The Most Widely Prescribed Med for Medicare Recipients?

June 22, 2015

Many of us are seeing patients who have been prescribed potentially addicting medication by another physician, and our level of vigilance needs to be high.

From the Editor

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First, the non-surprise.

I read an article in the May 12th issue of The New York Times about a study by the US Justice Department, which found that people with mental illnesses who are incarcerated are subjected to significant levels of physical abuse by guards. That study found that physical abuse requiring subsequent mental health services is experienced by a majority of both men and women who have an existing mental health problem in both state penitentiaries and local jails.

The fact that such a large number of incarcerated individuals require mental health services comes as no surprise. We’ve known for years that people with psychiatric illnesses who come in contact with the police often end up in jail rather than in a treatment setting. I’ve discussed in an earlier editorial the tragedy that in many locales there is no implementation of presently existing, relatively inexpensive training programs that could help the police more appropriately direct the mentally ill to evaluation rather than incarceration. Why this is the case is something that I can’t understand.

It’s bad enough these ill people are incarcerated, often from problems stemming directly from their inadequately treated psychiatric disorders. But it’s unfathomable that their abuse is deemed such minor news that the Times article was buried at the bottom of page 13.

Of course, the problems don’t start with incarceration. This May, the US Supreme Court heard arguments in a case about whether the Americans with Disabilities Act (ADA) requires police to exert extra effort at non-violent means of taking into custody a citizen with a mental illness. The case stems from a police shooting of a mentally ill woman whom the police were trying to arrest. If you have time to read more, just do an Internet search on arrests and the mentally ill. You won’t like what you see.

Now for the surprise, although I guess it probably shouldn’t be. The Wall Street Journal, in a story on May 3rd, reported on the most widely prescribed drugs for Medicare recipients. And the winner is . . . you probably didn’t guess it . . . hydrocodone! This drug was prescribed for over 8 million Medicare recipients. True: 45% of these were disabled and under 65, some physically disabled and suffering from severe chronic pain. But over 4 million elderly patients were also given prescriptions for the drug.

Like many states, my own state of Kentucky is home to a rampant epidemic of prescription opiate addiction. And the equally alarming national heroin epidemic is thought by some experts to be related to the fact that the street drug is now less expensive than the prescription opiates someone may have started with.

I confess I read The Wall Street Journal report with a bit of relief, since psychiatrists are not in the top 10 groups of medical specialists who prescribe oxycodone for Medicare patients. Unfortunately, family medicine and internal medicine physicians make up the vast majority of prescribers.

Many of us are seeing patients who have been prescribed hydrocodone or another potentially addicting medication by another physician, and our level of vigilance needs to be high. We’ve known for a long time that too many elderly patients are taking one or more medications with psychoactive effects. One of my geropsychiatric colleagues says that one of the most important parts of his review with an elderly patient is taking a thorough medication history. He says he often ends up trying to help his patients discontinue a number of medications. But, of course, opiate discontinuance requires a concerted effort by both the clinician and the patient, and it’s not easy to manage in a typical busy ambulatory practice with a day filled with 20-minute visits.

But the problem goes well beyond opiate prescriptions in the elderly. I recently was referred a patient in her 80s to help her discon-tinue use of a high dose of a benzodiazepine that had been prescribed for her for years by her family doctor. Given her declining cognitive ability, and unsteadiness on her feet, it seemed important to stop the drug, since both problems could easily have been affected by the medication. But after about 6 months of unsuccessfully trying to at least reduce her dosage, I reluctantly sent her back to her primary care doctor without any change, since she refused to even consider any alteration in her prescription.

And we know it’s not just with the elderly and not just with inappropriate prescribing of anxiolytics or opiates that there is a problem. The increasing number of 20- to 30-year-olds coming to us with “adult ADHD” and requesting stimulant medications is a real concern. Many patients in this age-group who are referred to our clinic are taking not only stimulants but also benzodiazepines-and they are not easily motivated to discontinue either one.

I believe, though, help with this and other thorny clinical issues is close at hand from Psychiatric Times. Over the past several months, I, with Michelle Riba our Deputy Editor, invited several prominent psychiatric subspecialty groups to join in a collaboration with Psychiatric Times to provide periodic clinical reports from their subspecialties on important topics for our readers. The first organization to accept and formalize the collaborative agreement is the American Academy of Addiction Psychiatry (AAAP). I’m anticipating that one of the first articles will address the problems of prescription drug abuse and how we can best help both our patients and our non-psychiatric colleagues with whom we might consult. (Please stay tuned for more information coming soon about the other subspeciality groups we’ll be working with.)