American College of Physicians blows this one: Pri-med "free" education on safe opiate prescribing, REMS and drug companies

I am mostly a pretty big fan of the American College of Physicians (ACP), the society that (usually) represents me as an internal medicine physician. They present meetings and conferences to spread new and relevant information and they promote gifted and hard working physicians and medical teachers. They are a force for organization in our profession which often fails to pull together and sometimes resembles a group of agitated hedgehogs. Some of the educational offerings that they produce are ground breaking, encouraging us to practice medicine that is more effective and patient centered. I do pay $525 yearly to maintain my membership, but that doesn't seem unfair.

So that is why I opened the slick tri-fold large format postcard that I got in the mail today rather than recycling it immediately. It said, "Practice safe opioid prescribing with ACP's resources." Over-prescribing opiate painkillers such as morphine, oxycodone and hydrocodone is a huge problem in the US. In 2010 60% of the nearly 40,000 opiate overdose deaths were due to prescription medications, and that number is continuing, I believe, to rise every year. In addition to relieving pain, medications of this class can make people stop breathing, fall asleep at inopportune times, make poor decisions, be unable to have bowel movements and other life ending scenarios. The US uses 80% of the prescription opiates produced in the world. Many of the opiates we as physicians prescribe end up being misused or abused or sold illegally. In the 1990s there was a huge increase in understanding that pain needed treatment and in the 10 years between 1997 and 2007 prescriptions for pain medication increased 600%. I see patients frequently in the hospital whose illnesses become life threatening because they use prescription opiate pain medications. There are nearly a half a million emergency room visits each year related to prescription opiate abuse and the cost in healthcare dollars of this problem is many billions of dollars. There is a problem with our prescribing habits.

The tri-fold postcard from the ACP offered a 6 hour continuing medical education credit online course on appropriate prescribing of opiate pain medications, with a focus on avoiding overdose and addiction. The course was free to me. When I went to the ACP site I was re-directed to Pri-Med's site where the audio and slide program was available. Pri-Med is a medical education company which makes low cost (to us) online programs on all sorts of subjects. The programs are so low in cost that they can't possibly actually cover the expense of creating the content. Hmmm. Vewwy Intewwesting.

I went ahead and took the 6 modules which covered appropriate use of long acting opiate pain medications to treat chronic pain. I learned some interesting things about risk factors for prescription pain medication abuse, some obvious (active ongoing drug abuse) and some less so (age 18-45 with family history of drug abuse). I learned about different opiates' side effects and interactions with other drugs based on the cytochrome P450 system. I also heard stuff I already knew, such as the fact that long acting opiates are not supposed to be taken "as needed" but should be scheduled and that most of them must be left intact, not chewed or crushed, in order to remain long acting. Most of all I was exposed to a bunch of brand name opiates and exactly how they worked and what doses were standard and how they compared to each other. What I didn't learn was how much each of these drugs cost and how those costs and potential advantages compared to generic long acting opiates. There was nothing useful about how to help pain patients get off of opiates or alternatives to starting them in the first place.

After a rather long program I felt as if I had been cornered by a drug rep (representative from a pharmaceutical company). I am not pleased. I have been effectively inoculated with wonder drug propaganda. In return I will have a certificate that says I have been educated in safe opiate prescribing, which many state medical boards now require for licensure.

Why did this happen? Here's the story. The FDA now requires that companies that produce long acting opiates do something to make less people die of their drugs. The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to ensure that the benefits of a drug or biological product outweigh its risks. For long acting opiates this consists of providing free education to prescribers and proving that at least 60% of them partake of these educational programs. Pri-Med makes its money from the healthcare industry, I'm guessing primarily from drug companies. This particular program skillfully combines risk mitigation with drug detailing. Clever pharma. 

I'm disappointed in the ACP, though. On their website they did mention that this educational activity was supported by industry, but it was in very small print. With $525 of dues money times 140,000+ members, along with other sources of income, the ACP does not need drug company support to create educational material. State boards of medicine require education in safe opiate prescribing, but they do not require that it be provided by drug companies. It sounds like drug companies may have to prove that their educational materials are being disseminated, but that is not the business of the ACP and is not my responsibility. And the shiny tri-fold postcard. Who paid for that?