Psychiatric Medications Kill More Americans than Heroin

www.rehabs.com/pro-talk-articles/psychiatric-medications-kill-more-americans-than-heroin/#disqus_thread

We often hear the shocking fact that deaths from heroin increased nearly 5 fold (374%) between 1999 and 2014, but rarely – if ever – do we hear that deaths from psychiatric drug overdoses have increased nearly 4 fold (278%) over the same time period. The data are summarized in Figure 1.

The biggest killers are sedatives (benzodiazepines such as Xanax and Z-drugs such as Ambien), antidepressants, psychostimulants (Ritalin, amphetamine, and methamphetamine), and antipsychotics, in that order, as shown in Figure 2.

What accounts for this high overdose death rate for users of psychiatric medications and for the steep climb in death rates over the past 15 years? A number of factors appear to contribute to this, including increased prescribing, increased polypharmacy (prescribing multiple drugs to the same person at once), increased off-label prescribing, and increased prescribing of psychiatric drugs by non specialists, including general practitioners, nurse practitioners, and others untrained in the field of psychiatry. We will proceed to look at each of these factors below.

According to data from the MEPS (Medical Expenditure Panel Survey) database, the number of prescriptions for psychiatric medications (i. e. sedatives, antidepressants, psychostimulants, and antipsychotics) increased 117% between 1999 and 2013, from 197,247,557 prescriptions in 1999 to 427,837,506 prescriptions in 2013. Meanwhile, death rates from psychiatric medication overdose climbed a whopping 240% over the same time period, from 1.31 deaths per 100,000 in 1999 to 4.46 deaths per 100,000 in 2013 (we are excluding the CDC death rate data from 2014 since the MEPS 2014 data has not yet been published).

Details of prescribing by drug class are given in Figure 3 and percentage of increase in prescribing is in Figure 4. Although the increase in number of prescriptions partially accounts for the increase in death rates, it is clear that it does not account for all of them, and that there must be other factors involved. Those primary factors are most likely polypharmacy, off-label prescribing, and non-specialist prescribing.

Polypharmacy

Although medical scholars use the word polypharmacy in several different ways, the simplest definition is “the prescription of two or more drugs at the same time.” In other words, drug mixing. In some cases, such as HIV treatment, polypharmacy is an evidence-based best practice. In other cases, such as psychiatric treatment, there is little research to back up most instances of polypharmacy; moreover, inappropriate polypharmacy can be harmful or even deadly.

Kingsbury and Lotito (2007) state that:

“A great deal of data exists about the dangers of polypharmacy. Persons with psychiatric disorders experience increased risk for adverse drug interactions because of the great frequency with which multiple medications are used. Using multiple antipsychotics concomitantly has been associated with increased mortality in patients with schizophrenia. Reports of adverse psychiatric polypharmacy effects are abundant, including increased duration of hospital stay.“

Kukreja et al. (2013) tell us that:

“While evidence for the added benefit of psychiatric polypharmacy is limited, there is growing evidence regarding the increased adverse effects associated with such combinations. Concerns with polypharmacy include not only possibilities of cumulative toxicity and increased vulnerability to adverse events but also adherence issues which emerge with increasing regimen complexity.“

Mojtabai and Olfson (2010) report major increases in psychiatric polypharmacy: in office-based psychiatry practices in the United States the median number of medications prescribed per visit doubled from 1 in 1996-1997 to 2 in 2005-2006 and the mean number increased by 40.1% from 1.42 in 1996-1997 to 1.99 in 2005-2006.

In Figure 5 we show the percentage of deaths due to drug mixing in each psychiatric medication class in 2014. Figure 6 lists the drug combinations with psychiatric medications which had the highest death rates in 2014.

Off-label and general practitioner prescribing of psychiatric medications: Off-label prescribing refers to prescribing a drug for a reason other than one which has been approved by the FDA. Although there are instances where off-label prescribing is based on sound published scientific evidence, this is not so in the vast majority of cases. Radley et al. (2006) found that only 4% of off-label psychiatric prescriptions had strong scientific support. Ali and Ajmal (2012) report that off-label prescribing carries clinical risks, such as adverse effects and unproven efficacy. Additionally, Mojtabai and Olfson (2011) report that 72.7% of antidepressant prescriptions in 2007 were written in the absence of any psychiatric diagnosis. Moreover, according to Mark et al. (2009) less than one fourth of prescriptions for psychiatric medications are written by psychiatrist, over three fourths are written by general practitioners, nurse practitioners, and others untrained in the field of psychiatry.

