Doctors should be at forefront of curbing abuse.
The deadliest drug problem in America is not heroin or cocaine or even crack cocaine. It’s the abuse of perfectly legal prescription pain medications — familiar names such as Vicodin and Lortab and generic hydrocodone.
Last month, federal regulators finally got around to recommending stronger restrictions on access to these medications by limiting refills and mandating more frequent visits to doctors to obtain prescriptions. Now doctors, who helped create the problem, need to do their share to control it.
OPPOSING VIEW: New rules could harm patients
Fourteen years have passed since Ronald Dougherty, a doctor and addiction specialist, noticed something odd at his clinic in suburban Syracuse, N.Y.: More patients were addicted to legal drugs than to illegal narcotics. He petitioned the federal government to treat these drugs as the growing danger they were.
Dougherty, it turned out, was as prescient as the federal government was sluggish. Since 1999, overdose deaths from narcotic painkillers in the U.S. have quadrupled. Every day, they kill 45 people and send 1,370 to emergency rooms. By contrast, cocaine kills 12 people a day and heroin kills eight.
One addictive painkiller, hydrocodone, is the most prescribed medication in America — 4 billion prescriptions a year at last count. Dr. Tom Frieden, director of the Centers for Disease Control and Prevention, said “doctors caused” this epidemic. “We’re prescribing massive amounts of opiates,” he told us last week, “and patients are getting hooked.”
Dealing with the problem has been tricky. That’s because these medications are indispensable for some people with extreme, chronic pain — particularly from terminal illness that renders addiction meaningless. And because easy access has powerful support from patient groups, drug chains, drug makers and many physicians. These lobbies have impeded the most promising responses.
One of the best solutions is state prescription monitoring programs designed to prevent addicts from doctor-shopping. Some physicians, unaware that a patient is getting multiple prescriptions from several sources, become unwitting accomplices to addiction. Others get rich running pill mills.
Databases to monitor prescriptions and prevent overlap are finally running in almost every state. Pharmacists can record when they fill certain prescriptions, and doctors can check patient histories. But most doctors don’t use these registries — a failure both mystifying and outrageous. Doctors should be in the forefront of combating abuse.
To deal with this, a few states — Kentucky, New York and Tennessee, with more in the works — require doctors to query the database. New York’s database used to get, on average, 10,000 queries a month. In the two months since the mandate, there have been 2.7 million requests.
Florida’s approach — which targeted pill mills and made use of a strong database — cut hydrocodone deaths by 16% in the first half of 2012, compared with the preceding six months.
The Food and Drug Administration’s recommendation can do the same. Patients can only receive three, 30-day prescriptions at a time. They must see a doctor every 90 days to get new prescriptions.
The strict limits could make it harder for some rural or homebound patients to get necessary relief, suggesting a need for some narrow exemptions. But that shouldn’t be used as an excuse for further delay in dealing with such a deadly public health problem.
N.J. addicts suffer from shortage of drug treatment facilities – See more at: http://www.northjersey.com/news/herion_paterson_drugs_rehab_parents.html#sthash.hgN5WdQj.dpuf
Three months after fleeing a Florida rehabilitation center, Amanda, a 24-year-old from Woodcliff Lake, was using heroin again. She stole her grandmother’s credit card, bought thousands of dollars worth of electronics and sold them in Paterson for drugs.
Which is how Amanda’s parents came to spend a Friday evening this July driving across New Jersey, their strung-out daughter in the back seat, looking for a facility that could treat her.
“We called eight or nine places,” Amanda’s father, James, recalled. “Nobody had a bed. Nobody.”
Insurance wouldn’t cover detoxification in an emergency room, rehabilitation clinics wouldn’t take her until she was clean, but every detoxification unit had dayslong waits for admission, James said. At a hospital in Summit, James encountered hallways full of “moaning and groaning” addicts waiting for beds and insurance clearance, he said. James was told at the front desk that if he paid cash, there might be a bed for Amanda the next morning.
A friend gave Amanda some Suboxone, a drug used to treat opioid addiction, so she could spend the night at her parents’ house. The next morning, they found a facility in Kearny that could take her.
