Prescription Drug Deaths Major Killer In The U.S.

View the Los Angeles Times analysis; a state-by-state map of drug-induced deaths; and a comparison of deaths from drugs, motor vehicles and firearms.

The Los Angeles Times has found that prescription drugs are responsible for thousands of deaths annually. Reporter Lisa Girion and the American Pain Society's Dr. Roger Chou discuss the findings and what might be done to address the problem.

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NEAL CONAN, host: This is TALK OF THE NATION. I'm Neal Conan in Washington. About 100 people a day die from drug overdose, and most of those are preventable deaths, in which doctors, pharmacists and patients all bear some responsibility.

A recent analysis by the Los Angeles Times found that drug deaths now outnumber those killed in traffic accidents, and prescription drugs are largely to blame. In part that's because we've steadily reduced traffic fatalities; safer cars, stricter laws, tougher enforcement. So where's the seatbelt for prescription drug overdose?

If you're in health care, how do we reduce the number killed by prescribed medication? Give us a call, 800-989-8255. Email talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, we'll talk with Atul Gawande about why coaches are important in all fields and at every level of experience, but first the problems caused by prescription drugs. Lisa Girion is a staff reporter for the Los Angeles Times, a contributor to the paper's coverage on this issue. She joins us from Culver City, California, and the studios at NPR West. Nice to have you with us today.

LISA GIRION: Thank you.

CONAN: And some may be surprised that heroin or cocaine aren't the leading cause of drug overdose deaths.

GIRION: Right. No, they're increasing but not as much as prescription drug overdose deaths.

CONAN: And what are the numbers like?

GIRION: Well, every - over the past few years, there's been about 12,000 prescription drug deaths involving prescription pain drugs and anti-anxiety drugs and closer to 4,000 each for heroin and cocaine.

CONAN: And as you look at those deaths by prescription drugs, they seem - well, prescription drugs have become underground drugs, too. You can buy Oxycontin from drug dealers.

GIRION: Absolutely. I've been out on undercover drug-buy stings where undercover Los Angeles County sheriff's deputies have purchased Vicodin, Oxycontin, drugs like that, right out on the street. This was a few blocks south of City Hall, very near my newspaper, a place I'd walked before and didn't realize it was an open-air drug market.

And it's also a place where, in the past, illegal drugs have been sold.

CONAN: And some people might think the problem is mostly teenagers, who either buy those drugs from open-air markets or pilfer them from their parents' medicine cabinets.

GIRION: Yeah, and that's what I thought when we first started looking into this. But as it turns out, when we backed up and looked at the death statistics that are collected by the government, most of the deaths occur among people in middle age, and some of the greatest increases in overdose deaths in the past five to 10 years are among people even older than that, in their 60s.

CONAN: Why?

GIRION: Well, I think - we don't know all the reasons, and there's a lot of research going on in this area now, but one of the reasons is that middle-aged people are on a lot of pain and anxiety drugs. They've got aches and pains, they've had, you know, surgeries, on-the-job injuries, things like that, and so they're taking these drugs.

CONAN: And so the drugs are available, but why do they overdose?

GIRION: Any number of reasons. We've seen a lot of cases where people start out with a workplace injury innocently enough and become dependent or actually addicted on the drugs and ultimately take too many.

We've seen cases in this older age group especially, we've seen some cases of women in their 60s also taking the drugs for pain who made the mistake of taking doses too closely together, and that was enough to cause their death.

CONAN: And there's also combinations of drugs. Sometimes doctors aren't aware that a patient is getting one kind of medication and prescribes something else for another condition, and then the two drugs interact.

GIRION: Yeah, we see that. We see people on - a lot of these deaths are poly-drug deaths, where we somebody who's on at least one pain drug, which are called opioids, they're synthetic versions of heroin. Then they'll be on an anti-anxiety drug, a benzodiazepine, like a Valium or a Xanax. And then they might also be on some kind of psychiatric drug, potentially prescribed by a second or third doctor.

And there are interactions and synergistic effects, but for the pain drugs and the anti-anxiety drugs, those are both respiratory depressants. So they both make it hard to breathe, and, you know, eventually you take one too many, and that's sort of the straw that breaks the camel's back.

