Sign of the Times

Epidemic of Oxycontin theft at Walgreens.

ROCHESTER, NH — Police are looking for a suspect who robbed the Walgreens Pharmacy on South Main Street early Sunday morning. According to Sgt. Gary Boudreau, police responded around 2 a.m. to the Walgreens at 104 South Main Street for a reported robbery. Boudreau said a single male entered the store, proceeded to the pharmacy counter and passed a note demanding certain prescription medications. The suspect left the store with an undisclosed amount of OxyContin, Oxycodone and Xanax.

COLORADO SPRINGS, CO--The Colorado Springs Police Department's Robbery Unit is seeking assistance identifying the suspect in the Aggravated Robbery of the Walgreens located at 4713 Flintridge Dr in Colorado Springs on January 4, 2011 at 4:22 pm. During the robbery the suspect approached a pharmacist, threatened he had a weapon and demanded Oxycontin. The suspect fled the store with an undisclosed amount of Oxycontin.

WESTBROOK, CT--State Police are investigating strong armed robbery at a Walgreens in Westbrook. State Police say a man entered the Walgreens and demanded narcotics from the pharmacist around noon on Thursday. Police say he made off with more than 100 OxyContin pills.

TIGARD, OR--The Tigard Police Department is investigating a robbery that occurred Monday afternoon at the Walgreens store at 13939 S.W. Pacific Highway. An employee called 9-1-1 to report the incident at approximately 5:10 p.m.  Police officers arrived and began searching for the robber, who had  demanded OxyContin from an employee at the prescription counter. The robber displayed and threatened the employee with a black handgun, police said.

POST FALLS, ID -- Investigators hope surveillance footage will help them catch a pair of Oxycontin robbers who hit a Post Falls Walgreens Sunday. Police say two men walked into the Walgreens at 706 E. Seltice Way at about 11:00 a.m. and approached the pharmacy counter. One of the men handed an employee a "threatening note", demanding the powerful painkiller. The clerk complied with the note and handed over an unknown amount of pills.

LEXINGTON, KY--Police are looking for a man who stole more than 700 prescription pain pills at gunpoint from a Lexington pharmacy early Monday morning. Witnesses said a man wearing blue jeans and a gray hooded sweatshirt with the hood up entered the store, displayed a handgun and demanded OxyContin tablets. He appeared to be about 6 feet 3 inches tall and about 180 pounds. He drove away in a brown pickup truck after bagging 772 pills, according to a police report.

SPOKANE, WA--OxyContin robberies in Washington have prompted an unprecedented response from one of the nation’s largest pharmacy chains. New time-delayed safes have been installed in Walgreens pharmacies across the state to hold supplies of the powerful painkiller. The timed locks take several minutes to open, halting immediate access to a prescription drug that’s prompted about a dozen robberies at Spokane County Walgreens stores since last fall, often at gunpoint or knifepoint.

Photo Credit: http://localspice.blogspot.com

Codeine Blues: End of the Line for an Opiate with Issues

Canada, UK consider phasing out the drug.

Among the many memorable anecdotes that have been uttered at the opening of an AA or NA meeting, surely one of the great ones is this: “I’m an addict, and a heroin junky. I went to the dentist today, and he sent me home with a prescription for Tylenol 3. And I thought: Do I really want to endanger my sobriety over a shitty buzz like codeine?”

Canada and the United Kingdom are ready to phase it out entirely. The U.S. Food and Drug Administration (FDA) issued a warning about it for nursing mothers as far back as 2007. Codeine, widely popular for its low euphoriant effects, and subsequent (if theoretical) decreased potential for abuse, may not be as strong as morphine and dilaudid, but it is perhaps the most commonly prescribed opiate in the world—and it comes with a major flaw. Unlike other opiates, codeine is very unpredictable in its interactions with an enzyme called CYP2D6. This enzyme is a primary workhorse in the body’s process of breaking down and excreting many different drugs. Poor metabolizers produce less of this crucial enzyme, which means that drugs are broken down and excreted at a much slower pace (See my earlier post ).