In my personal experience running an alcohol support group, I have had countless women tell me that, despite admitting they were drinking too much, their GPs still prescribed an SSRI antidepressant and, shortly after starting the antidepressant, their alcohol consumption went through the roof. This is not surprising, in light of the fact that research by Naranjo et al. (1995) showed that women treated with SSRIs drank significantly more than women given a placebo; a survey by Graham and Massak (2007) also found antidepressants were useless for reducing drinking in women. Unfortunately, doctors who have been encouraged to write off-label prescriptions frequently jump to the conclusion that women who drink too much must be depressed, so they wind up prescribing an antidepressant that actually makes them drink more. There is a great deal of potential harm which can result from off-label prescribing.

Alternatives to Drug Therapy

Wouldn’t it be great if there were some way we could permanently change the wiring of the brain to ameliorate or eliminate things like depression, anxiety, and schizophrenia without a lifetime reliance on potentially deadly drugs? Actually there is: it is called psychotherapy.

Everything you do which changes the way you think also changes your brain. Recent neuroimaging studies of people who have undergone Cognitive Behavioral Therapy (CBT) by Porto et al. and by Quide et al. show different patterns of brain function than those who have not had such therapy. There is another type of psychotherapy known as Dialectical Behavioral Therapy (DBT) which incorporates mindfulness and meditation practices into CBT. A large body of neuroimaging studies by Newberg demonstrate that mindfulness and meditation practices also permanently change the functioning of the brain.

But what about schizophrenia? Isn’t the only hope for schizophrenics to keep them doped up in a zombified stupor until the day they day? A recent New York Times article titled “New Approach Advised to Treat Schizophrenia” says no; the best treatment for schizophrenics is minimal use of antipsychotic drugs and lots of psychosocial therapy. The article then goes on to tell us that there is actually nothing “new” in this treatment approach, as it has been used in Scandinavia and Australia with great success for decades. It is only new to American psychiatrists who are too ignorant and arrogant to learn anything from the rest of the world and will only accept a study that has been carried out in America. But the reality is that it is not new – even in America. It is the model pioneered by Loren Mosher back in the 1970’s before Big Pharma got him fired from his post as chief of NIMH’s Center for the Study of Schizophrenia…because he was interfering with the profits from their latest huge money maker: antipsychotic drugs.

The reality is that drugging patients into a stupor with huge doses of antipsychotics prevents recovery from schizophrenia. This is why third world countries like India and Nigeria have much higher recovery rates for schizophrenia than the US; they cannot afford antipsychotic drugs which have good short term effects and very bad long term effects. Harding’s Vermont study found that half to two thirds of unmedicated schizophrenics recovered and Harrow found similar results. This is in stark contrast to medicated schizophrenics whose recovery rate is around 10 to 20%.

Conclusion

When prescribed appropriately, psychiatric medications are lifesaving, life changing wonder drugs. However, when over-prescribed or inappropriately prescribed they can lead to great harm and even death. What is needed is a major curtailment of polypharmacy, off-label prescribing, and non-specialist prescribing. The use of psychiatric drugs needs to be reduced to a mere fraction of current use rates and needs to be replaced or supplemented with appropriate psychosocial interventions which include not only therapy but such basics as housing, food security, and education. Money needs to be invested in social change rather than pill popping if we wish to create a healthy nation.

Would we say that just because insulin is good for diabetics that everyone should take it? No, that is nonsense because it would totally destroy a normal metabolism. Yet this is exactly the approach we are taking with psychiatric medications thanks to the misinformation that Big Pharma feeds to doctors and the general public in order to increase their sales and line their pockets.

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A new wrinkle in the cannabis/rights issue:

17-year-old Native American man was issued a cannabis card through Alternative Wellness, a consortium of physicians I work with. He had sustained a back fracture as a passenger in a car crash at age 16. He was offered opiate therapy and declined. He has found cannabis to help his severe back pain. He obtained Two physician signatures as required by law for pediatric cases.

He was given a urine drug screen prior to the start of his wrestling season, he displayed his cannabis card to the athletic director, his urine drug screen came up positive for cannabis only, and they mistakenly suspended him from participation in sports for 10 days. Their next mistake was to recheck his urine two weeks later and it was still positive for cannabis( not surprisingly, given cannabis takes 30 days to clear). Then they suspended him for 30 days, effectively ending his wrestling season.