CONAN: And it's interesting, as you looked at the situation with traffic fatalities, a lot of those advances, improvements - in terms of greater car safety, in terms of stricter laws, in terms of stricter enforcement - they were made urgent by lobbying groups like Mothers Against Drunk Driving, that sort of thing. People were outraged that this was going on.

Is there any kind of similar organizations, any kind of similar passion in this issue of prescription drugs?

GIRION: Absolutely. We have talked to many, many - again, it's the mothers, as it happens, and in one case a father, as well, a man named Bob Pack out here in California. But there's lots of parents of kids who die, teenagers, who are shocked at the ease with which their children were able to get drugs either from doctors or on the street or what they call a rainbow or Skittles party where kids will throw drugs into a bowl and take a handful.

And they're very shocked, and they're trying to bring attention to this issue, and they're working with state lawmakers and people in Washington. There are bills all the time coming up to try and address this. But I think we're still at the point where the solution, the seatbelt, isn't quite clear.

CONAN: The seatbelt isn't clear. Obviously, there's a combination of things that improve car safety, too, and it's not going to be one magic bullet. But you may think it's apples and oranges; cars and traffic accidents and prescription drugs, but both things are necessary to our society. You're not going to control the supply side by banning it. People are going to need prescription drugs for good purposes.

GIRION: Precisely, and I think that's one of the reasons why - we weren't the first to make the comparison between drug deaths and traffic accident deaths. Public health officials with the CDC and others have been looking at these too, kind of trend lines of, you know, sort of large numbers of preventable deaths, as they've been coming together for several years.

And you're right. I mean, it's ironic. It's - in a way that you've got these technologies, you know, one that helps us all be mobile and the other one that helps us live with pain, but there is a downside and a risk to using both.

CONAN: We're talking with Lisa Girion of the Los Angeles Times about a recent story that she's been doing on the problems posed by prescription drugs. We'd like to hear from health care people, those of you who work in health care - pharmacists, doctors, nurses and people involved in dispensing these drugs. And 800-989-8255. Email talk@npr.org. Where do we find that seatbelt? Let's start with Douglas and Douglas with us from Rochester in New York.

DOUGLAS (Caller): Hi, thanks for taking my call. I've been - I was an alcohol and drug counselor 30 years ago, and I've been watching this problem for a long time. It's not new. What I wanted to comment about is: One, I had a family member who was seriously injured by prescription drugs, not dead, but is on permanent disability as a result of them. So there's another side to the issue.

What I wanted to comment about was I have several physicians who are clients of mine; I have a counseling practice, and both the emergency room physicians have expressed the same problem, which is that they're under pressure in the situation that they're in, and they're graded in a certain way on their performance, which includes patient feedback.

So they'll get clients, patients coming in who are drug-addicted, on Oxycontin, other drugs like you've mentioned, and will press for the drugs. They're under a lot of time pressure. They have a lot of people to see. If they spend the time discouraging that patient, it ends up scoring negatively against them.

So they feel a high degree of pressure to write the prescription, to get rid of the drug-seeker so they can go on and treat the people who really need help and also to keep themselves from being in a place where they could lose their position because they're getting negative scores against them from drug-seeking patients.

CONAN: And I'm sure that you put it that way and people think, well, gee, that's hardly ethical, and they're not supposed to be giving drugs to addicts.

DOUGLAS: Yeah, absolutely true, hardly - not ethical, but on the other hand, if your family's well-being is based on your ability to maintain that job, there's a lot of pressure for you to not get those negative scores, and there's no incentive in the system for you doing the right thing.

Both the physicians who see me do the right thing every night, and it's exhausting them, but they're surrounded by physicians who don't. So they get excessive pressure because the other physicians in the system are writing those prescriptions. They're fighting against the tide, and they're risking their professional standing to do so.

CONAN: Douglas, thanks very much for the call, appreciate it. Let's bring another voice into the conversation. Dr. Roger Chou is an associate professor of medicine at Oregon Health and Science University. He's also the director of clinical guidelines development at the American Pain Society. He joins us now from his office in Portland, Oregon. Nice to have you with us.

Dr. ROGER CHOU: Thanks for having me.

CONAN: And I wanted to bring you to respond to that point that our caller made, that doctors feel a lot of pressure to give out dangerous drugs.