 Specifically, as two physicians recently wrote in the Canadian Medical Association Journal (PDF),

“polymorphisms occur in the cytochrome P450 isoenzyme CYP2D6 that enhance codeine metabolism to morphine.” In 2007, following the death of an infant nursed by a codeine-using mother, the FDA “warned nursing mothers that if they took codeine after childbirth, their newborns might be at risk for a morphine overdose,” according to a New York Times report.

Alternatively, other metabolizers may have little or no reaction to codeine-based medications. Drugs of abuse severely complicate these enzymatic issues, since addicts and alcoholics are not known for volunteering information about their condition to medical or hospital personnel.

Testing for the enzyme is possible, but not likely to catch on with cash-strapped medical and dental centers. Dr. Noni MacDonald at the University of Halifax and Dr. Stuart MacLeod at the University of British Columbia argue in the CMAJ that these genetic variations “can have potentially serious clinical consequences. The wrong combination can result in toxic levels of morphine, even at conventional doses of codeine.” The younger the user, the more susceptible he or she will be to these effects, “possibly because of age-related maturation differences in the blood-brain barrier.” The authors warned that serious side effects “including life-threatening respiratory depression,” have also been reported in adults.

The ultrafast metabolizing variant of CYP2D6 is not evenly distributed throughout the world’s population. The number of people in danger of experiencing high morphine levels after codeine use range from 40% in North Africa to 3% in Europe, the authors say. Rates in the U.S. are 8%, meaning roughly one in ten Americans risk an adverse reaction when taking codeine.

Since the groups at highest risk are infants and children, nations have taken various steps to mitigate the risk. “Switzerland sets the minimum age for codeine-based treatment at 1- years, the Netherlands at 1 year, the United States at 3 years and Canada at 2 years.”

Despite these controls, the authors strongly argue for “a more direct approach,” calling for doctors to “stop using the prodrug codeine altogether and instead use its active metabolite, morphine. Not only is the metabolism of morphine more predictable that that of codeine, but also it’s cheaper.” So codeine is just not consistently good at what it does. Problem is, an opiate doesn’t have to be good to be great, as innumerable codeine addicts can attest.

The argument in Canada made sense to Britain’s watchdog agency for medicines, the Medicines and Healthcare products Regulatory Agency (MHRA). According to a report in The Independent by science editor Steve Connor, the MHRA “wrote to medical authorities in the UK warning that its experts have advised that all over-the-counter liquid cough medicines containing codeine should no longer be used in children under the age of 18,” and that “the risks of [over-the-counter] cough medicines for children containing codeine outweigh the possible benefits.”

Codeine is typically offered in paired form, with either acetaminophen or aspirin, as protection against opiate abuse. In theory, a drug abuser would be likely to trigger a Tylenol overdose before reaching an opiate overdose on codeine pills. However, it is perfectly possible to maintain an active opiate addiction on prescription Tylenol 3s, Fiorinal, or Phenergan cough syrup, among other drugs.

And finally, I would not be revealing any great secrets by suggesting that the extraction of codeine from a codeine-acetaminophen tablet through basic solubility and filtration procedures may not be something one needs to be a chemistry major to pull off. 

The OTC medicine industry in the UK views all of this as a tired argument. A spokesperson for Britain’s Proprietary Association, which represents over-the-counter manufacturers, said: "There has already been a long-drawn-out discussion of codeine. If its value as a pain reliever had not outweighed the risks then it would have been withdrawn and the point is that codeine still has a value as a pain reliever.”

photo credit: http://www.buzzle.com/

Mixing up the Medicine: What Alcohol Doesn’t Go With

Drug/Drink interactions are no joke. 

--Mixing alcohol with certain antibiotics, like Furozone and Flagyl, can lead to headache, nausea, vomiting, and even convulsions.

