Alabama leads the nation in prescriptions for narcotics such as OxyContin. (LA Times)
BIRMINGHAM, Alabama -- Alabama has the highest rate of prescription narcotic use in the nation and the fifth-highest prescription narcotic cost, according to a study by Express Scripts, the health care company that manages pharmacy benefits for 1-in-3 Americans.
"This is the first time that we've looked at narcotics," said Rochelle Henderson, director of health services research for Express Scripts.
Henderson and her two fellow researchers found an average of 1.17 narcotic prescriptions per year filled for every privately insured person in Alabama, according to analysis of 2010 Express Scripts data. This was much higher than the national average of 0.67 prescriptions per person per year.
A "prescription" was equivalent to a 30-day supply of a narcotic, or opioid, drug. Opioid is the preferred medical term for these medications.
The reason for this high use in Alabama is not known, but it suggests that Alabama is one of the highest opioid users in the world. The U.S. has only about 5 percent of the world's population but uses about 80 percent of all the opioid drugs, according to Drug Trend Report 2011.
Prescription narcotics include drugs such as codeine, morphine, oxycodone, hydrocodone, oxymorphone, tramadol and fentanyl. They can give significant relief of chronic or acute pain, but they also can lead to dependency and abuse.
According to the federal Centers for Disease Control and Prevention, narcotics such as oxycodone, hydrocodone and methadone caused 305,900 emergency room visits in 2008 and 37,000 deaths in 2006.
While doctors don't want to go back to the period before about 1990, when serious pain was undertreated, the Harvard Health Letters said in 2011, there has been a surge in overdoses and deaths from prescription opioid drugs.
About 4,000 Americans died from opioid overdoses in 1999, both as suicides or unintentional deaths. By 2007, that more than tripled to about 14,500 Americans.
Some of that comes from what public health experts call "illegal diversion," meaning the pain medications were used as illegal drugs to get high, not treat pain. Addicts may go from doctor to doctor trying to score opioid prescriptions.
Express Scripts runs a fraud, waste and abuse program to try to spot such patterns, Henderson said.
"For every $1 in potential pharmacy fraud," she said, "there is a $41 cost impact on the medical side (for unneeded medical exams and tests)."
It's a public health worry, too, said Jim McVay, director of health promotion and chronic disease at the Alabama Department of Public Health.
"We are certainly concerned with substance abuse in the state of Alabama," he said. "Clearly we are concerned with diversion, and with people who present (themselves at doctors' offices) with false symptoms."
Charles Thomas, state pharmacy director for the Alabama Department of Public Health, said the federal Drug Enforcement Administration also has reported Alabama as one of the highest narcotics prescribers in the nation, but the state is taking steps to try to spot abuse.
"We have the prescription drug monitoring program, which receives a record of all controlled prescriptions in the state," Thomas said.
Each week pharmacists send in the information and it is posted by the Health Department. Pharmacists and doctors can look at all the prescriptions for controlled substances that have been filled for a certain patient.
"One drug chain has required all doctors and pharmacists to sign up to use the program, and that's Walmart," Thomas said. "I think it's a great move."
The Health Department also prints a list of all patients who have gone to six or more doctors, or six or more pharmacies in a single month to get controlled substances. The monthly list usually has 15 to 20 names on it, and the Health Department then sends a letter about each patient to every pharmacy and doctor the patient has used.
Snapshot of workers
Illegal use of drugs is clearly part of the overdose problem. A West Virginia study cited by the Harvard Health Letters found that half the people who died from opioid overdoses never got a prescription from a doctor.
But another study published in the Annals of Internal Medicine showed that people taking narcotic drugs legally for long periods also could face trouble -- in a sample of 10,000 such patients, 51 suffered overdoses and six died.
The Express Scripts study of opioid use excluded patients whose narcotic prescriptions were billed under Medicare, Medicaid or Workers' Compensation. Those people might have a higher use due to cancer or injuries.
"We wanted to get a picture of the working population," Henderson said.
Alabama's per-member, per-year cost for opioids was $51.59, versus a U.S. average cost of $43.99. The only states ahead of Alabama for per-member, per-year costs were Oklahoma, Nevada, Utah and Ohio.
The challenge for physicians and pharmacies, the Express Scripts study suggests, will be how to manage prescription narcotics to detect fraud, avoid overdoses, and reduce abuse or dependency -- all while balancing those risks against the goal of pain relief.
The Express Scripts study was presented earlier this summer at a meeting of the International Society for Pharmacoeconomics and Outcomes Research in Washington.
By Jeff Hansen -- The Birmingham News
Published: Monday, August 27, 2012, 6:30 AM