By R Carter.
I last reported data from Ohio Department of Health in March 2019. In that report Ohio reported on more than just drug overdose deaths. Ohio has begun to release some information from its PDMP, in these reports you will see much more. In this series there will be data which goes back to 2010 when the State first began keeping records. This series will update that report and take a closer look at overdose deaths related to prescription opioids and illicitly manufactured Fentanyl (IMF). With several hundred documents to review I will update and clarify as I work through the facts.
Ohio continues to show a progressive decrease in the number and amount of prescribed opioids which began in 2010. In amounts measured for all Ohio Counties by Average Daily MME per Patient and Quarter, prescribed opioids have dropped from a high of 23.3 in 2010 to 16.4 MME in Q3 2019. That’s a 30% reduction over the last nine years. In amounts measured for all Counties by Average Daily MME per Capita for all Ohio residents per County and Quarter, amounts have decreased from a high of 2.5 MME per resident in 2010 to 1.06 MME in Q3 2019, or a 42% reduction over nine years.
In contrast to these declines a new report on the use of Buprenorphine (Suboxone) during the same time frame, shows only a slight decrease in its use for chronic pain patients, but with an overall decrease per capita. From Q1 2010 to Q3 2019, the daily MME for Suboxone drops slightly from 24.1 MME per patient by County and Quarter to 22 MME in Q3 2019. Compared to a per capita basis, the daily dosage dropped from 2.6 MME per Ohio residents to 1.5 MME per person by Q3 2019. This suggests that while overall prescribing dropped, a high percentage of patients were being migrated to Buprenorphine.
Once again this reflects fear which exists on behalf of prescribers through the optics of feeding an addiction problem which is clearly based in the black market sales of illegal drugs. For those unfamiliar with Suboxone, here are the risks if you are a chronic pain patient.
First of all, Suboxone is not a pure Mu-opioid agonist, unlike traditional opioids. This quote from Providers Clinical Support Systems, “Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: Implications for clinical use and policy.” Drug Alcohol Depend S0376-8716 (14)01025”.
“Despite the increasing clinical use of buprenorphine (BUP) and buprenorphine/naloxone (BUP/NX), there are still questions about how the binding of these medications to the mu-opiate receptor in the brain relates to their treatment effects. One important clinical question is whether there is any benefit to prescribing higher doses than those needed to prevent opioid withdrawal.”
Naloxone is the leading drug used to reverse the effects of Mu-opioids, Naloxone competes with other opioids for receptor sights in the brain and spinal cord. When occupying a receptor sight, they offers no pain relief benefits. Consequently either Buprenorphine or the same mixed with Naloxone requires significantly higher doses actually leading to greater difficulties and greater risk should force tapering occur.
In either case Buprenorphine’s lack of affinity for Mu-opioid receptors makes it a poor pain reliever for the most difficult types of pain. For this reason, the FDA has not approved it for use in chronic pain management. It’s only FDA indication is for Opioid Use Disorder because of these well documented effects. From my perspective, Buprenorphine is not much better than Tramadol for managing chronic pain.
Secondly, although physicians often prescribe medication for what is known as “off label” use, because of the stigma associated with any kind of opioid use, a patient is at greater risk by agreeing to take Suboxone when it is offered. As we’ve seen so many times before, once started on pain management, and subsequent to a physician backing away from treating chronic pain, a patient is forced to look elsewhere for a prescriber. Since all physicians are now required to check a PDMP before prescribing, most physicians will take one look at a history of Suboxone treatment and automatically assume the patient has a history of drug abuse. And for that reason will likely refuse to prescribe anything. This makes taking Buprenorphine a stigma trap which all chronic pain patients should try to avoid.
The next graph looks at total doses, a single pill is considered a dose of opioid. This graph like the others is for each pain patient and per capita during the same time frame, Q1 2010 through Q3 2019. Total average doses per patient, per County and Quarter, in 2010 was 147 doses. By Q3 2019 that had dropped to 129 or a 13% decrease over nine years. On a per capita bases, the drop is more significant showing a 51% drop from a high in Q3 2010 of 17.04 pills per resident to 8.35 pills per resident in Q3 2019.
With regards to Buprenorphine (Suboxone) the trend is similar to that seen in the previous Buprenorphine graph. From a high in Q1 2012 of 151.87 doses per patient, per County it dropped to 129.47 doses in Q3 2019. On a per Capita bases, it reached a high of 17.19 doses per resident in Q3 2011 to a low of 8.9 doses per resident in Q3 2019. That’s a 51% decrease per resident over nine years, yet the dosage per chronic pain patient barely decreased.
This trend suggests that while total doses of Buprenorphine per resident were dropping, in contrast to that, more chronic pain patients were being migrated to Buprenorphine for pain management. Setting many up for the stigma trap that would follow, when a physician chose to exit the practice of pain management, leaving their patients high and dry. Such a move adds injury to insult.
In Part 2 I’ll look at a heat map of Ohio counties, starting in 2010 compared to Q3 of 2019. You will see how dramatically efforts at curbing prescribing in Ohio, have impacted the State and more specifically chronic pain patients.