CHOU: Yeah, I think that's true. I think there are circumstances where physician performance is graded, and part of that may be patient satisfaction-dependent. And I think that one of the things we've learned in kind of understanding how pay-for-performance and those kinds of incentives work is that it isn't always necessarily about making the patient happy.

Physicians need to make tough decisions sometimes about what's appropriate and what's not, and in some cases, that may mean not using opioids and having to explain why. And I certainly agree that we shouldn't be punishing physicians for making good clinical decisions.

CONAN: Do you agree that sometimes that can be the perverse result, though?

CHOU: Yeah, I mean, I think that can happen. I think in primary care settings, it also happens where, you know, we're in the business of trying to help people, and, you know, a lot of these patients, especially the ones with chronic pain, are really suffering. And these drugs are viewed by many people as, you know, the only thing that's going to help them, even though we know from the evidence that we're accumulating now that these are not a panacea, that they don't tend to take away the pain completely and that there's a lot of downsides. And so, you know, we need to be more sophisticated and thoughtful about how we use these drugs, and in some cases, like I said, we may not be making patients happy because they feel like we're not doing what they want.

CONAN: We're talking about drug overdoses. If you're in health care, how do we reduce the number killed by prescribed medications? Where's the seatbelt that will bring down the startling number of preventable deaths? Give us a call, 800-989-8255. Email us, talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

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CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan. For the most part, causes of preventable deaths continue to drop steadily, not drug overdoses. Decades of safety measures and tougher regulations helped drive traffic fatalities lower, to the point where drugs now kill more Americans than traffic accidents, more than 37,000 in 2009.

And prescription drug overdoses are a particular concern and almost entirely preventable. Cars eventually got seatbelts, airbags and other safety features. Where's the equivalent of a seatbelt for drug overdoses? If you're in health care, how do we reduce the number killed? 800-989-8255. Email talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Our guest is Lisa Girion, a staff reporter for the Los Angeles Times. We've posted a link to the article she helped write, "Drug Deaths Outnumber Traffic Fatalities in U.S.," at our website, npr.org. Click on TALK OF THE NATION. Also with us, Dr. Roger Chou, who's an associate professor of medicine at Oregon Health and Science University and director of clinical guidelines development at the American Pain Society. He's with us from Portland, Oregon.

And let's see if we can get another caller on the line. This is Marcella, Marcella with us from Houston.

MARCELLA (Caller): Hello, thank you for having me on. I'm a labor and delivery nurse, and what I have noticed out of my years, things that would reduce it is better evaluation of mental health status of some of the patients. Because we tend to get some patients who abuse and also share those drugs and have come across problems while being on those prescription drugs.

CONAN: So better mental health evaluation. How does that help?

MARCELLA: Well, for - I mean, I actually do some of that evaluation. What I found is that patients, when they're not having pain anymore, but they have that medicine on-hand, they tend to take that to help to sleep. It gives them a stable mood, some of them, like the Vicodin. I've had patients confess that when they've been depressed, they've taken those medicines also so that they can alleviate some of the bad feelings that they're having, and they're not being evaluated for the mental health.

So I'll make those referrals, but they'll still sometimes abuse those medications for that reason.

CONAN: Lisa Girion, is that something you found in your work?

GIRION: Well, yeah. We have seen a lot of cases where there was some kind of mental health issue going on and potentially some psychiatric drugs onboard, along with the pain drugs. And so - and I think there's a lot of active research in that area, the extent to which mental health problems either cause or have something to do with addiction and overdose.

CONAN: Marcella, thanks very much for the call.

MARCELLA: You're welcome, have a wonderful day.

CONAN: Here's an email from Ann(ph). I'm a psych nurse practitioner in Washington. I also have a 17-year-old. We need avenues to get rid of narcotics we no longer use or need. Drug take-back programs help. Over the weekend, our 17-year-old admitted she stole my husband's old back-injury narcotic and sold it. We have to flush or put these pills in the trash.

Dr. Chou, I don't think we're supposed to flush these pills.

CHOU: No, I mean, they're - there are safe ways to dispose of those pills, and it's actually correct we do need better ways for patients to get rid of unwanted pills. It's actually - I believe the statistics are that most of the overdoses occur from - not from buying the drugs from the street but actually from getting them from a family or friend.