William’s grandfather William has been a patient of mine and contacted me about this.

I spoke with Williams father Jake and he delineated the whole story to me.

At some point the athletic director recommended William obtain a prescription for Marinol, hoping that that would settle the issue.  Marinol is a schedule II Rx often given for nausea. It is derived from cannabis, highly expensive, yet often used in patients who want to use cannabis while having a “legitimate“ prescription.

Because time is of the essence I wrote that Prescription and sent it to William’s father Jake.

Apparently, William is still suspended, endangering his entire wrestling season.

William is now 18. He and his father are still working hard to save his wrestling season.

Jake, the father, presented the Rx to the coach, AD, and principal.

They each told Jake,”Well, this is above my pay grade”, and William remains suspended.

Weirdly, because of the positive urine screen for cannabis William is being forced to go through alcohol and drug treatment counseling. Another weird factor is the person doing the urine drug screening is the person doing the drug and alcohol counseling. My concern Is that we are taking a young man with goals, thwarting those goals, then teaching him about drugs and alcohol while he has nothing to do as his wrestling teammates keep working out.

In the same way as taking a infant away from their breast-feeding mother is a violation of civil rights, prohibiting a young man with a legitimate cannabis card from wrestling also seems to be a violation of his civil rights.

I have not used last names In this letter, though Jake has given me permission to talk to anyone about his son’s case.

I was a wrestler in high school. I remember how important my sport was to me. I have also worked in Wolf Point and Poplar in the past, so I care.

If this kind of case sparks your interest please contact me at 406-439-0752.

I will happily share with you the family’s contact information.

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The Medical Board of California has launched investigations into doctors who prescribed opioids to patients who, perhaps months or years later, fatally overdosed.

The effort, dubbed “the Death Certificate Project,” has sparked a conflict with physicians in California and beyond, in part because the doctors being investigated did not necessarily write the prescriptions leading to a death. The project is one of a kind nationally, although a much more limited program is operated by North Carolina’s board.

So far, the board has launched investigations into the practices of about 450 physicians and referred the names of 72 nurse practitioners, physician assistants and osteopathic physicians to their respective licensing boards.

To date, the regulators have formally accused at least 23 doctors of negligent prescribing, and more accusations are expected. Some of the accusations, like one 63-page document filed against Dr. Frank Gilman, a San Diego internist, detail hundreds of prescriptions for one patient over four years, most of them by him. Gilman did not respond to a request for comment.

Using terms such as “witch hunt” and “inquisition,” many doctors said the project is leading them or their peers to refuse patients’ requests for painkiller prescriptions — no matter how well documented the need — out of fear their practices will come under disciplinary review.

The project, first reported by MedPage Today, has struck a nerve among medical associations. Dr. Barbara McAneny, the American Medical Association president and an Albuquerque, N.M., oncologist whose cancer patients sometimes need treatment for acute pain, called the project “terrifying.” She said “it will only discourage doctors from taking care of patients with pain.”

The influential California Health Care Foundation also has pushed back against the project, saying it could harm patients. (California Healthline is an editorially independent publication of the California Health Care Foundation.)

Unusually aggressive for the board, the program is a reaction to the by now well-known phenomenon of physicians over prescribing opioids. Nationally, a host of policy changes and educational efforts have driven down the rate of opioid prescriptions in recent years.

The goal of California’s program, quietly launched four years ago, is not necessarily to link a doctor’s specific prescription to a specific patient’s death — although many of the cases do — but to find doctors whose patterns of prescribing are so dangerous they may lead to patients’ ultimately fatal addictions.

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Steve,

It’s a weird situation, Employer got on the phone with Caremark yesterday and verified I can fill that prescription and they would cover it. They even called the pharmacy and were told all they were waiting for was my Dr to verify the prescriptions. They claimed their phones were down for 24 hours.

Now today the Drs office let me know that CVS would not under any circumstances accept me as a customer because of my high dose.

So the insurance carrier Caremark will cover the dose but CVS will not fill it.

Now I have to pharmacy shop to find one that will fill my prescriptions. In the mean time I can’t go to work because of the pain and getting sick from withdrawals.

   I have been exchanging emails with this pts for months and has been put thru the ringer by various healthcare providers. This pt needs a high dose of opiates due to a accident 2-3 decades ago and taking this high dose enabled this pt to engage in a highly technical job on a full time basis and generating a income way above the average.