Amanda’s story is typical. As heroin and prescription painkillers ravage parts of the state, at least a third of New Jersey addicts seeking treatment cannot get it. A shortage of treatment facilities, coupled with high costs and insurance hurdles, leaves tens of thousands each year without adequate or timely care, and their families scrambling for help. In 2009, the latest year for which state figures are available, at least 30,000 adults and 15,000 adolescents were turned away from treatment.
Thousands more do receive treatment, only to cycle in and out of emergency rooms and rehabilitation programs, their inpatient stints cut short by insurance plans, lack of cash, or relapse. Even the most comprehensive insurance plans tend to limit coverage of inpatient care to 14 days or less, leaving families to choose between paying thousands of dollars out-of-pocket for the standard 28-day treatment or pulling an addict out of care.
“There is without doubt a treatment shortfall in this state,” said Dan Meara of the National Council on Alcoholism and Drug Dependence, who estimated that some places turn away half those seeking treatment. “There is not enough funding, and there are not enough beds.”
And the situation is growing worse, placing a burden on the state’s hospitals and criminal justice system. Over the past five years, the number of emergency room visits for behavioral health issues has nearly doubled — much of that increase attributed to substance abuse. The number of drug-induced deaths is also on the rise, with hundreds throughout the state and thousands nationwide dying from prescription painkiller and heroin overdoses.
This surge, coupled with concern over crime and violence associated with drug addiction and mental illness, has spurred the federal government into action. Health care reform is expected to extend substance abuse treatment benefits to 62.5 million more Americans by 2020. And on Friday, the Obama administration announced regulations that will require insurance companies to cover addiction and mental health care in the same way physical illnesses are covered.
But it will take time for these regulations, which do not extend to Medicaid managed-care plans, to become part of the health care system, which is fraught with delays in all areas of treatment. With addiction — when even small gaps in treatment can mean relapse or death — these interruptions are demoralizing, terrifying and sometimes fatal.
In New Jersey, middle-class families may be hit hardest by the cost of addiction treatment. They often do not qualify for public services that serve the uninsured and indigent, and which can be more rigorous than private rehabilitation. Nor can they afford to pay out-of-pocket for treatment, which can cost more than $1,000 a week for private inpatient care.
“The middle class is the one that gets squeezed,” said Frank Greenagel Jr., recovery counselor at Rutgers University and chairman of a state task force on heroin and opiate addiction. “They have insurance, but maybe insurance doesn’t cover it all.”
Even families like Amanda’s that have resources — financial stability, good insurance, patience — find that it is extremely difficult to break the grip of addiction. By this summer, Amanda’s 27-year-old brother had already been through eight facilities, from California to Maine, for his addiction to prescription painkillers and heroin. James, who asked that the family’s last name not be published because of privacy concerns, has estimated that he has spent $400,000, not including travel and legal expenses, on his children’s addictions. They went through treatment centers so often that they now gets “alumni” discounts.
Take Judy Castiglione of Jefferson: She is $90,000 in debt after three years of trying to keep her son William off heroin. “Finding an open bed was almost impossible,” she said, and insurance rarely paid for it. In the meantime, she said, she was “Crazy Mom”: She had GPS built into her son’s car, monitored his phone and wound through downtown Paterson in a white minivan, armed with a baseball bat, searching for dealers.
Or Joe Sardonia, who works for the Monmouth County Parks Department, who said caring for his 20-year-old daughter, a heroin addict, has left him frustrated and broke.
“In most cases, when my daughter wanted help, she couldn’t get it,” Sardonia said.
And then there is Kim Kaupp of Mendham: Kaupp pretended to be his son, Jack, while on the phone with the insurance company, claiming to be high in order to secure treatment. Jack Kaupp died at age 26 in February 2012: His father found him in a Morris Plains welfare hotel, a needle in his arm.
Their stories, along with interviews with dozens of parents, clinicians and authorities, portray a broken treatment system that often compounds the misery of addiction. They show the challenges that New Jersey and the United States face in translating policy into effective and affordable care.
But there are also success stories: programs that work, addicts now sober. Officials at Bergen County public services try to find a bed for any resident who needs it. State officials are mobilizing to stem the tide of addiction. For the parents whose children have turned a corner, this is cause for hope and cautious optimism.