--Chronic alcohol consumption increases the risk of liver damage from surgical anesthetics like Ethrane and Fluothane.

--Alcohol decreases the effectiveness of Inderal, a common medication used to control blood pressure.

--Continued high levels of alcohol activate the enzymes that metabolize Tylenol and other forms of acetaminophen into compounds that can impair the functions of the liver.  In older persons, the combination markedly increases the risk of gastric bleeding.

Get your exercise, eat your vegetables—and don’t mix alcohol with a list of common medications about as long as your arm. Unfortunate but true. But let’s face it—people cut corners on this matter all the time. People like to drink.  With 70 percent of the adult population consuming alcohol at least occasionally, and more than 10 percent consuming it on a daily basis, the 14 billion prescriptions doctors write annually, accounting for more than 2,800 prescription drugs (plus another 2,000 over-the-counter medications) means that the “concurrent use” of booze and pills is inevitable (figures from NIAAA).

But it’s my job to be the wet blanket, and soldier on, and present my readers with a list of common drugs, which, if any of my readers are taking them regularly, means they should not be getting their drink on.

What is actually going on when alcohol and prescription drugs interact? The amount of drug that reaches its site of action is known as its availability. Alcohol can have a direct effect on a drug’s availability and hence its effectiveness. Alcohol in acute doses—a drink now and then, or a few drinks over several hours—can increase a drug’s availability by competing for the same set of enzymes of metabolization. This increases the chances of harmful side effects. Alcohol in chronic doses—long-term heavy drinking—can have the opposite effect, decreasing a drug’s availability and effectiveness by activating metabolizing enzymes, even in the absence of alcohol.

I have edited the list to eliminate low-risk, trivial, or commonly understood interactions. Most people, for example, know that drinking seriously on top of prescription sedatives, opiates and other painkillers, or anti-anxiety medications like Xanax and Valium, is universally understood to be a risky venture. That particular combination is how lots of people stop breathing, permanently.

Having glossed those categories, we move on to a blizzard of other restrictions for daily drinkers, some very serious, some less so. They have been culled from the University of Rochester’s excellent University Health Service site,  and from publications available at the website for the National Institute on Alcohol Abuse and Alcoholism (NIAAA). An extensive list of references can be found at NIAAA’s Alcohol Alert.

--Other antibiotics  that may be responsible for adverse effects, according to the NIAAA, includes Acrodantin, Flagyl, Grisactin, Nizoral, Nydrazid, Seromycin, and Tindamax (all trade names).

--Cardiovascular medication that can cause possible problems if combined regularly with alcohol include Coumadin and Nitroglycerin which may become less effective, while blood pressure meds like Catapres, Lopressor, Accupril, and several others may lead to dizziness and fainting.  The NIAAA also notes potential reductions in the therapeutic effects of reserpine, methyldopa, hydralizine, and guanethidine.

--Allergies/cold medications react with alcohol in the usual way—increased drowsiness, and possible dizziness, particularly in the elderly. Drugs containing diphenhydramine, like Benadryl, or chlorpheniramine, like Tylenol Cold and Flu, can prove substantially more sedating with alcohol.

--The anti-ulcer medications Tagamet and Zantac “increase the availability of a low dose of alcohol under some circumstances.”

--Thorazine, a common antipsychotic, can lead to “fatal breathing difficulties” when combined with alcohol, according to the NIAAA.

--The anti-seizure drug Dilantin may not control epileptic seizures as effectively in chronic drinkers.

There are others, too many to list here. But if you are a chronic drinker—and you know who you are—don’t be so quick to dismiss the variously-worded DO NOT MIX WITH ALCOHOL warnings if you find them on your pill bottles.

Photo Credit:  http://www.doitnow.org/

U.S. Leads World in Prescription Drug Use

It’s complicated.

Wait, wait, it’s a good thing. Mostly.  Or maybe.

