Ohio ADF Statement
Good morning,
My name is Dr. Elizabeth Lottes and I work at Maryhaven, here in
Columbus. Patients receive medical and psychiatric treatment for
substance use disorders, which includes alcohol, stimulants,
sedatives and opioids. There is a detox unit, outpatient treatment
program, which includes methadone, buprenorphine and
naltrexone, women’s program, a research department and many
other programs. I work in research on federal grants from the
National Institute of Drug Abuse, which is part of the National
Institute of Health. I am also the physician in charge of the
medication assisted treatment programs that use buprenorphine
and naltrexone.
I work primarily with patients that have opioids as the substance of
abuse. Substance abuse disorder is a chronic medical condition that
can be treated. But like other chronic medical conditions such as
diabetes and hypertension, there will be successes and set backs
but care shouldn’t be abandoned. Unlike diabetes and
hypertension, people with addiction have a high rate of mortality at
younger and younger ages. Twenty years ago most people knew a
friend or a family member who had a problem with alcohol. Today
most of us in this room know someone with an opioid addiction or a
death due to opioids. Sadly, 89% of the 22.7 million people aged 12
and older who have a substance use disorder go untreated.
One of my patients was an all star soccer player who played on a
traveling team. When he was 11 years old he suffered an ACL tear,
which was repaired surgically. With his physical therapy he was
started on Vicodin as needed for pain. Unfortunately he became
addicted to the Vicodin and began stealing to buy more opioids. In
one year, at the age of 12 he began shooting heroin and continued
for 6 more years. I saw him during his senior year for detox, which I
would like to say was successful but it wasn’t. He relapsed back to
heroin and died of an overdose. The majority of the patients I treat
are heroin addicts but greater than 95% of them started on
prescription opioids. There are also the patients who have used
only prescription pain medicine and are now seeking treatment.
The vast majority of patients started using prescription pain
medicine in their teens. The cost of prescription opioids on the
street is $1 per milligram. So if a person is using 10 Vicodin 10mg
tablets a day, they now have $100 day habit. Many of the people still
on prescription opioids are using upwards of $300 a day.
How do people get started? Most tell me that when they were 11-12
years old they started stealing pills from medicine cabinets. All
agree that it is far easier to get pills than alcohol. People realize
rather quickly, that depending on the route taken, that some will
yield quicker and more potent euphoria. When taken orally the
opioid will reach the brain in 20-30 minutes, inhaling the opioid
will allow it to reach the brain in 3-5 minutes and injecting it will
allow it hit the brain in 7-8 seconds. I have older patients, who
recall when oxycontin hit the market and had no abuse deterrent
formulation. The medicine was easily ground into a powder, heated
and liquefied for a potent injection. Given the destruction that
occurred in Southeast Ohio, pharmaceutical companies did change
the formula so that Hillbilly Heroin was no longer injectable.
Unfortunately it did not motivate all manufacturers to go farther
with the abuse deterrent formulation. Patients have shared that
shaving pills with a hose clamp yields a very fine powder that
produces a good high when inhaled. This is the route almost all
adolescents and young adults use for prescription opioid abuse.
The current legislation accomplishes what was started with the
reformulation of oxycontin and will further the lower the risk of
abuse with inhalation with the new abuse deterrent formulation.
The US Dept. of HHS/FDA issued a Guide for Abuse Deterrent
Opioids : Evaluation and Labeling in April of this year. The FDA was
moved to delineate exactly how opioids should be developed to
resist known or expected routes of abuse.
There will be costs and the legislation is forward thinking in
addressing these issues with the insurance companies. When
compared to the costs the opioid epidemic is costing the nation, it
will be cost saving in the long run. It is time this technology was put
into action to save lives. Of concern, is the recent approval by the
FDA for use of oxycontin for children aged 11-17 year-olds. Pain
control is vital for all patients of all ages that suffer. By enlarging the
window for patients able to get oxycontin , it will be even more
important to ensure the safety of all. I also work in hospice and
pain control is a main goal, so I do not believe that restricting
opioids is the solution. However it will increase the safety of
effective pain management if abuse deterrent formulations are
used. In 2013, 6.5 million people 12 years of age or older reported
using prescription medications for nonmedical reasons.
Another aspect of this legislation is very vital concerns the Press
Ganey item that asks patients if their pain was adequately treated.
As a physician, I am the first to admit that when I started in
medicine a patient’s pain was not always adequately addressed. But
the pendulum has swung too far from that point. Emergency Room
physicians are compensated based on the Press Ganey scores so
they often feel caught between two forces. One side is to write
appropriate and adequate pain medications while the other side
exhorts to prescribe for almost everyone so that the hospital gets
full compensation for services. It is currently an untenable situation
for patients, physicians, hospitals and insurers. It has gotten so out
of control that patients that I am treating in an opioid treatment
program with medications such as buprenorphine or naltrexone are
fearful of going to the hospital. Whether it be for a skin abscess or
an infected tooth, patients in current treatment who tell the
physician that they can’t take opioids because of their sobriety- will
always be given a script of an opioid prior to discharge. To
underestimate the power of these patient satisfaction surveys and
their impact on payment is extremely short sighted by society. By
removing Question #17 , it would relieve the burden of many ER
physicians to give every patient an opioid.
Finally as a addiction medicine physician, I would encourage all
members to consider the impact opioids are having on citizens of
Ohio and the path of destruction that continues to run through
every city, suburb, and county. No physician wants to lose any
patient to a disease that can be treated. Just as parents and
communities are ill equipped to handle the mounting overdose
deaths that striking younger and younger people. The disease of
addiction knows no zip code. Please help make medical care safer
by passing this Abuse Deterrent Formula legislation.
Thank you for your time and attention.