Fewer hospital sites
The path to recovery begins with detoxification. But even as more New Jersey residents — particularly suburban young adults — are seeking help for heroin and opiate addiction, fewer hospitals offer treatment.
Bergen Regional Medical Center now has the only designated detoxification facility in the county; its 54 beds are almost always full, with 12 to 18 new patients arriving each day, said Thomas Rosamilia, vice president for behavioral health services.
“There is nothing harder than sending somebody home without a bed,” he said. “You never know if they’re going to come back.”
The number of behavioral health cases in New Jersey emergency rooms jumped from 289,851 in 2007, to 521,518 in 2012 — an 80 percent increase, said Kerry McKean Kelly of the New Jersey Hospital Association. “The physicians and nurses in our ERs will tell you pretty consistently that substance abuse is a major contributor to the overall growth.”
Emergency rooms will stabilize patients and release them even though the patients have limited access to further treatment, Kelly said. Statewide, families and clinicians alike report that long-term inpatient and outpatient treatment programs often cannot take them.
“At that point, once you’re clean, where do you go?” said Sue Debiak, coordinator of the Bergen County Office of Alcohol and Drug Dependency. “It is astounding to me that people can’t get help. People are driving around looking for a place to put their son. You don’t see hospitals closing diabetes or cancer care services.”
From July 2009 to July 2010, state-licensed treatment facilities admitted 78,313 patients. In the 12 months before July 1, 2013, that number was nearly 85,000. Some 45 percent were for heroin and opiate addiction, more than any other drugs.
At the same time, the state’s expanding drug court program — which aims to treat, rather than incarcerate, certain drug offenders — is sending more people into mandatory care, further increasing the squeeze in publicly funded treatment centers. Officials say the 102 state treatment facilities may be near a saturation point.
Jennifer Kaupp said finding a bed for her son, Jack, was a “full-time job.” The Kaupps spent upward of $300,000 on a “merry-go-round” of treatments for Jack, maybe 10 percent of which was covered by insurance.
“They know you are desperate, they know you will do anything,” said Jennifer Kaupp. “You are watching your kid kill himself.”
In the end, the Kaupps let Jack go — he spent his last months homeless, moving between shelters and charity facilities.
“The professionals said you cannot keep enabling him,” Kim Kaupp said. “Just let him hit bottom, and he’ll eventually come back.”
“But he never did,” said Jennifer Kaupp.
Judy Castiglione still weeps when she remembers reporting her son, William, to the police. And how he cried out for her as he was led down the driveway in handcuffs. “Part of me regrets it because now he has a felony record,” Castiglione said. “But part of me doesn’t because I think he would be dead today.”
The criminal justice system is now seen as the best way to get somebody into treatment, parents say — especially drug courts, which are tough and thorough.
“In New Jersey, the only way to get help is if you commit a crime,” said James, whose son is now in the drug court program.
Part of the disconnect between insurers and treatment stems from the nature of addiction, clinicians say. Mental illness is poorly understood and politically sensitive. And addiction, in particular, is replete with undertones of morality, responsibility, entitlement. Success in treatment can be difficult to measure, and relapse is common.
From the parents’ perspective, insurance companies perpetuate a cycle of ineffective treatments, James said. “They keep paying for you to stay two weeks, 20 times, instead of sending you away for six months. He gets out, big hugs, doing OK, goes back to work. Two weeks later, relapse.”
Insurance companies have seen a “heavy trend toward opiate use in the Northeast,” said Mary Mcelrath-Jones of UnitedHealthcare, adding that the insurer was working to “increase access to effective evidence-based treatments.”
“We always err towards as much rehabilitation as possible in the environment that most closely mirrors the environment in which the person will live,” said Susan Millerick, a spokeswoman at Aetna. An addict may need in-patient treatment, “but to the extent that we can get them home or community-based and provide them with support, then that’s typically what will be covered.”
But that goes against the counsel of addiction experts, treatment programs and families themselves, who say long-term treatment that removes addicts from their environment is often most effective.
Addiction care is also expensive.
“There has to be a check on the appetite for coverage,” Ward Sanders, president of the New Jersey Association of Health Plans, said. “You can’t just close your eyes and say this is appropriate coverage — coverage would be unaffordable for everybody.”
