Activities of the Fellows and Senior Fellows of the Coastal Research Group: Bruce Behringer's Testimony to U. S. Senate Special Committee on Aging

In this new feature, of the Coastal Research Group website, we will highlight some of the important activities, in which the Fellows and Senior Fellows of the Coastal Research Group and the National Consortium on Community-Based Medical Education are engaged.

Last month, Bruce A. Behringer, a Coastal Research Group fellow, testified before the United States Senate’s Special Committee on Aging.  Behringer is Associate Vice President of East Tennessee State University’s Office of Rural and Community Health.

The following is his testimony:

Bruce A. Behringer, East Tennessee State University

Thank you Chairman Kohl and Senator Corker and Members of the Committee for allowing me to contribute some perspectives regarding prescription drug disposal.  I can only assume that the inclusion of “Drug Waste” in the title of the hearing has a double meaning – that of unused medications and that of the scourge that misused medications now inflicts upon many families and communities across our country.

Allow me to state that I am not an expert in pharmaceuticals, substance use and abuse, or the legal frameworks which we have created to protect ourselves from the problems. Instead, I have learned about this issue through many interactions over time with rural Appalachian communities, with concerned health professionals and students, and with regional and state leaders aware of our “numbers” that only partially describe the breadth and depth of our problems. Over the years, in almost every communities with which I have had the honor to work, the two health issues that dominate most lists of community health concerns and worries are cancer and substance abuse.

Drug abuse is a nationally recognized health problem. Diversion is a small and unintended outcome of a legal and medically necessary process at the end of a long chain of events that feeds some unknown amount of drug abuse and leads to negative economic, social, educational and health impacts. From one perspective, we would not need to discuss diversion of medications if they were not prescribed or dispensed. The pharmaceutical industry has been very effective in meeting and cultivating Americans’ demands for immediate relief – better, stronger, and faster pain relievers. We live in a culture of expectation that there is “a pill for every ill.” Marketing of medications leads to patient demand. Patient demand influences providers’ prescribing patterns, which in turn dictate the business of pharmacies.  Pharmacists dispense powerful pills into households and communities.  Once those substances get into the hands of patients, another whole set of very uncontrollable behaviors that affect diversion take over.

I have learned that the vast majority of patients do not seek pills for diversionary purposes. Patients from areas of the country like East Tennessee have many legitimate needs for pain medications. Our people work in dangerous occupations like farming, forestry, and mining. We have one of the nation’s highest cancer death rates leading to dispensing strong pain medications for palliative care. We are the homeplace of many Veterans who require long term use of medications because of military injuries and service-related osteoarthritis.

Once controlled substances are dispensed, human nature takes over. Patients may not use the full number of pills, hoarding unused pills for future use, sharing with other ill family members, or, in some cases, for selling to others.

Tennessee continues to rank either first or second among all states for prescriptions per capita. DEA 2006 state data reports indicate extraordinarily high amounts of control substances in the state – Oxycodone (189% higher than US rates), hydrocodone (277% higher), Morphine (285% higher) and Mepeirdine (417% higher) as measured in milligrams per 100,000 population.  The rate of unintentional poisoning deaths increased 53% 2002-2006 in Tennessee (TN Controlled Substance Monitoring Data Base). In fact, Tennessee’s increase is less than for many other states. In some regions of the country, more people die of unintentional poisonings from prescription medications than from traffic accidents. Increasingly, front page stories report the all too frequent drug sales busts, confiscations, overdose deaths. Now even our smaller towns and rural areas are confronted with drug-related violence and murders from the street trade in pills. These are frightening visions for our elderly citizens who use these pills and are fearful for their own safety.

Misuse of prescription medications is an amoeba-like problem. This includes the changing use of substances being abused, a broadening circle of people involved  in the street trade of dangerous pills, and a complex involvement of even well-meaning people wanting to help others. What we are learning from law enforcement reports is the great diversity in the source of diversion and abuse. Some pills are from filled prescriptions that patients resell rather than use. Some pills are stolen. Many pills confiscated in our area are from out of state physician practices known to prescribe pain medication, some in neighboring states and some from the now all-too-well-known round trips to the Florida pill mills.

No one is certain about the size and description of the diversion problem. There is no central national data base that reliably exposes the depth and breadth of the prescription medication abuse problem in the Tennessee or in the United States. The most reliable place-based and population data may be its unfortunate end points – mortality and arrest records. This data is not deemed totally reliable or available for analysis.