And so there's definitely an element where people are getting a hold of these medications. So part of it is having these take-back days. It's actually very tricky to get rid of these drugs because you can't bring it to the doctor's office and have them get rid of them. That's actually against DEA regulations because then the clinician is viewed as serving as a drug dispensary, essentially, and most clinics aren't equipped to do that.

The other thing that we have really encouraged is for people to store these drugs safely, so the use of lock boxes. You know, treat these drugs like they're cash because they really are. One of these pills can fetch, you know, staggering amounts of money, and people need to be aware of that.

CONAN: Lisa Girion, I guess that's the source of those Skittles parties you were talking about.

GIRION: Absolutely. That's where it comes from. People tend to keep these drugs around if they don't finish them, and because they're prescribed by doctors and come to you in the orange pharmacy vials, kids tend to think that you can take them, get high, have your fun, and it's all going to be OK. And of course that couldn't be further from the truth.

CONAN: Yeah, it's medicine, it can't hurt you, yeah.

GIRION: Right, right, right, right. But the painkillers are basically a version of heroin. So they're every bit as dangerous as heroin, and that's where these deaths are coming from.

CONAN: Let's see if we can get another caller in. Let's go to Kyle(ph), Kyle's with us from St. Paul.

KYLE (Caller): Something I've noticed is working in - as a pharmacist with pain clinics, collaborating with doctors and pharmacists, working on patient-specific basis, we've had a lot of resistance as pharmacists getting involved in that setting, where we help monitor appropriate drug use, appropriate doses, the drug interactions.

We're having a hard time getting some doctors to collaborate with us and include us in the care, aside from the other inherent problems everyone's already talked about.

CONAN: As a pharmacist, do you feel that sometimes your profession contributes to this, too?

KYLE: That we contribute, as well?

CONAN: To the problem, yeah.

KYLE: Well, you know, ultimately the doctors are the ones writing the prescriptions. They're the ones writing the numbers on it. If I see a number that I don't like, I can call and ask about it, but ultimately it's up to the doctor to fill that or not, or to approve it.

If I have a patient there in pain, I want to help them, and if they have a legit, legal prescription from a doctor, then I'm inclined to fill it. If I suspect wrongdoing or any other things, I can refuse but at the sacrifice of the patient not getting their pain control, possibly becoming violent because they're not getting their prescriptions, which has happened with people, you know, getting fed up and wanting their pain meds now.

CONAN: Dr. Chou, should patient - should doctors be working more closely with pharmacists?

CHOU: Yeah, I think we should be. And one of the initiatives that we think may help with this is what we call prescription drug monitoring programs. So one of the problems that happens is that patients will go from ER to ER or from doctor to doctor and get - obtain multiple prescriptions, which is dangerous because each doctor doesn't know what the other one is prescribing, number one.

And then, you know, the patient is exposed to a lot of different drugs all at once. So these prescription drug monitoring programs will be able to tell physicians and pharmacists when patients are getting prescriptions from multiple providers.

The problem is that the monitoring programs have been somewhat fragmented, meaning that they're on a state-by-state basis. So like, for example, here in Portland, as a Portland doctor, I don't have access to the Washington system, and for those who know the area, Portland's right next to Washington state. It's not very hard for someone to cross the state border to get these drugs.

And I think many of us believe that a more integrated, national-level system would be one way to help prevent some of these deaths. Many of these deaths are related to this doctor shopping.

CONAN: And I wanted to bring you back in, Lisa Girion, doctor shopping, we've seen that in many different places, but the push to have electronic records and that sort of stuff, it's very difficult.

GIRION: Right, well, there's a couple of points that were brought up. One is the pharmacists, and the other is this idea of prescription drug monitoring. Most of the states now have some form of prescription drug monitoring. The doctor pointed out one problem, and that is when people cross state lines, and we know these do with these kinds of drugs all the time.

The other thing is, in a lot of the states, including California, the systems are still under development, and they're still kind of clunky, and there hasn't been a lot of uptake. There aren't, you know, a majority of doctors who are actually using them in real time to check and see if this patient who walks into my ER, you know, was at the hospital down the street this morning, you know.

So they're not well used, and the studies that I've seen that have looked at overdose mortality in states that have prescription drug monitoring programs have found that so far, they haven't been effective in bringing the death rate down. So it's an idea, but I think it's one where the experts believe there's room for a lot of improvement.