A rehabilitation center told Joe Sardonia that his daughter needed long-term residential care; but insurance would only cover intensive outpatient, he said. “It appears that they do their best to get people out of rehabilitation as soon as possible,” he said. “She wasn’t home 24 hours before she overdosed.”
Sardonia said he understands that both sides have financial concerns.
“I get it,” said Sardonia, who has already spent $20,000 on treatment. “But it just doesn’t seem like the program is set up so that there is a degree of success.
“Economically, it’s a nightmare,” he added. “Emotionally, it’s a nightmare.”
As the Affordable Care Act aims to reshape treatment nationally, Governor Christie, an advocate for drug courts and substance abuse treatment, recently announced that the state-employee benefit program would provide for mental health parity, including addiction coverage.
But despite moves to expand coverage, there remains a statewide shortage of facilities and qualified clinicians. And after addicts are released, they often cannot find housing, employment or education — barriers that sometimes challenge sobriety.
“Every time he went to rehab, and got out, now what?” Jennifer Kaupp said. “There is no care for these people after they go through these programs.”
The Kaupps, like many parents, fear that an entire generation of young adults will be lost to opiate addiction. They estimate that their area has buried a half-dozen people Jack’s age in the past few years. This year, Bergen County has lost more than 20 people to overdoses. Ocean County has seen nearly 100 heroin- and prescription pill-related deaths so far in 2013.
But there are many more casualties of the statewide epidemic of heroin and prescription-painkiller abuse. Sardonia’s daughter recently moved into a halfway house but has few prospects for the future.
“She has no money of her own, no resources, no education, no job,” Sardonia said. “It’s sad, it’s very sad.”
James said his two children are now in recovery; his son recently landed a new job in New York. “There is hope, because I’ve seen it,” James said. September was the first month in three years he had not paid a bill for rehab.
William Castiglione is now living in a group home for recovering addicts and has been clean for more than 60 days, he said. “Some days it’s easy, some days it’s not,” Castiglione said. Today, Castiglione has a broad, muscular build; at the height of his addiction, he said, he weighed 135 pounds.
Castiglione has seen the insides of jail cells and rehab facilities from Florida to New Jersey. In the end, he said, it’s not the location that matters — it’s the addict’s desire to get clean.
“Jail is just as good as a rehab, if you’re ready,” Castiglione said. “If not, the best place in the world isn’t going to make you stop.”
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Northjersey.com : News
N.J. addicts suffer from shortage of drug treatment facilities
Sunday, November 10, 2013 Last updated: Sunday November 10, 2013, 4:32 PM
BY REBECCA D. O’BRIEN
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William and his mom, Judy Castiglione.
VIOREL FLORESCU/ STAFF PHOTOGRAPHER
William and his mom, Judy Castiglione.
TRENTON — Seeking to curb the unprecedented abuse of heroin and opiates in New Jersey, state lawmakers Thursday took the first step toward comprehensive reforms of the state’s approach to substance abuse treatment and prevention.
Experts from the medical field spent more than two hours testifying before the Senate Health, Human Services and Senior Citizens Committee, explaining the yawning gap between science and public policy, and offering recommendations on how to narrow it.
Some of the recommendations were simple enough that they could be implemented with an iPhone, but most others would take time and money.
But committee chairman Joseph F. Vitale, D-Middlesex, said opiate abuse in New Jersey has become a public health crisis and a pressing priority in recent months among legislators.
“People need to know that this is as important an issue in terms of health care as any other epidemic,” he said.
Experts were armed with enough statistics to prove it.
The state has had more than 700 opiate overdose deaths since 2009. Forty-six percent of treatment admissions last year were for heroin or opiates. Overdoses lead all accidental deaths in New Jersey, and of those, opiates have been involved in 75 percent, said Dr. Louis E. Baxter, the president and executive medical director of the Professional Assistance Program NJ, a drug and alcohol counseling services.
Camden, Essex, Middlesex, Monmouth and Ocean counties lead the way in overdose deaths, Baxter said.
With a little more than 6,000 beds for 72,000 people seeking treatment, there is a logjam seeking treatment for “this epidemic (that) has spread,” Baxter said.
