1990s saw hard push for legal opiates

Washington’s emergence as a state with one of the highest rates of both opiate prescriptions and deaths was not, in hindsight, an accident.

In 1995, Purdue Pharma introduced OxyContin in an aggressive marketing campaign, pitching the drug as a salvation from chronic pain. The next year, Washington’s Medical Quality Assurance Commission issued new liberalized guidelines addressing the undertreatment of chronic pain. By 1999, they had been codified into law specifying that “no disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed.”

The relaxation of the rules resulted in a run-up in prescriptions. In 1998, the average daily dose of morphine equivalents prescribed was 80 milligrams, said Dr. Gary Franklin, medical director for the state’s Department of Labor and Industries. By 2002, it had nearly doubled to 140 milligrams.

The same trend was going on around the country. In 1997, opioid sales amounted to 96 milligrams/person in the United States. A decade later, they had mushroomed to 698 milligrams/person, Franklin said.

Franklin was among the first to notice an alarming corollary effect: The drugs used to kill pain were also killing people.

“Workers were coming in for low back sprains and dying,” he said. In 2005, Franklin and his colleagues published the first paper in the country to link worker deaths to prescription drugs.

As the deaths and hospitalizations continued to mount, an even more unsettling trend emerged: the disproportionate escalation of deaths among the state’s Medicaid population.

The rise in the death rates of Medicaid patients tracks with the state’s cost-saving decision to move many of its poorest residents to the cheapest, most potent pain reliever available: methadone.

For decades, methadone was associated with treatment for heroin addiction. But it can also be used to treat pain, and currently more than two-thirds of all methadone prescriptions are written for pain, not treatment for addiction, said Caleb Banta-Green, researcher with the University of Washington’s Alcohol and Drug Abuse Institute.

While it’s the least expensive of all the opiates, it’s also much stronger than morphine, more addictive and trickier to manage.

When it’s used for treatment of opiate addictions, it’s heavily regulated; patients have to go to a methadone clinic and take their doses under supervision.

When it’s prescribed for pain, there is no such supervision. People pick up the prescription and take it as they would any other pill. But because methadone doesn’t produce the same euphoric high as other narcotics, it’s more difficult for people to tell when it’s left their system. That’s one reason people overdose on it more frequently.

In 2003, the state agency that administers Medicaid made methadone the “preferred drug” for long-acting opiates on its formulary, the list of drugs Medicaid covers. Because methadone is so much cheaper than oxycodone or other types of pain pills, the move drove down costs considerably, said Dr. Jeff Thompson, medical director of the state’s Medicaid program. A few years ago, the agency was spending $20 million annually on painkillers for Medicaid patients. Now it spends about $12 million, he said.

But as costs came down, deaths went up. And many patients are still on high doses of painkillers. Medicaid has between 3,000 and 4,000 patients who are already over the new legal threshold of 120 milligrams a day, he said. About 700 are over 1,000 milligrams a day, and a few people are on up to 10,000 milligrams a day.

Studies have shown the risk of death increases up to ninefold at 100 milligrams.