On the pharmacy side, I've seen a whole range of responses from pharmacists. We've seen everything from pharmacists who won't take prescriptions from doctors that they believe are passing bad prescriptions. They just - you know, and a lot of times the big chains will do that. Some pharmacists will actually report doctors who they think are passing out bad prescriptions - you know, too-high doses, that kind of thing - to medical boards. And there will actually be investigations that result from that.

But we've also seen cases where the pharmacies themselves have been, you know, accused of being complicit and sort of part of the, you know, distribution of these drugs for the wrong reasons.

CONAN: The doctors write the prescriptions and say this store down on that corner will help you out?

GIRION: Yeah, and I just wrote a story about a case in L.A. about a month ago where the pharmacist is accused of giving a list of customers' names to an allegedly, you know, dirty doctor who just wrote prescriptions to the names and sent them back to the pharmacy to be filled by this drug distribution ring that actually smuggled them into Mexico where they were sold to people from San Diego at border pharmacies.

CONAN: Thanks very much for the call. Appreciate it. Let's see we go next to - this is Chris, and Chris with us from Moses Lake. That's in Washington. Go ahead, Chris.

CHRIS (Caller): Hi. Thanks for having me on the show. This is an excellent subject. This is an important subject, this prescription pain addiction. I was addicted to pills. Same thing, I had an injury on the job, and it wasn't months after that injury, I had another injury, so it just further extended my addiction to prescription painkillers. What comes down to it, the doctor takes you clean off. They don't - I never got instructions that you have to come - you lower down on it. So when my prescription was up, there I am faced with this addiction.

That's what puts you out in the streets, by getting doses that are way overboard for what you need. Again, if you're taking 10 milligram Vicodin, all of a sudden all you can find is 30 milligram Oxycodones or 80 milligrams OxyContins. The issue, I feel, is like people overdosing, is the doctors don't help you get off it. And now I'm on a program. It's Suboxone. But to have a doctor in your area that's able to prescribe you Suboxone, those doctors are still few and far between. And not only that, they can only take so many patients.

So I'm lucky enough. It's like I hit the lotto. And if it wasn't for that, there's no doubt I'd be dead. If I wasn't dead, I would certainly still be addicted. And that addiction is so powerful, it - you can't face it. Maybe some people can, but for the majority of the layperson have to deal with that withdrawal is absolutely crippling. It's not gonna do it. So what I'm getting at is if they have these programs more available for you - when you're addicted and you tell a doctor that you have to have them, you're instantly categorized into this stigmata, and now you're a prescription pain-chasing patient...

CONAN: Dr. - let's bring Dr. Chou in. Doctors who prescribe this medication, should they - when they wind up those prescriptions and take the patient off, should they provide help to get the patient - to provide help to the patient?

CHOU: Yeah, absolutely. And I think this is an area where many doctors are, frankly, not trained to do very well. First of all, we're not trained very well at identifying patients who aren't responding well to the opioids and, you know, for every other drug we would take, that we would stop that medication. But, in many cases, opioids just kind of get continued. So we need to be trained better at learning and understanding when we need to stop these medications. And then when we do so, we need to be able to help patients get through this withdrawal period and treat the addiction like it needs to be treated.

And I think it's absolutely right that we - at this time we lack resources to do that effectively in a lot of cases. It's - these programs can be expensive, and many patients who need them can't get into them or can't afford them. And so being able to provide these is really a critical piece of, you know, how we're gonna be able to tackle this problem.

CONAN: Chris, thanks very much and good luck.

CHRIS: Thank you.

CONAN: Appreciate the call. We're talking with Dr. Roger Chou, who's director of clinical guidelines development at the American Pain Society. And he's with us from Portland. Also, Lisa Girion, a staff reporter for the Los Angeles Times. You're listening to TALK OF THE NATION from NPR News.

And this email from Martha, who writes, seatbelt for overdosing? I'm a nurse who works in oncology. At one point we devised childproof prescription bottles. Just as we have passwords to help us keep our Internet contacts protected, perhaps some company could devise a dispensing tool wherein only those who are to be taking the drug could have access to the pill bottle. Lisa Girion, any technological approaches like that that might alleviate this problem somewhat?

