NC Medical Board Statement on Drug Overdose Prevention

The North Carolina Medical Board has published the following Position Statement on Drug Overdose Prevention.

Drug Overdose Prevention

The Board is concerned about the three-fold rise in overdose deaths over the past decade in the State of North Carolina as a result of both prescription and non-prescription drugs. The Board has reviewed, and is encouraged by, the efforts of Project Lazarus, a pilot program in Wilkes County that is attempting to reduce the number of drug overdoses by making the drug naloxone* and an educational program on its use available to those persons at risk of suffering a drug overdose.
The prevention of drug overdoses is consistent with the Board’s statutory mission to protect the people of North Carolina. The Board therefore encourages its licensees to cooperate with programs like Project Lazarus in their efforts to make naloxone available to persons at risk of suffering opioid drug overdose. * Naloxone is the antidote used in emergency medical settings to reverse respiratory depression due to opioid toxicity.

Why We Shouldn't Blame Benzos

Sometimes I hear from well-meaning medical practitioners that methadone is unfairly maligned as it is blamed for so many deaths. Benzodiazepines, these doctors argue, are to blame for so many methadone poly-drug deaths. Benzodiazepines are the real killers. I don't buy it. While admittedly the dangers of combining benzodiazepines with methadone are well-known in the medical community, many people dependent on benzodiazepines continue to use them for years and years, without dying. In addition, benzodiazepines are highly addictive, and withdrawal can lead to fatal seizures. The New York Times recently reported:

"A majority of victims also used large quantities of alcohol or benzodiazepine sedatives but few would have died without an opioid as the primary culprit. 'You can take a lot of benzodiazepines without dying,' said Dr. Charles E. Inturrisi of Weill Cornell Medical Center, who said they strengthen the depressive effect of methadone."

What I am concerned about more than all the people using benzodiazepines, is all the doctors prescribing methadone to the people using benzodiazepines. A patient with a long-standing history of benzodiazepine use should not be started on methadone until the physician confirms the patient is benzodiazepine-free.

Why People Die From Methadone

There has been a debate for some time about why people are dying from methadone toxicity. I don't mean why methadone the drug causes deaths-- that is something that is well-understood in the medical/scientific community, given the highly variable half-life among individuals and the risks to those who are opiate naive. What I mean is that the medical community wants to blame deaths on the methadone clinics andn the methadone clinics want to blame the physicians, and when push comes to shove, they all would rather blame it on diversion. Diversion of methadone from those legally prescribed it is a problem, and street use of methadone is apparently responsible for thousands of deaths. That should make sense to us. But remember that if diversion is causing deaths, then the physicians prescribing it to patients who then lose it, sell it or have it stolen bear a large part of the responsibility for the methadone on the street. But as much as the educated and employed want to blame the "addicts" for this epidemic, many deaths are attributable not to street use, but to use as prescribed by a physician. Eric Eckholm with the New York Times recently reported: "Misuse by abusers was first seen as the problem, but now, said Dr. H. Westley Clark, director of the Center for Substance Abuse Treatment of SAMHSA, 'We know that a significant share of the methadone deaths involve doctors making well-intended prescriptions.'" That is what is so tragic about methadone deaths in the U.S. The following study from the Jouornal of Forensic Sciences found over 48% of methadone deaths werew attributable to well-intended presciptions by doctors.

