Purer, high potency heroin coming from Mexico is causing significant increases in overdose deaths, also doctor shopping and ways for Rx management, and the continuing issues of addictions by health care professionals
Transcript (edited):
CNS: Heroin and opium are in the news this week. There is a report about the purity of the current black tar or brown tar heroin coming in mostly from Mexico and how thats creating a rash of overdoses increasing by many percentages or hundreds of percent the number of deaths occurring from heroin overdose. In 2000 about 2000 deaths were reported across the U.S. and in 2008 the number is up to 3000, thats still a significant rise. And there is another story about pill pushing physicians and more about doctor shopping by drug abusers and the ongoing issue of abuse of prescription drugs by hospital personnel. So Darryl, how do you view these things and their interactivity?
DARRYL: Its fascinating Im not sure they have a lot of interactivity, but theyre all timely and theyre all expected. First of all, the heroin story were kind of overdue for another downer epidemic. Weve been on this cocaine and methamphetamine thing for awhile, about 30 years, and thats the limit of how long an upper or downer fad goes. So, were now ready to turn the corner and go to downers. We see here in Oregon as well as all over the country a rising abuse of heroin increased heroin overdoses and also an increase of prescription opiates. So maybe there is a tie-in with prescription drugs and the health care professionals and general public starting to use more prescription drugs, or abusing more prescription drugs. But the heroin story is an old one. In terms of overdoses, they are much more linked to the variations in purity of heroin than it is to anything else. And when we see we see rashes of them, you dont see, you know, a steady number of heroin overdoses every year when we see rashes of them, especially occurring in any municipality or any state or something, its usually linked to a pure form of heroin thats come in. The latest story I think was in Montana or something, it could have very well have been California or Oregon or any place else actually talks about tar heroin. Tar heroin has always been a more pure form of heroin in terms of actual milligrams of drugs, but less pure in terms of separating all the adulterants and ingredients and things leftover from the processing of opium from the opium poppy into morphine and then morphine into heroin. It was a Mexican cartel, a third one, out of 1980s that learned how to much more easily process the morphine thats in opium to concentrate it without eliminating all the other adulterants and all the plant materials and everything else in opium and then easily converting the morphine that was in that resultant product into heroin by adding acetic acid to it or concentrated vinegar. And that really is a simplified process, but it also resulted in a much more potent form of heroin because it was hard to cut. You know, when its a finished product, it looks like tar. Its tacky, sometimes has a great sheen, black sheen to it and its, you know, its very hard, so .
CNS: What do you mix that with?
DARRYL: Yeah, maybe tar or something else. So, as it got to the street and it was sold in smaller quantities. Its in gram quantities instead of a bag of heroin, which is like 300, 400 mg of powder. But powder you can do anything to, so everybody who touched it wanted some profit on it, or wanted to support their own habit, would step on it. They would add all kinds of things – instant coffee if you want brown heroin, they add any kind of white powder to it quinine, lactose or anything to step on it or dilute it. Well tar was hard to cut, so it comes in anywhere from 60 to 80% pure or 60 to 80% of it is actual heroin and thats compared to you know, the street heroin in the 1960s and 70s was only like 1 or 2%…
CNS: 5% is what it said in that story.