While the headline may suggest a story that is either shocking or self-evident, depending upon your point of view, the British study it refers to is based on the level of uptake of prescription drugs for 14 different diseases in 14 different countries. It is not a study of prescription drug abuse, but rather a look at legitimate medical treatment of diseases like cancer, multiple sclerosis, and Hepatitis C.

Measured by volume of use per capita, Americans consume more prescription drugs than any other country.  We’re number one! They can’t touch us! (Spain ranked second, and France was third. New Zealand, Sweden, and Germany ranked at the bottom.)

Seriously, though, we mostly knew that about America already. Another way to look at these numbers is to turn the question around: Why, for example, is the UK in 10th place for cancer drug usage, despite near-universal health coverage? Why aren’t other countries dispensing larger amounts of recognized medications for such diseases as Hepatitis C and rheumatoid arthritis? So, one question the report seems to raise is: why do other developed countries have worse access to prescription drugs than we do?

UK Health Secretary Andrew Lansley, quoted in an article for Nature News, stressed that “high usage does not necessarily equal good performance, nor does low usage indicate a failing.” At the same time, however, Lansley announced a new government fund of 50 million English pounds  “to increase access to cancer drugs.”

With those caveats in mind, we find that the report concludes… well, in the end, the report acknowledges the wide variations in international usage, but concludes that “there does not appear to be a consistent pattern between countries or for different disease areas or categories of drug.”  The study group did not find any uniform patterns that held across drug categories or disease regions. In fact, the report invites interested stakeholders to submit their best thoughts on the matter to internationaldruguse@dh.gsi.gov.uk

Despite this absence of firm conclusions or hypotheses, the report does manage to note some common themes:

-- “Differences in health spending and systems do not appear to be strong determinants of usage.” But even here, the report goes on to offer some thoughts on the dominance of the U.S. “For example, ‘supplier-induced demand’ was felt to be a greater issue in the USA because of the payment structures in that country: where suppliers can charge more for delivering a particular treatment, this may provide perverse incentives to prescribe those drugs.” And: “The majority of countries reviewed provide (almost) universal coverage, with residence in the given country being the most common basis for entitlement to healthcare. The USA is the only country not offering universal access to healthcare; entitlement to publicly funded services is dependent on certain conditions…”

--“Clinical culture and attitudes towards treatment remain important determinants in levels of uptake.” The same reasoning would apply to the U.S., as psychotherapists have struggled for a foothold in the brave new world of medications for diseases with strong mental and emotional components.

--“A country that spends more on healthcare or a country which operates few controls on prescribing could be expected to use more drugs.” But I thought the report said that differences in health spending and systems didn’t make any difference…

Here is the problem with attempts at surveys of this kind. (Departments at the United Nations do a lot of them, as do individual countries.) Mike Richards, the UK’s National Cancer Director, compiled the report--“Extent and causes of international variations in drug usage”—and further qualified the findings: “For some disease areas, high usage may be a sign of weaknesses at other points in the care pathway and low usage a sign of effective disease prevention.”

It is similar to the problem of quantifying addiction. The amount of addictive drug consumed often tells us very little about the problem, or the prospects for amelioration.  However, in a survey like this one, I think coming out on the top is, on balance, better than coming out on the bottom.

What Would a Genuine Drug War Look Like?

An essay on biomedicine and the body politic.

Millions of addicts in America want effective treatment, and cannot get it. Funds for research and treatment are still scarce, compared to money for interdiction and law enforcement. What would happen if we took the billions spent on interdiction and let it flow into addiction research and treatment? What would happen if we gave people truthful, accurate information about drugs, and trusted them to make intelligent decisions more often than stupid ones? Can it end up any worse that the present state of affairs?

