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.

Pill Head: Book Review

Desperately seeking Vicodin.

Recently, the Office of National Drug Control Policy, home of the nation’s “drug czar,” released a survey of the nation’s drug use, demonstrating that prescription drugs used non-medically have become the nation second most “abused” drug, after marijuana. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) chipped in with a cheery report that painkiller drug abuse had increase by a staggering 400% from 1998 to 2008.

 Radio entertainer Rush Limbaugh’s 2006 bust put prescription drug abuse on the public radar. Limbaugh surrendered to authorities on a charge of prescription fraud involving pain pills, the result of a three-year investigation into Limbaugh’s addiction to oxycontin—an addiction that may have cost him his hearing.  (Earlier, in 2001, Winona Ryder was arrested for shoplifting and found to have collected 37 prescriptions for painkillers from a total of 20 different doctors.)

Joshua Lyon, the young author of Pill Head: The Secret Life of a Painkiller Addict, can tell you exactly how people have pulled that off: Steal a prescription pad. “Doctor shop” with a list of hard-to-disprove physical ailments. (Migraine is a favorite.) Impersonate a physician and call a pharmacy if you have his or her Drug Enforcement Agency (DEA) number. Perhaps connect with a corrupt pharmacy employee, or with an organized ring of truck thieves. Another favorite is stealing pills from old people. Or you can suck it up and try buying them in bars or on the street. For a while, Joshua Lyon found a workable shortcut: “I just posted a bulletin on my MySpace page, asking if anyone had any Vicodin they wanted to sell. By the next day I had three different offers.” Users have learned to easily circumvent the time-release formulations by crushing the pills and snorting the powder, like Edie Falco’s Nurse Jackie. Corrupt doctors don’t appear to play a major role in much of this, even though they are a favorite DEA whipping boy.

Lyon’s pain pill odyssey began in 2003 when, as a 27-year-old reporter for Jane magazine, he was assigned a story about the “no prescription needed” Internet pill farms that were stuffing everyone’s email inbox with spam about cheap drugs. The author placed his orders, and in a few days, received Fed Ex boxes containing Xanax, Valium, and Vicodin. In only one case was he required to talk to a prescribing doctor over the phone. The "doctor" briefly asked him why he wanted painkillers, and then simply asked him how many pills he wanted.

No stranger to drug use, and a frequent habitué of the gay club scene in New York City, Lyon quickly discovered that prescription opioids were his drugs of choice. “The media,” he writes, “hadn’t dubbed us ‘Generation Rx’ for nothing.” A DEA official told Lyon: People taking Vicodin or hydrocodone, which is probably the most popular pharmaceutical drug in the United States, get the same rush as they would taking heroin, but you’re taking something that people perceive to be safe.”

There is at least a partial answer to prescription drug abuse: digital prescription databases. Unlike other addictive drugs, opioid medications begin life as legal compounds, licensed and produced under specific federal guidelines. The implementation of an electronic prescription drug reporting system, something several states have already undertaken, is a first step, but is obviously limited by the lack of a federal clearinghouse. And privacy concerns have hampered attempts to systemize the collection of prescription records from different doctors.

A health worker in a Lower East Side naloxone program told Lyon that if he called the ambulance about an OD, “don’t tell them that it’s an overdose. Tell them your friend has stopped breathing. They’ll come faster that way.”

All of this makes the ready availability of naloxone, the anti-overdose drug, an ethical imperative. See my posts on overdose kits for opioid addicts HERE and HERE.

Graphics Credit: http://blog.makezine.com/