GIRION: Well, that's interesting. That's a little bit more sophisticated variation on the methadone clinic, where if you are coming off a heroin addiction - and nowadays, many times, an OxyContin or Vicodin, you know, a prescription drug addiction, you go to your clinic. You get your methadone. You take it in front of a clinician. And it stays there. It doesn't get distributed out into some gray or black market.

Another kind of seatbelt that's happening is the drug companies are working to create - in fact, the maker of OxyContin just came out with sort of a gel. The pill is actually enrobed in a gel, and so it can't be crushed and snorted or inhaled. It can't be taken all at once the way addicts like to take it. The problem with that - and when they do come up with these sort of new versions of pills is the addict community gets busy trying to figure out how to defeat it.

And I think within a month or two after the latest version of OxyContin came out, I was hearing from addicts and from law enforcement folks that they had figured out a way to defeat it. And I won't tell your readers or your listeners how to do that.

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GIRION: But - I won't share that, but they've figured it out.

CONAN: Here's another email. This from Mo(ph). As a veteran who receives benefits at the local VA, I've been personally affected by this problem. I have chronic pain in my lower back from a congenital problem exacerbated by injuries. However, on the one or two times a year I have a particularly painful flare up and need real pain control measures, I am denied effectively strong pain control simply on the basis that in the distant past I reported my alcohol intake as moderate and that I suffer from depression.

I understand, statistically I may be at risk for abuse, but my particular history includes no abuse of these or other medications, no alcoholism. Yet I spend 10 to 15 days a year in pure, senseless and avoidable misery. I hope there's a solution for this soon too. And Dr. Chou, people in pain like that, as you've said earlier, they think that this is the solution.

CHOU: Yeah. And I think this is the really tough situation where, you know, we know that these drugs can be dangerous. We know that they're not super-effective. I mean on average, you know, people think of opioids as super-powerful pain drugs, but on average you're talking about a 20 or 30 percent pain relief for chronic pain at least, which is not very high compared to what we can get for post-surgical or other types of acute pain. So they're not perfect drugs by any means, but there are people who might benefit from them. And the challenge is trying to figure out, you know, how to prescribe them. We need to do a better job of assessing the patient for their risk.

I think earlier people had - somebody had brought up the issue of psychological problems and how those can predict possible problems with these medications. And there's other risk factors that we need to train doctors to better look for and to better deal with. And we can prescribe the drugs in many patients, but we need to be able to structure our care so that it matches what their risk profile is, meaning that if somebody does have some risk factors, we need to be able to do things like give limited numbers of pills, you know, monitor them, maybe do some urine drug testing, follow them up frequently, all those kinds of things that we need to do to be more safe at...

CONAN: Dr. Chou, can you stay with us? We're going to take a couple more question on this when we come back from a short break. Lisa Girion, we're going to ask you to stay too. Stay with us. I'm Neal Conan, TALK OF THE NATION, NPR News.

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CONAN: We're continuing our conversation on the preventable deaths caused by prescription medication. Our guest, Lisa Girion, who wrote about that for the Los Angeles Times. And also with us, Dr. Roger Chou, an associate professor of medicine at Oregon Health and Science University and director of the clinical guidelines developments at the American Pain Society. And let's get another caller in on the conversation. Andrew is on the line, Andrew with us from Hinton in West Virginia.

ANDREW (Caller): Hi, Neal. I'm a public defender, and I find that 80 percent of the crimes that my clients are involved in are prescription-pill-driven. I always ask the judge at sentencing, when are we going to see a doctor in here? I mean, these are prescribed pills, and they are the most powerful, highly addictive drugs that are made, and they're prescribed again and again to apparently healthy people who have minor injuries or a tooth removed. I believe that's the seatbelt. These doctors should be easy to catch. And at least where I work, I have never seen a doctor who overprescribes prosecuted. Thank you.

CONAN: Thanks very much. Well, Dr. Chou, should - I'm sure there have been cases, in fact I know there have been cases.

CHOU: Yeah, there certainly have been. And, you know, it's this thing, I think that you don't want to get into a situation where doctors aren't able to prescribe medications legitimately, which I think, you know, despite all the alarming data - and I don't think anybody denies that the data are very alarming - that most prescriptions are probably legitimate, and they're well-meaning, and they're done in people who have real pain, who we're really trying to help. So I don't think we want to lose sight of that.