Susan Sontag’s warnings about the danger of disease as metaphor still ring true. In modern American society, heart disease, cancer, AIDS, alcoholism, and cigarette addiction account for millions of deaths. They are all disease entities with strong psychological and behavioral components—complicated, multicellular, multi-organ disorders. But they have all been associated, at one time or another, with negative personality traits and moral flaws. The less we know about the mechanics of a human disorder, the more likely we are to view its external symptoms as signs of laziness, or neuralgia of the spirit, or as a form of damage caused by specific kinds of thoughts and emotions. Without a doubt, all kinds of flaws are sometimes expressed in the behavior of people who have these disorders. Yet none of these flaws can be considered the root cause of the diseases.

The genuine drug war is being fought in the arena of biomedicine. Addiction is being added to the roster of physical disorders once thought to be symptoms of insanity, but which are now seen to be physiological disease entities with mental components. The real crisis is the indisputable fact that there exists today an appalling shortage of funds for biomedical research. The cause of the dilemma is a fundamental misunderstanding among politicians and the public about how diseases can be understood and conquered. Research into the viral mechanisms of the common cold may ultimately yield more insights into AIDS then all of the directed research now underway. In biomedicine, there is no guarantee that goals can be reached through the front door, by a systematic assault akin to an engineering project. We cannot, for example, hope to cure addiction, or even the common cold, by means of the same methods we used to put a man on the moon.

There are, however, certain things we can do immediately, if we are serious about drug abuse. To begin with, we can attend to the staggering number of drug-related deaths, injuries, and hospitalizations caused by the abuse of prescription medications. The government itself has proven the case for this contention in numerous reports issued by the National Institute on Drug Abuse and other official bodies. According to the U.S. Department of Health and Human Services, older Americans account for more than half of all deaths from drug reactions, leading one to suspect that the majority of drug fatalities in this country stem from accidentally fatal overdoses by heavily medicated senior citizens. Our national fixation on illegal drugs has blinded us to the verifiable facts about prescription drug abuse.

We also need to recognize the problem of underprescribing morphine and other addictive painkillers for children and adults in hospital settings. One of the great scandals to come out of the drug war is the growing understanding that potent painkillers are not being offered in sufficient amounts to patients suffering intractable and agonizing pain.

“There’s a certain amount of hysteria about narcotics among doctors,” maintains one researcher.

At least half of all cancer patients seen in routine practice report inadequate pain relief, according to the American College of Physicians. For cancer patients in pain, adequate relief is quite literally a flip of the coin.

A September 10 New York Times report highlights studies by the World Health Organization which amply document the ongoing scandal in pain management. At least 6 million cancer and AIDS patients currently receive no appropriate pain treatment of any kind. In addition, WHO estimates that four out of five patients dying of cancer are also suffering severe pain. The numbers of untreated patients suffering intractable, unrelieved pain from nerve damage, burns, gunshots, sickle cell anemia, and a host of other medical conditions can only be guessed at. Typically, non-addicted patients take morphine therapeutically for pain at doses in the 5 to 10 mg. range. But experienced morphine addicts regularly take several hundred milligrams a day—a huge difference. In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold

These outcomes, rather than flashy cocaine seizures at the border, represent the lasting fruits of the drug war.

Photo Credit: www.foreignpolicyjournal.com

Common Medicines That Can Kill You [Guest Post]

Legal but lethal.

[Today’s post was written by Kat Sanders, who regularly blogs on the topic of pharmacy technician certification. She welcomes your comments and questions at her email address: katsanders25@gmail.com.]

Medicines are supposed to save lives, but as with all things that are not used responsibly, they end up killing people more often than not when they are abused. It’s not just illegal drugs that kill; even the ones that are prescribed have the potential to become dangerous when they are not used as they are supposed to be. While we know that heroin, crack and other illegal substances cause death in the event of an overdose, we are not aware of many others that are relatively unknown, but just as dangerous. The below list is not exhaustive but details just a few of the drugs that could lead to death if abused.

