Viewpoint: Are Doctors to Blame for Prescription-Drug Abuse?

Conscientious and well-trained physicians have contributed to the crisis of opioid-pain-medication addiction

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Prescription painkillers are creating a massive public-health crisis. Since 1990, deaths in the U.S. from unintentional drug overdoses have increased by over 500%. Most of this rise can be attributed to prescription painkillers, which now kill more people than heroin and cocaine combined. Where are all these pills coming from? Not Mexico. Not all from those Florida “pill mills.” Many of them are coming from prescriptions generated by doctors like us who are seeking to help our patients with real pain. It’s true: conscientious and well-trained doctors are partly to blame for the rapidly rising death rate among Americans from prescription pills.

The backstory goes like this: in the 1980s and ’90s, the medical community recognized that patients in pain were often undertreated. Oligoanalgesia, the scientific term for undertreatment of pain, rightly concerned a lot of people. Studies showed that doctors didn’t do a good job asking about pain or treating it properly when they did identify it. Worse, there were documented disparities in pain treatment: affluent white patients were much more likely to get their pain addressed than poor or minority patients.

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In response, there was a major effort to redress this oversight. Doctors were encouraged to think about patients’ pain severity on a self-reported numerical score as a “fifth vital sign” (in the same league as blood pressure and body temperature). Next, medical students and trainees were instructed that patients could never become dependent on narcotics if prescribed for legitimate pain. (We both remember being taught this myth.) Last, opioid pain medications like oxycodone (the active ingredient in Percocet) and hydrocodone (the active ingredient in Vicodin and Lortabs) were framed as safer alternatives to nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen and Vioxx that could trigger peptic ulcers or cardiac conditions. Some of this push toward opioids was driven by the drug companies that made them. And some of it was driven by patient-advocacy groups (many with opaque ties to these drug companies) and medical societies seeking to boost treatment for patients with debilitating pain.

Unfortunately, we went too far in that direction. From 1999 to 2010, the amount of opioid narcotics prescribed by American doctors tripled. The numbers for kids are just as worrying: narcotic prescriptions for children have doubled since the 1990s. Let’s try to put these numbers in context: in 2011, enough hydrocodone was prescribed to medicate every American around the clock for a month.

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Beyond the increase in prescriptions, doctors are more likely than ever to diagnose patients with chronic-pain syndromes. The Institute of Medicine estimates that 100 million Americans have chronic pain. That would mean that almost 1 in 2 people has chronic pain, if you exclude children.

It’s hard to know what has changed so drastically to drive these massive numbers, either on the diagnosis side or the treatment side. But one thing we do know is that chronic pain almost always starts as acute pain, usually from an injury or surgery. Many of the afflicted patients are given opioid prescriptions, but their pain persists — possibly from hyperalgesia, a hypersensitivity to new pain caused by those very opioid prescriptions. Between tolerance and hyperalgesia, patients often need escalating doses of opioids just to feel pain-free. Higher doses of painkillers may disturb breathing patterns during sleep, and the additional use of sleeping medications or alcohol can be lethal. This is at least partly why we are seeing so many prescription-medication deaths.

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Medical guidelines already state that doctors shouldn’t choose opioids for most patients with chronic pain. But we doctors also need to start scaling back on prescribing opioids for acute pain, since some acute pain turns into chronic pain. Everyone with new pain should be started on a high dose of ibuprofen (like Motrin or Advil) or acetaminophen (like Tylenol). These medications have been proved to work as well as the opioids even for conditions like gall-stone attacks. For some patients, we can add a prescription for a limited number of opioid pills to be filled only if absolutely necessary. With that small prescription should come a big warning. Something like: “These drugs are highly addictive, even in short-term use. These drugs have been associated with death, even in therapeutic dosing. These drugs, when accidentally ingested by children, are fatal.” As doctors, we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain. It may take an extra few minutes, but it will save lives.

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21 comments
gaiamom
gaiamom

As a person with chronic pain disease for the last 7 years, the problem I see with this approach is that Docs are now suppose to remove the opioids without any real viable treatment plan. Large doses of over the counter drugs will not work for many pain patients, especially over a lifetime, and we are using our current opioid treatments in order to work and care for our children. Removing those medications without offering new treatments that WORK is basically sending us straight to disability and, for too many, the path to suicide. I would be thrilled if I could find something that worked for my pain, and did not have the side-effects of my current pain meds, it just doesn't exist for me yet. Please invest in research.

