, and they quit breathing, it doesn't take a rocket scientist to know we might have a problem."  State Plans Emergency Warning 12-21-2011

PHARMACY AND THERAPEUTICS COMMITTEE MEETING

February 15, 2012

a few excerpts:

"And we’re left with the background problem, which is what we had when we looked at the Oregon Medicaid study from 2007, which is that the number of people who are prescribed methadone have a much higher rate of substance abuse history and also a much higher risk of opioid death than people prescribed other types of long-acting opioids. And so to pin the cause of those deaths on methadone relative to other long-acting opioids is tricky. And in the 2007 study when they controlled for history of substance abuse there was no longer and increased risk with methadone. I would say that there is no question that this is a very high risk class" Barak Gaster

I'd like to know Mr. Gaster, if this is an accurate statement, how many were dying before??!!

"it’s interesting that when the PDL was instituted in 2004 it coincided roughly with a…the brakes being put on and the rise of methadone deaths. And so it’s hard to say that methadone being on the PDL is contributing in a significant way to the number of deaths." Really Mr. Gaster... 

"So if you remember back in August… this is Jeff Thompson. We brought to you the top 20 prescribers represent 70% of the high dose in Medicaid and we sent letters and gave them feedback reports and I personally called all 20. And they are all actively engaged in the new law. They are getting education. Some are pain specialists. Some are primary care doctors. Some are ARMPs that do refill mills or refills. And all very concerned with what’s going on and are actively engaged with us."  

Susan Rowe: "This may crossover into DUR but we’ve talked about other classes of medications that also increase respiratory depression. And so my thought is that on our agenda for this next year would be to look at some of our pain patients and how many are getting concomitant benzodiazepines, muscle relaxants and other things that put them in danger as drug combinations are used." here

What a good idea! I can't help but wonder why education about the use of prescription drugs and over the counter drugs which pose a risk when used concomitantly with opiate pain medications were not part of prescriber education already... 

via Investigate West

New Prescription Drug Law Holds Promise, but Concerns Linger

JANUARY 22, 2012
By Carol Smith
InvestigateWest

a few excerpts:

"The passage of a new law, regarded as one of the toughest in the nation, makes Washington the first state to require dosing limits for doctors and others who prescribe these medicines. The law, RCW 2876, went into effect January 2, but those who have watched the epidemic spiral out of control still see significant challenges ahead."

Lax Oversight

"A key limitation of the new law: While it gives state regulators a reason to discipline doctors, the statute does not require the state to check whether doctors or other medical professionals are breaking it.

"That’s in contrast to the U.S. Drug Enforcement Administration, which monitors whether medical professionals with narcotic permits are following its rules. The new state program also falls short of Washington’s Medicaid program, which routinely tracks how much narcotic medication doctors hand out. Instead, the system set up by the new law relies on complaints from patients or medical professionals to trigger investigations.

"As a result, the Medical Quality Assurance Commission, which investigates doctors and other healthcare professionals, can’t say how much of a problem excessive prescribing is for Washington doctors, dentists, advanced nurse practitioners, physicians assistants and other providers licensed to prescribe these powerful medications.

"The state’s actions came after the doctor’s offices had been raided the previous year by DEA agents, an action that resulted in charges related to financial transactions the DEA indicated could be used to hide drug trafficking activity.

"Doctors and others disciplined for drug-related issues are usually given chances to go into rehab, get additional training, or pay fines. In 2009, however, Spokane-area doctor Keith L. Hindman, went to prison for health care fraud and prescribing controlled substances for non-medical purposes.

"The DEA, in contrast to the state, does carry out surprise inspections. The agency has shut down the top five prescribers in the state over the last several years, including a clinic in Vancouver, Washington.

"For his part, Thompson of Medicaid sent a letter last summer to the top 20 doctors prescribing opiates to Medicaid patients, alerting them that they’d been flagged for the volume of their prescribing.

“That doesn’t mean they are good or bad doctors,” he said. “There is no definition. However, it does say, it’s worth looking at why they are so high.” here

Jeff Thompson: 

In 2009 there were 35 prescribers that Thompson was concerned about. Between Feb. 2009 and April 2010 the five top pain drug prescribers were prosecuted. A sixth, the top neuroleptic prescriber, whom Thompson stated in his April 22, 2010 email accounted for 1-2% of the entire Medicaid Rx budget closed her office. It seems that it would be advisable to investigate and prosecute her criminal behavior, and perhaps retrieve the money defrauded from the public coffers...NO Effort was made to recoup the money defrauded from the people of Washington through the Medicaid program...   

It appears the warning letters sent were a response to Grassley's investigation. 

A strange thing about the data that Washington State sent to Senator Grassley's office: Why weren't the national provider numbers issued in 2007 used to identify the top prescribers listed?