DARRYL: 5%…later on and compared to that its a huge difference. So if somebody is used to injecting an amount of drug to get a certain effect, but that drug theyre injecting is much stronger in its concentration of heroin, theyre going to more likely overdose and thats what we see happening. But heroin is growing. Theres more treatment requests for heroin. Theres more overdoses from heroin and I think its just right the vanguard well maybe the vanguard is actually the prescription opiates the Vicodin, OxyContin, and this is coming in. As people get addicted to opiates, they often times develop a much more rapid tolerance than you do to other drugs so they need more and more and for whatever reason, opiates lend themselves very quickly to injecting it for that rush, you know, that euphoric rush you get from opiates. Heroin is a drug that offers that so its been very commonly seen that you graduate from the Darvons and the codeines and into the Vicodin, OxyContin, heroin very quickly. Also when they bring in heroin like this, they usually introduce it as chasing a dragon. You know, smoking it. Putting it on aluminum foil and heating it or heating up a knife and pressing a knife onto the surface of the tar while youve got a straw stuck in your mouth a McDonalds straw and breathing that vapor in, which is the heroin is strong enough that youre going to get high by causing it to sublimate or causing it to go into smoke and then smoking it. But as your need for it gets more and more and you want more quantity and stronger rush, it lends itself to addiction. So thats what were seeing with the heroin. Now the story about nurses becoming addicted and as you mentioned, medical professionals are much more likely to be an addict, per capita than the general population. Thats always been studies have been borne out. Why? Maybe they have access to drugs. Maybe they see the effects of drugs more. Theyre in high stress situations, as you say, or occupations. So whatever reason, there is a lot more addiction amongst nurses and doctors. Now, what that story, I think was trying to point out is, that in nurses as well as physicians and also pharmacy programs, you usually have peer programs — when a nurse is suspected or caught diverting or misusing drugs, the peer organizations move in. They usually intervene on the person and they usually have a contingency. You know, you go through treatment. You will take a leave from work. Your license is going to be suspended for a year or more. Youre not going to work and youre going to participate in rigorous drug treatment and youre going to do better or we turn you over to the law and you lose your license forever plus you get criminally prosecuted. And what this article is saying, is that they dont like that. They dont like if somebody say has diverted, theyve diverted their Vicodin or their Percodan or morphine tablets from their patients or Fentanyl tablets from their patients to abuse them, that they think those nurses should be immediately turned over to the criminal justice system and fully prosecuted for their crime. I think thats a little bit short sighted in that it may discourage nurses from coming forward on their own and in a lot of the treatment programs right now, many of the medical professionals will come forward on their own. They want to seek help and get treatment and want to maintain themselves as a medical professional and realize how much of a threat this is on their profession. The other thing is that it may encourage sort of underground or secret practices that may harm patients even more. Places like Oregon have wrestled with this question and unfortunately they have moved the treatment systems for all medical professionals out of the hands of their peers. You know, it used to be peer pharmacy program, peer nursing program, peer medical program, but this article may be a result of what happened in California where in California, nurses and medical physicians programs were felt to not really monitor, not really rigorously ensure that their fellow professionals were participating in a program, which led to patient harm. And thats a big concern that is driving this patient harm. And patient harm does result from an impaired physician. You know, youre going to have a surgery performed by somebody whos loaded at the time well errors are going to happen or if youre going to be given medication by a nurse who is stealing your morphine to inject you with salt water, well, thats not a very good thing. So, there is that concern about it. But I really think that the programs Ive seen the peer programs are good. And they have a way of contingency planning with their addicted professionals and a really good way of monitoring and then covering the patient care. Making sure the patients they were treating get good care so that the professional can get involved in treatment and ensuring that they are in treatment. And if they dont if they drop out of treatment, if theyre not participating, they get a positive UA, well then there really is a signed agreement in the contract that the only option we have if this happens is to turn you over to the cops. You know, and to violate you because youre a danger not only to your patients, youre a danger to yourself. So, Im kind of mixed on that. Im not sure how I lean on that.
CNS: Yeah, it is you know, we talk a lot about the need for more treatment, so its you want to encourage that rather than toss them into jail. But it is it is a case where there is a potential for greater harm to other people being in that kind of healing profession.
DARRYL: Yeah thats a rough one. The other story that you mentioned is about the doctor shopping and thats been a chronic issue with prescription drugs ever since there has been abuse of prescription drugs. I remember I had a client in San Francisco actually an Asian client who, as a little kid got his ankle mangled in a lawn mower or something like that a power lawn mower, and so as an adult, it healed, but it was the worst looking, ugliest ankle you ever saw in your life. And it was just his money train. I mean he would go into a doctors office, undo his shoe, show his ankle and complain of pain and there it was you know, the Vicodin, Darvon, whatever it was and that was his money train. But the situation is doctors are going to try and monitor you and also pharmacists and nurses are going to monitor you. They get one patient with an exorbitant amount of drugs and prescriptions, theyre going to bust you. So its not just doctor shopping. Its actual pharmacy shopping. You go to multiple pharmacies. You take that mangled ankle or you complain of something, a migraine headache that is so severe, some difficult pain, fibromyalgia is a good one right now that you cant really see whats causing the pain, but we know people have severe pain and need treatment and you complain about the same symptoms, you know what the symptoms are going to prescribe to and you go to multiple doctors and get a prescription from each one and then go to multiple pharmacies to get them filled. So you end up with a huge stock of prescription opiates and that you can abuse or prescription sedatives or prescription stimulants. And then you can either sell them or you have enough to abuse. You see theres a difference when somebody takes something for pain, its different than when they take it for abuse or addiction purposed. Ive even had people in severe pain, save up their medication not take the Vicodin or OxyContin, 1 every 4 to 6 hours, but take all 50 of them at a time, then go without the medication for several days because theyre more interested in the addiction and less interested in getting relief for their pain. So its a whole different process. But an easy way or maybe a more modern way of dealing with this, and Im surprised that this story came out because in Oregon, and California moved on this many states are moving toward schedule 2 and schedule 3, maybe even all scheduled prescriptions being in a national computer base.