He and other experts said there are fundamental flaws in New Jersey’s treatment options and access to them, which they suggested is an indictment of the nation’s approach to substance abuse.
Drug addiction is not about drugs, it’s about brains, said Susan E. Foster, the vice president and director of policy research and analysis at the National Center on Addiction and Substance Abuse at Columbia University. It must be diagnosed early, treated individually and monitored regularly for a long time, she said.
Foster, citing a 2005 study by the center, said 3 cents of every dollar was spent on substance-abuse prevention and treatment in New Jersey, while the remaining 97 cents went to “shovel up after the fact — in our jails, in our health care programs, in our schools, assistance programs and even our workforce.”
A “full treatment experience” — detox, medication, therapy — results in a success rate of about 80 percent and at far less cost, Baxter said. Gov. Chris Christie last week said it costs New Jersey roughly $24,000 to treat an addict through the state’s drug court program, but $49,000 to jail them for a year.
Treatment providers are another area with problems.
Less than 6 percent of treatment referrals come from health care providers, she said. Most referrals come from the criminal justice system, she said, “indicating our failure to prevent and treat the disease until the costly consequences occur.”
Foster said in the U.S. there is no reliable estimate on who is providing addiction care. There are few restrictions on who “can hang out a shingle and say ‘I’m providing addiction treatment,’ ” she said, adding that few medical professionals are well enough trained to provide treatment for addiction.
In New Jersey, as in most states, the largest number of people offering treatment are drug counselors, whose minimum requirements are a high school diploma or its equivalent, she said.
“Addiction care is largely disconnected from mainstream medical practice,” Foster said.
Baxter and Foster also recommended, among other things, requiring addiction education in all health care curriculums, participation in the Prescription Drug Monitoring Program, a campaign to educate the public on opiate abuse, and expanding insurance options to include long-term care.
Vitale, the committee chairman, said the meeting was the first step toward “comprehensive” changes to the state’s approach to substance abuse treatment. He said the Christie administration is eager to discuss options, but comprehensive change will be costly and time-consuming.
“We have to have a blueprint,” he said. “And to say that we can’t do it because of the money — we can do it, but it takes time.”
Policy Impact: Prescription Painkiller Overdoses
What’s the Issue?
In a period of nine months, a tiny Kentucky county of fewer than 12,000 people sees a 53-year-old mother, her 35-year-old son, and seven others die by overdosing on pain medications obtained from pain clinics in Florida.1 In Utah, a 13-year-old fatally overdoses on oxycodone pills taken from a friend’s grandmother.2 A 20-year-old Boston man dies from an overdose of methadone, only a year after his friend also died from a prescription drug overdose.3
These are not isolated events. Drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs.4
100 people die from drug overdoses every day in the United States.4
What Do We Know?
The role of prescription painkillers
Although many types of prescription drugs are abused, there is currently a growing, deadly epidemic of prescription painkiller abuse. Nearly three out of four prescription drug overdoses are caused by prescription painkillers—also called opioid pain relievers. The unprecedented rise in overdose deaths in the US parallels a 300% increase since 1999 in the sale of these strong painkillers.4 These drugs were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined.4
The misuse and abuse of prescription painkillers was responsible for more than 475,000 emergency department visits in 2009, a number that nearly doubled in just five years.6
More than 12 million people reported using prescription painkillers nonmedically in 2010, that is, using them without a prescription or for the feeling they cause.7
The role of alcohol and other drugs
About one-half of prescription painkiller deaths involve at least one other drug, including benzodiazepines, cocaine, and heroin. Alcohol is also involved in many overdose deaths.8
In 2008, there were 14,800 prescription painkiller deaths.4
How Prescription Painkiller Deaths Occur
Prescription painkillers work by binding to receptors in the brain to decrease the perception of pain. These powerful drugs can create a feeling of euphoria, cause physical dependence, and, in some people, lead to addiction. Prescription painkillers also cause sedation and slow down a person’s breathing.
A person who is abusing prescription painkillers might take larger doses to achieve a euphoric effect and reduce withdrawal symptoms. These larger doses can cause breathing to slow down so much that breathing stops, resulting in a fatal overdose.