I had the honor to teach a course in the new Gatton College of Pharmacy at East Tennessee State University (ETSU) this year entitled “The Relationship of Pharmacy and Health Disparities in the Appalachian Region.” Pharmacy students collected data and viewpoints from community organizations and regional leaders to describe factors involved with controlled substance use and diversion. Their general conclusions reflect a unique perspective of the next generation of health professionals who must help address our collective problems:

1. Education

Diversion of controlled substances is truly an issue that affects all people in all communities. We need a balanced approach to increasing awareness of the multiple manifestations of the problems. We need to underscore the intertwined responsibility of patients as consumers, of medical care providers as prescribers, of pharmacists as dispensers, of law enforcement and judicial system as regulators and protectors. We should not allow the growing time pressures in the health care system to be an excuse for not ensuring that every patient receives warnings from their prescriber and counseling from their dispenser about the dangers of misuse of controlled substances. Among the student recommended actions:

– Physicians and other prescribers need to be educated not just on what to prescribe, but also the science of the addiction.

– Pharmacies should guarantee that pharmaceutical practice requires patient counseling and medication management for all prescriptions being used by patients and potential danger of mixing medications.

– Patients should be educated about risks of misuse of the drugs they are prescribed, the dangers of not properly storing them in their homes, how to dispose of unused pills, and never to share pills with others.

– The general public needs to be told the truth about the growing scope of accidental poisonings. Community attitudes should engage health providers to be accountable in part for the volume of controlled substances being used while challenging health insurers to pay for patient education and medication management. At the same time, we should ensure that the public pendulum should not swing so far as to deny access to prescription medication that is truly needed.

– All students who become prescribers and dispensers should have required interprofessional opportunities to learn their legal responsibilities and to experience how to have that difficult communication with other health professionals to confront questionable situations of prescriptions for controlled substances.

2. Prescription Drug Monitoring Systems:

Clinicians need full information about a patient’s current use of controlled substances when they assess the patient and form a treatment plan. Having unencumbered healthcare provider access to controlled substance prescription information is critical for better clinical decision-making and for enhanced patient safety.  More informed healthcare providers are in a better position to prevent narcotic overutilization and drug diversion and can protect the patient and the community from narcotic intoxication and dependence. States have developed prescription monitoring programs that are underused as a resource. Not all prescribers or dispensers use in-state or tap out-of-state registries. Action should be taken to:

– Reduce complications in using state monitoring systems. All states’ systems should assure timely access to data. NASPER should be funded so that states are able to implement these programs.

– National standards for interoperable state systems should enable timely inquiries that would allow detection of doctor shopping cross state lines. This is important for states like Tennessee which is bordered by eight other states.

– Formally inquire why major prescriber and dispensing groups do not currently use data bases. Cost to practice, legal privacy interpretations and concern for patient dissatisfaction have been cited. The national importance of the issue and a nationwide intent should be made clear that all public and private sector healthcare providers should use databases prior to prescribing or dispensing controlled substances. Perhaps additional national incentives should be considered.

3. Take-Back Programs:

Many communities across the country have successfully sponsored and promoted programs to dispose of no longer needed prescription drugs. ETSU pharmacy students participated in three such programs and reported that the public enthusiastically appreciated relieving themselves of old stockpiles of personal and family pills. Hundreds of pounds medications were received, including a prescription bottles dating from over 30 years ago. Take-back activities promote a visible and united community front for personal action and public education. Events demonstrate a common cause among law enforcement, pharmacies (chains and independents), medical providers, solid waste, senior centers, schools, children’s services, and prevention agencies. Students however pointed out that a lack of clear understanding of policies regulating these events dissuades some professionals from participating. Clarification is needed from all agencies (FDA, EPA, DEA, and ONCDP) regarding the laws and regulations regarding disposal of unused medications.

Diversion turns the wonders of modern medicine into poison. The poison has led to addictions that gnaw at the fabric of our families, our communities, our economy and our nation. It is hard to describe all characteristics of the amoeba-like condition of misuse of controlled substances. It is harder to contain that which appears to not be able to control its own form. The Committee should adopt and create a balanced vision and encourage Congress:

– Not to be timid in regulating what is needed to protect the public;

– Encourage a national effort that involves multiple stakeholders, levels of government, and public and private sectors; and

– Challenge those involved in both demand and supply of controlled substances to see their responsibility and role for preventing the daily tragedies that are pronounced in the media.

Thank you for this opportunity to share the views of many concern citizens and health professionals from East Tennessee and Central Appalachian region.