NPF: Non-Pharmaceutical Fentanyl has been responsible for more than 1000 deaths (those that have been reported--there are definitely going to be many more that went unnoticed or unreported) between 2005 and 2007, according to the US Center for Disease Control and Prevention (CDC). NPF is a painkiller, one that is also illegally produced and sold because of its narcotic effects. Since it is much cheaper than heroin, sales are high, as are the deaths that it is responsible for. What people do not realize is that when this drug is produced illegally, it is 30 to 50 times more potent and risky than heroin.

Codeine: We would hardly think that the cough syrups we obtain over the counter could end up killing us, but the codeine they contain is a narcotic that causes hallucinations if taken in large amounts. And when cough syrups are abused, they could end up being potentially dangerous, like the case of Chad Butler, the rapper more popularly known as Pimp C. The singer already suffered from sleep apnea, and large amounts of codeine combined with sleep apnea is apparently enough to cause respiratory problems and cause death.

Acetaminophen (Paracetamol): While paracetamol alone cannot cause death, if you are a habitual drinker, your liver is already weak and damaged. And when you take large doses of paracetamol under such conditions, you may start feeling the symptoms in a day or two; you may experience a stomach ache, vomit, and feel pretty ill. Death, if it occurs, happens after four or five days after the overdose, if you do not take any treatment at all in the interim.

Opioid painkillers and Anti-depressants: This combination was responsible for killing up and coming actor Heath Ledger. The star, who was said to be increasingly despondent and depressed, was on anti-anxiety drugs and painkillers as part of his prescription. An overdose (a combination of six different drugs that included sedatives and painkillers) found him dead, just before the release of the blockbuster movie The Dark Knight, the latest in the Batman series and the one that saw him winning a posthumous Oscar for his devilish portrayal of the Joker.
The CDC reports that accidental drug overdoses are responsible for the death of more than 22,000 Americans every year. In fact, it is the second leading cause of preventable deaths, next to automobile accidents. And this is why we need to be extra careful and exercise caution when handling drugs and medicines.

Photo Credit: Canwest News Service

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If You’ve Seen One Drug Czar....

The language of drug politics.

In a May 29 post on his Salon blog, Drug WarRant, Peter Guither deftly deconstructs the language of drug czarism, and its corrosive effect on rational dialog over drug policy:

--So far, there has been little or no discussion of marijuana from the newest drug czar, Obama’s man Gil Kerlikowske, now director of the White House Office of National Drug Control Policy. “I've got to admit that it's a nice change from the reefer madness reign of Walters,” Guither writes. “Maybe Kerlikowske is following my mother's age-old advice... If you can't say something nice (and he can't by law), then don't say anything at all.”

--Prescription drugs are “the new crack.” To his credit, Guither worries about this new emphasis, and where it is likely to lead: “The prescription drug "epidemic" will be an excuse to further crack down on diversion, which will end up continuing the focus on pain doctors who prescribe large amounts of pain medication, with DEA agents deciding they know more than doctors. The result will be even more people suffering, unable to get the pain medication that actually makes life possible for thousands of people.”

--Drugs cause crime. As proof, Kerlikowske cites the statistic that half the men arrested in ten major U.S. cities tested positive for some sort of illegal drug, as reported by USA Today. From this data, Kerlikowske concludes that there is “a clear link between drugs and crime.” Guither notes that “There's a lot of reasons that people who have been arrested would tend to test positive for illicit drug use than the general population..... A very large percentage of arrests are for drug crimes, which naturally skews the population. Then there are socio-economic factors and a lot more.”

However, what the new drug czar is implying, writes Guither, is that drugs cause crime. “But implying that drugs cause crime is a lie. And that's what drug czars do.”

Kerlikowske has also come out in favor of greater use of drug courts as an alternative to prison sentences. Bill Piper, director of national affairs for the Drug Policy Alliance Network, told USA Today he agreed that drug use should be seen as a public health issue, but that “people shouldn't have to get arrested to get treatment."

Photo Credit: Lifehype Magazine

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