In 2010, 2 million people reported using prescription painkillers nonmedically for the first time within the last year—nearly 5,500 a day.7
Where the drugs come from
Almost all prescription drugs involved in overdoses come from prescriptions originally; very few come from pharmacy theft. However, once they are prescribed and dispensed, prescription drugs are frequently diverted to people using them without prescriptions. More than three out of four people who misuse prescription painkillers use drugs prescribed to someone else.7
Most prescription painkillers are prescribed by primary care and internal medicine doctors and dentists, not specialists.10 Roughly 20% of prescribers prescribe 80% of all prescription painkillers.11,12,13
Who is most at risk
Understanding the groups at highest risk for overdose can help states target interventions. Research shows that some groups are particularly vulnerable to prescription drug overdose:
- People who obtain multiple controlled substance prescriptions from multiple providers—a practice known as “doctor shopping.”14,15
- People who take high daily dosages of prescription painkillers and those who misuse multiple abuse-prone prescription drugs.15,16,17,18,19
- Low-income people and those living in rural areas.
- People on Medicaid are prescribed painkillers at twice the rate of non-Medicaid patients and are at six times the risk of prescription painkillers overdose.20,21 One Washington State study found that 45% of people who died from prescription painkiller overdoses were Medicaid enrollees.20
- People with mental illness and those with a history of substance abuse.19
Where overdose deaths are the highest
The drug overdose epidemic is most severe in the Southwest and Appalachian region, and rates vary substantially between states. The highest drug overdose death rates in 2008 were found in New Mexico and West Virginia, which had rates nearly five times that of the state with the lowest rate, Nebraska.4
Drug Overdose Rates by State, 20084
What Can We Do?
There are many different points of intervention to prevent prescription drug overdoses. States play a central role in protecting the public health and regulating health care and the practice of the health professions. As such, states are especially critical to reversing the prescription drug overdose epidemic.
The following state policies show promise in reducing prescription drug abuse while ensuring patients have access to safe, effective pain treatment.
Prescription Drug Monitoring Programs
Thirty-six states have operational Prescription Drug Monitoring Programs.22
Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients. They are designed to monitor this information for suspected abuse or diversion—that is, the channeling of the drug into an illegal use—and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help prescribers and pharmacists identify high-risk patients who would benefit from early interventions.
CDC recommends that PDMPs focus their resources on
- patients at highest risk in terms of prescription painkiller dosage, numbers of controlled substance prescriptions, and numbers of prescribers; and
- prescribers who clearly deviate from accepted medical practice in terms of prescription painkiller dosage, numbers of prescriptions for controlled substances, and proportion of doctor shoppers among their patients.
CDC also recommends that PDMPs link to electronic health records systems so that PDMP information is better integrated into health care providers’ day-to-day practices.
Patient review and restriction programs
State benefits programs (like Medicaid) and workers’ compensation programs should consider monitoring prescription claims information and PDMP data (where applicable) for signs of inappropriate use of controlled prescription drugs. For patients whose use of multiple providers cannot be justified on medical grounds, such programs should consider reimbursing claims for controlled prescription drugs from a single designated physician and a single designated pharmacy. This can improve the coordination of care and use of medical services, as well as ensure appropriate access, for patients who are at high risk for overdose.
Health care provider accountability
States should ensure that providers follow evidence-based guidelines for the safe and effective use of prescription painkillers. Swift regulatory action taken against health care providers acting outside the limits of accepted medical practice can decrease provider behaviors that contribute to prescription painkiller abuse, diversion, and overdose.
Laws to prevent prescription drug abuse and diversion
States can enact and enforce laws to prevent doctor shopping, the operation of rogue pain clinics or “pill mills,” and other laws to reduce prescription painkiller diversion and abuse while safeguarding legitimate access to pain management services. These laws should also be rigorously evaluated for their effectiveness. View your state’s prescription drug laws.
Better access to substance abuse treatment
Effective, accessible substance abuse treatment programs could reduce overdose among people struggling with dependence and addiction. States should increase access to these important programs.
These recommendations are based on promising interventions and expert opinion. Additional research is needed to understand the impact of these interventions on reducing prescription drug overdose deaths.
The amount of prescription painkillers sold in states varies.4
The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999. Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for one month.
View detailed list of rates