This pt has seems be entangled in the new CDC guidelines and pain specialists who are exempt from such guidelines but are still functioning under the premise that they are not and targeting this pt to being weaned down to the 90 MME’s limits.

It will be interesting if this pt is forced to go on disability, if an attorney will be able to see the “substantial financial damage” that is being caused and willing to take on a case on a contingency basis ?

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A little known group is making decisions about which Orange County lives are worth living

https://www.ocregister.com/2019/01/21/a-little-known-group-is-making-decisions-about-which-orange-county-lives-are-worth-living/amp/

The affordability and accessibility of health care coverage continues to be a kitchen-table concern for Orange County residents and their families. The California legislature in 2018 took important steps to introduce transparency to the health care system and reduce what patients pay out-of-pocket for their medications. Unfortunately, a little-known Boston-based organization is making determinations right now about which Orange County lives are more valuable than others and who should have access to the medical care they need.

The Institute for Clinical and Economic Review (ICER) is a research organization and medical review board that makes recommendations about whether new medications are “cost-effective” and whether insurance companies should cover those treatments. To arrive at its recommendations, ICER uses a complicated mathematical formula called a “value framework,” which determines how much an insurance company should spend on any given person.

The problems with ICER’s research and methodology are legion, but the fundamental problem is this: ICER is making decisions about the value of a human life – about what a life is worth and whose life is worth saving – based only on financial considerations. If you are an Orange County resident living with a life-threatening or chronic disease, such as cancer, cystic fibrosis, arthritis, or many others, ICER’s formula is likely to determine that your life is worth less than that of a healthy person.

Simply because a patient has the misfortune to get a disease does not make his or her life any less valuable than that of a healthy person.

Another deficiency in ICER’s approach is that they fail to give meaningful consideration to what patients living with the affected conditions say about what improves their quality of life. There is little transparency into what goes into ICER’s formulations or how they arrive at their conclusions, which means other researchers are unable to analyze and replicate ICER’s results. Finally, in addition to being cruel and punitive, ICER’s one-size-fits-all approach to insurance coverage is likely to discourage efforts to develop innovative new treatments for many chronic and life-threatening conditions. It’s just a bad model.

If ICER were simply a research organization publishing reports that collected dust on a shelf, the stakes would not be nearly so high for California patients. However, payers have recently begun to use ICER’s assessments to deny patients access to treatments.

Pharmacy benefit manager (PBM) CVS Health recently announced a new prescription drug management program that would exclude from its coverage some new treatments that do not meet ICER’s cost-effectiveness benchmarks. Earlier this year, the state of New York decided to cap Medicaid spending for a cystic fibrosis treatment based on ICER’s research. This happened without public comment, which makes the precedent even more dangerous.

The conclusions that ICER reaches are less surprising given that ICER is backed by the insurance industry. Blue Shield of California and Kaiser are both funders of ICER. Steve Pearson, the founder of ICER, is a former insurance executive and has worked for the health insurance industry lobby group America’s Health Insurance Plans (AHIP). The board of ICER includes representatives from Blue Shield, Kaiser and UnitedHealth. Former Enron trader John Arnold, a prominent funder of insurance industry interests through his foundation, has given ICER $19 million.

It is time that we stop pretending that ICER is a neutral arbiter of the value of medicine and instead recognize them for what they are: an insurance industry-funded PR machine whose goal is to drive up insurer profits at all costs, even at the expense of patients.

Physicians are in the best position to know how to treat a patient. He or she knows the patient’s medical history, how the patient responds to treatment, and any other biological factors that could impact the success or failure of a medication. Decisions about how to treat patients should not be made based on an algorithm or what is most profitable for a health insurance company. No two patients are alike and so the ICER one-size-fits-all approach does not work.

The rising cost of health care is perhaps the most critical health care issue facing Californians. As we continue the conversation about meaningful solutions, California policymakers should consider the full range of cost drivers, look at who is funding attempts to influence policy, and be wary of health insurance company interests making recommendations about what an Orange County life is worth.

Chris Buchanan is on the board of the Neuropathy Action Foundation, an Orange County-based patient advocacy organization.

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Why are Ohio’s medical marijuana prices so high?

https://www.cincinnati.com/story/money/2019/01/20/why-ohios-medical-marijuana-prices-high/2602221002/

Moments after CY+ Dispensary sold some of the first legal medical marijuana in Ohio, the crowd of patients waiting outside for their turn to make state history wanted to know one thing: How much?