Methadone toxicity fatalities: a review of medical examiner cases in a large metropolitan area.
J Forensic Sci. 2007 Nov;52(6):1389-95.
Shields LB, Hunsaker Iii JC, Corey TS, Ward MK, Stewart D.
Office of the Chief Medical Examiner, Urban Government Center, Louisville, KY 40204, USA.
Over the past several years, Medical Examiners in Kentucky and around the nation have observed a dramatic rise in drug intoxication deaths involving the prescription medication methadone. This documented rise in methadone-related deaths requires a better understanding of methadone's pathophysiology and the ways it contributes to significantly increase morbidity and mortality. This study reviews 176 fatalities ascribed to methadone toxicity by the Office of the Chief Medical Examiner in Kentucky between 2000 and 2004. Postmortem toxicological analysis recorded a more than 10-fold increase in methadone toxicity fatalities, rising from 6 cases in 2000 to 68 cases in 2003. Of the 176 methadone-related fatalities, methadone was the only drug detected in postmortem blood and urine toxicological analyses in 11 (6.25%) cases. The mean methadone blood concentration of all 176 cases was 0.535 mg / L (0.02-4.0). The following psychoactive medications were detected: antidepressants (39.8%), benzodiazepines (32.4%), and other opioids in addition to methadone (27.8%). Cannabinoids were detected in 44 (28.4%) cases and cocaine or metabolite in 34 (21.9%) cases. Of the 95 cases with a known history of methadone use, 46 (48.4%) involved prescription by private physician. The interpretation of blood methadone concentrations alone or combined with other psychoactive drugs requires consideration of the subject's potential chronic use of and tolerance to the drug. A thorough investigation into the practices of procurement and use/abuse of methadone is essential to arrive at the proper designation of the cause of death.

Project Lazarus

Project Lazarus is a pilot program in Wilkes County, NC, to provide intranasal naloxone to patients at risk of opiate overdose. Naloxone is administered to reverse the CNS depressant effects of opiates. The pilot program will provide free naloxone kits to health care providers, who can then provide them to high risk patients and families, to use in the event of opiate poisoning. To read more about the project and the data supporting it, click on this link.

http://www.ncmedboard.org/Clients/NCBOM/Public/PublicMedia/lazarus.pdf

Of the people I know who lost a family member to opiate toxicity, including oxycontin, methadone and fentanyl, having a naloxone kit would have been useless, because they did not appreciate at the time that the family member was dying. Respiratory depression occurs over time. Families report that the person was sleepy, breathing heavily and snoring for several hours before he was found dead. The families thought nothing was wrong, and they did not intervene. For each family I know who lost a son or father to methadone overdose, they had plenty of time to call EMS, had they only known they were witnessing respiratory depression. But they didn't know, so they didn't call. Education and informed consent, it seems to me, will go a long way toward preventing unintentional deaths from methadone and other opiates. Naloxone is not a bad idea. But the education that is sure to come to the patients who are given the naloxone is what we really need.

Doctors Settlements and Verdicts To Be Published in NC

The N.C. Medical Board has passed a new rule requiring the posting of certain payments made by physicians in NC to patients as a result of a claim of negligence. The measure was hotly debated, and the question has been posed whether giving the public access to this information will serve the public. Information for its own sake can be debated. But from a purely practical standpoint, the question is whether the posting will change anyone's behavior. I suppose that depends on whether patients use the medical board site to gather information about prospective physicians before scheduling an appointment. The effect of the new rule thus far has been to prevent settlements of cases currently in litigation. Seems that some doctors who were perviously open to settling a claim are now choosing to take a chance that a jury will not find them liable for a patient's injury. Does that ultimately serve the public? We will watch and see.

Florida Death from Prescribed Methadone

Florida has passed legislation known as "tort reform" which places limits on what a person can recover in a medical malpractice case. For example, the statute sets out who can claim a loss for the death of a person, and what kinds of losses can be claimed. Funeral expenses are recoverable, as is the wage loss to the heirs of the deceased. But what if the person who died had no children and no spouse? What are the losses? His lost wages are not recoverable, as no one was depending on his income. His funeral expenses are recoverable. His parents can claim a loss for his society and companionship. But the statute caps the amount of money that can be awarded for this loss. A mother called me yesterday to tell me that she has contacted law firms who have refused her case because her son who was given a drug overdose in a hospital had no heirs or spouse and the case "just wasn't worth it." If there is no consequence to medical providers who cause the death of a patient, will the medical providers change their behavior? How can the loss of a human life be "just not worth it?"

Oxycodone Dosing Error

I got a call a couple of weeks ago from a grieving father. He found his 27 year old son dead in his bed one morning in February. His son had earlier that day been to a new doctor for his chronic back pain, and the doctor had prescribed 120mg of oxycontin /oxycodone without any information from the young man that he could tolerate this high dose. The labelling for oxycontin describes a starting dose of 10 mg. The cause of death has been ruled oxycodone toxicity.