CNS: Well thats what I was just going to say. You would I mean this sounds like a logical, if not national, then statewide
DARRYL: Yeah, statewide computer bases.
CNS: Of course that you know, like were close to the border of California here, so you would want to you might want it to be federal but then theres privacy concerns that come out of that one, but if it is I mean clearly its a problem and this article refers to a new law in Wisconsin. It doesnt go to the question its aimed at the drug abuser. It doesnt resolve or even address the issue of doctors who will too easily write prescriptions and what to do about that. I dont know.
DARRYL: Yeah and thats also been a difficult one, Howard. Just in Oregon especially and other states, there has been initiatives for the last 10, 20 years where doctors are accused and sanctioned for under prescribing things like pain medication and for comfort medication that theyre not prescribing enough and so theyre in between, you know, making sure they give adequate medications to patients who need it, but trying to weed out those doctor shoppers and you know, the people who are scamming to get drugs. So thats a very difficult position to put doctors in, but the computerized system, see we had triplicates for medication in most states for very long and they were extremely effective. When I was in California, when a prescription that was a schedule 2, a class 2 drug something like morphine, something like Percodan, something like Nycental, something like Fentanyl was prescribed to a patient, you could only do it on a triplicate prescription form that was provided by the attorney general of that state. And many states had the same law. And one of the triplicate one copy is retained in the patients file in your record as a doctor. Patient gets 2 copies and he takes it to the pharmacy and the pharmacy that fills it sends one copy .retains their copy and sends one copy directly to the attorney general every month. And the attorney general without computers, I guess had a lot of aids in the staff, would sort through that and pick out of there was an excessive amount of both doctors who were prescribing because doctors were looked at you know, if one doctor had a small practice and 90% of them were getting Valium, so to speak, then theres definitely an issue there unless that doctor is specializing in care that needs to do that, but they weeded out doctors who were prescribing. And thats one of your questions, how do we address the professionals that are prescribing, but they also picked out patients who were doctor shopping, getting a lot of duplicate prescriptions for the same problem and abusing them. Now heres the deal. In all the studies, I remember in California, the day that a medication was deemed to be a scheduled 2 in that state and therefore went on a triplicate prescribing practice on that day from that day forward, 75% of the prescriptions for that drug in that state disappeared. So thats effectively controlling it. Now theres criticisms on both sides. You know, one side says this shows you how effective this is and theres 75% over prescribing of these medications and a huge amount of people doctor shopping. But the other side is saying, no you know what happened is that so many doctors are so afraid and patients dont want to be identified that they just go onto other drugs and theyre never going to be into this if its a triplicate drug and that there are other patients who need it and doctors should prescribe it but dont because theyre afraid of the attorney general looking at them. Although it is controversial, I think from the history of triplicate prescriptions, we have a way of now, in this state moving toward it and other states where they can actually take every controlled drug and computerize I mean feed it into the computer and monitor it on computer bases prescription wise and have the computer spit out if theres any unusually high amounts of drugs going to single patients or high amounts of certain abusable drugs that are coming out of one physicians writing habits.
CNS: Well, its interesting and its all related and its not going to go away. So we will continue to talk about it and keep you apprised as we can. As ever, comments and questions are most welcome. Stop by the website, which is cnsproductions.com. You can also stop by and look at our forum section, which is right next to the blog section there in the website and theres some interesting comments from Darryl, answering peoples questions there also. And of course you can leave a question there as well. So Darryl, any closing thoughts?
DARRYL: Thanks for some great stories. You picked out some good ones, I think that are interesting and highlighting whats happening right now in terms of the drug trend or the drug pulse of America.
CNS: OK. Well talk soon. That wraps our pod for today. Thanks for visiting the CNS Podcast. Please check back soon for the next in the series and visit our website, www.cnsproductions.com