They weren’t happy with the answer: $50 cash for a small plastic container holding 2.83 grams of dried marijuana bud, or just under $500 an ounce.

“I’ll buy one today to say I did it, but I can get it a lot cheaper than that elsewhere,” said one man who declined to be named.

How cheap? Michigan dispensaries charge between $150 and $300 an ounce, depending on the variety, or strain. Patients say that’s similar to prices for illicit marijuana in Ohio. 

Dispensaries sold 8.7 pounds of marijuana on Ohio’s first day at an average price of$538 per ounce, according to sales figures released Thursday.

Why so much? There are a few reasons.

Regulated and tested

Marijuana sold in legal markets have a hard time competing with product sold on the black market for several reasons.

Legal marijuana businesses have to comply with regulations for pesticides, tracking every plant with sophisticated software, security and more. They also pay taxes, and because marijuana remains an illegal substance on the federal level, they can’t deduct expenses the way other businesses can.

Ohio law requires every medical marijuana product to be tested by an independent state-licensed lab. There are only two in operation. The labs test for pesticides, mold and other contaminants. They also test for amounts of various marijuana compounds including THC, which generates a high, and cannabidiol, or CBD, which doesn’t.

Ohio’s program allows individuals with one of 21 medical conditions to buy and use marijuana if recommended to them by a physician. Eligible conditions include AIDS, cancer and others where consumers’ immune systems could suffer from tainted marijuana.

Limited supply

The state has licensed 29 businesses to grow marijuana, but only 14 have finished building their facilities and been approved to start growing. None of the state-licensed processors are operating, so oils, lotions, patches, edibles and other products are not yet available. 

The four dispensaries that opened Wednesday sold only dried marijuana flower, or bud, from a handful of medical marijuana cultivators.

“If I wanted to open today, I had to buy it from them,” said Mike Petrella, who owns Ohio Valley Natural Relief dispensary in Wintersville.

Dispensaries set prices based on what they pay for the product; state regulators have no authority to limit or change prices. Most of the varieties sold Wednesday were priced the same. Officials from the first four open dispensaries say prices should go down as more cultivators harvest and compete.

Some dispensary owners plan to offer discounts to veterans, senior citizens and others. The Forest Sandusky offers a 20 percent discount to veterans.

More regulations

In Michigan and other states, flower can be packaged in the dispensary. Not in Ohio.
Growers and product manufacturers are the only ones who can package products, and dispensaries have to sell products in the original, sealed packaging.

Ohio has some of the highest marijuana business licensing fees in the country – $200,000 a year for large-scale growers and $70,000 every two years for dispensary owners. Businesses pay additional fees to the state to register employees and pay a $100 fee for each strain or dosage of a product.

“There’s a higher cost of production to adhere to all the regulatory requirements and to deliver that product to the consumer,” said Jason Erkes, spokesman for Cresco Labs, which operates CY+ Dispensary. Cresco also has an Ohio cultivation license and operates medical marijuana businesses in Illinois and Pennsylvania.

Prices in Illinois averaged $450 an ounce during the first week of sales in 2015. Current prices there range from $240 to $420 an ounce, according to dispensary websites.

Pennsylvania started selling flower in August 2018, and prices are now hovering around $300 to $480 an ounce, according to dispensary websites.

The ‘Ohio tenth’

One specific regulation sets Ohio apart from the 33 states that allow cannabis for medicinal use.

Rules set by the Ohio State Pharmacy Board, which oversees dispensaries, require marijuana flower and infused products to be packaged in certain amounts, called “whole day units.”

A unit of dried flower is 2.83 grams, or 1/10th of an ounce. Where did that number come from? State law limits patients to buying and possessing no more than a “90-day supply,” but didn’t define it in law.

The pharmacy board decided to set that number at 8 ounces of dried flower or an equivalent amount of THC in marijuana products. The limits came from a panel of pharmacists who reviewed clinical research about the marijuana compound. 

No other state has calculated limits this way.

The only product sold Wednesday was little containers with one “Ohio tenth” of buds inside.

On Tuesday, pharmacy board spokeswoman Ali Simon said flower had to be packaged in 2.83 gram amounts. On Thursday, Simon clarified it can be packaged in greater amounts, as long as the total is made up of whole daily units.

Buckeye Relief, a large-scale cultivator in Northeast Ohio, planned to start packaging in larger quantities after the first day of sales.

“I’m sure we’re all trying to drive costs down for patients over the long haul,” Buckeye Relief CEO Andy Rayburn said.

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