But I do think that, you know, there - that some clinicians have become rather cavalier about prescribing these drugs. There was a perception that they were safe. This was fueled in part by the belief that things like OxyContin and the long-acting drugs were going to be safer and that we could prescribe them without worrying quite so much. But, you know ,we've had a long history of this with these medications. Heroin was actually developed as a less addicting form of morphine and was marketed as a cough suppressant when it first came out.

So we've been trying to figure out non-addicting types of opioids for a long time. We need to be smarter about how we use these drugs and, like I said before, how we assess the patients and how we monitor them and take them off the drugs when they're not benefiting from them.

CONAN: Lisa Girion, not only do you have people taking the OxyContin, which is supposed to release its pain medication slowly over a period of time, and crushing it and, as you said, snorting it and getting everything at once, there's also been abuse now of fentanyl, which is presented in a patch.

GIRION: Right. Fentanyl patches come in at least three doses, as far as I'm aware. But it is 100 times more powerful than morphine, so it's very, very powerful. It was developed for cancer pain, for breakthrough cancer pain. And because it's for cancer and people who are - could be very sick and nauseous and unable to hold medication down, it comes in a patch form. And it also comes in lollipops. And we have seen several deaths, many deaths where people die with one, two, three, up to five fentanyl patches on their bodies, and it just knocks people out.

CONAN: Here's an email from Meria(ph) - I hope I'm pronouncing that correctly - in Castro Valley, California. I have chronic back pain and work in health care. I have repeatedly asked for non-medication interventions, including acupuncture and chiropractic, because I have firsthand experience with addicted patients. But my insurance will not cover these. We need better coverage for alternative therapies. And, Dr. Chou, is that something that doctors could lobby on too?

CHOU: Yeah, absolutely. I mean, the chronic pain, as I alluded to earlier, is a really complicated phenomenon where there's a lot of psychosocial kind of aspects to it, meaning that people can have the same degree of damage on an X-ray when you look at their back, but one person's pain can be much, much worse than another person's. And so addressing these psychosocial factors like depression, like how to cope with pain, how to relax when you're having pain, using some of these other alternative types of therapies like exercise and manipulation, all of those things, we think are really part of how to best treat chronic pain and may reduce the use of opioids substantially.

The problem is many insurance companies don't cover them or these programs aren't always available and so - yes - making these better, more available, I think, would be a great step forward.

CONAN: Lisa Girion, one reason they don't cover them is they say there's no evidence that they work.

GIRION: Right. Well, it's interesting because, in the workers' compensation system in California, which just underwent sort of a wrenching reform overhaul, one of the things that was curtailed was chiropracty and there are some people who believe - like who study the system - believe that we've seen an escalation in the use of opioids, pain killers, to treat injuries, you know, joint injuries, back injuries; that kind of thing, whereas in the past, those people would have spent more time with chiropractors or in physical therapy, that kind of thing.

And so those limitations are pushing people onto pills and that's creating its own set of problems.

CONAN: This email is from Mae(ph) in Reno. You've not mentioned a common error made by doctors prescribing an adult patient who has lost a lot of weight. My own father was overdosed by such carelessness.

Dr. Chou, I assume that would be when they don't necessarily see the patient in the office.

CHOU: Well, and part of it also is that people aren't always - you know, our mantra is for people to start low and go slow, that there's no rush to get somebody to, you know, high doses of opioids and - yes - there are many factors that can affect how people metabolize their opioids, including, you know, weight, size and kidney function and liver function and what other drugs they're taking.

And so, yes, people need to be really careful. The other aspect that hasn't been mentioned is that some of these drugs are actually pretty tricky to use. Methadone, in particular, has become a widely used opioid because it's inexpensive and long-acting, but its pharmacology is quite complicated. It's a very long-acting drug and we actually think that there are overdoses occurring because people are starting them and then going up on them too quickly.

So there's certainly some education that needs to be done for providers in terms of how to prescribe these drugs more safely.

CONAN: Well, thanks very much for being with us today. We appreciate it.

CHOU: Thank you.

CONAN: Dr. Roger Chou from Portland, Oregon and the Oregon Health and Science University.

Lisa Girion, thank you for your time, too.

GIRION: Thank you.

CONAN: Lisa Girion joined us from NPR West in California. She's a staff reporter for the Los Angeles Times. Coming up, coaches.

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