EDDoc
EDDoc

BarbaraJohnson
The ED is not the right setting to obtain long term pain medication,
for a variety of reasons. We are unable to follow up on patients after
we discharge them. There is just too much potential for abuse and no
avenues for us to track how many prescriptions are handed out to
patients that come see us. Drug seekers are not a myth, they are out
there in droves and it is very difficult for us to determine who is
coming in with an agenda, addicts that "ER shop" and hop from one ED to
the next getting scripts at each one are part of daily life in the ED.
Unfortunately people that have legitimate complaints suffer because of
this. A small script and referral to Pain Management is the standard of
care at the ED and will remain so until there are some real legislative
changes to protect patients from prescription drug abuse.
As
someone else said, I am tired of being the gatekeeper for narcotic
medications. EDs should institute a national policy of no narcotics,
period, unless you have an easily demonstrable cause (broken bone/severe
laceration/appendicitis/etc). All others with their nebulous complaints
of migraines/chronic abd pain/chronic musculoskeletal pain/etc should
seek pain specialists that are much better qualified than us to treat
such ailments.


calypso1411
calypso1411

More information on these types of healthcare issues can be found at www.thepatientsresponse.com

thearmbarkid
thearmbarkid

Notice how the authors say that opioids "were framed as safer alternatives to non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen and Vioxx," yet the authors never post anything to disprove the statement?  It's because IT'S TRUE!  Opioids are indeed the safest pain relief option modern medicine has to offer, but hey, that doesn't fit their "opioid addiction as the boogeyman" narrative so they conveniently omit that fact.

The authors also conveniently omitted the well-documented fact that opioid addiction only occurs in around 5% of all patients.  But then again, they proudly admit that they think doctors should use scare tactics to discourage patients from obtaining pain relief beyond OTC medications, so this isn't surprising.

It's also not surprising that they're Ivory Tower academic doctors who don't even treat patients, so their thoughts on how to treat patients should be taken with a grain of salt.  After all you know what they say, "those who can, do, those who can't, teach!"

ShamsAci
ShamsAci

Hope there would be safe pain killer drugs in the market certified by by the authority concerned after having them well checked and highly researched.

BarbaraJohnson
BarbaraJohnson

Other causes of chronic pain include arthritis, both Rheumatoid and osteoarthritis, lupus, Ehlers Danlos Syndrome, polyarthritis, cancer, heart failure, sickle cell anemia, multiple sclerosis, DJD, nerve damage or neuropathy from diabetes and a myriad of others. Don't be fooled into believing chronic pain is not an epidemic. Try laying in bed for 15 minutes without moving and tell me you don't experience pain. Now imagine if you were so sick, you couldn't move yourself in bed and think how many in nursing homes who have to be moved because they are too weak to move themselves. Then tomorrow, when you are out Christmas shopping, ask the people around you if they have pain, how long they have had it and what they do for it. You will be suprised at how many people walk around and NEVER have a pain free day. Pain prevents people from working, loving, caring. A better question is how many people have committed suicide as a result of not having pain relief? I know of several who have tried because no one believes how bad their pain really is. Please, please please resolve yourselves to be compassionate. Treating someone with tyelenol and anti-inflammatories results in liver failure, bleeding intestines, depression due to unresolved pain. Large doses of Ibuprofen are not effective when an arthritic's joints are rubbing bone to bone and the damaged nerves of a spinal column cause constant muscle spasms or the demilenating neurons of multiple sclerosis causing severe numbness, and burning and the pain associated with sickled cells trying to get through small capillaries in a sickle cell patient. I have seen sickle cell patients go from hospital to hospital in pain crisis because the doctor thinks they are 'faking' because they are homeless and so won't admit the patient and won't do the bloodwork to prove otherwise. These so-called MD who wrote this article are out of touch, uncompassionate and uneducated in the field of pain management.

BarbaraJohnson
BarbaraJohnson

I am an RN with 35 years experience in pain management. I am published, experienced and appalled at the unsubstantiated claims in this article. The standard set by The World Health Organiztion is that pain is whatever the patient says it is. According to the National Health Institute, there are 110 million sufferers of Chronic Pain, so of course there are more prescriptions being written as physicians attempt to help those in constant chronic pain. Emergency room physicians are NOT board certified in pain management and have NO SPECIAL straining in the field so these two individuals who wrote this article are speaking out of turn. They speak from the perspective of Emergency Physicians who merely assume a patient is 'drug seeking' becuase they come into the emergency room in pain. A pain assessment does NOT mean you simply take a 'fifth vital sign' and shoot them up with drugs and get them out of the emergency room. Pain is a complex field that involves assessment of the patient which may require x-rays, lab work and follow up with a team of healthcare providers who can assist a patient who has recurring pain. These patients do have pain and need to have their pain relieved by a qualified physician who is BOARD CERTIFIED in Palliative Care. This is a physician who has had specialized education in managing pain and symptoms. Often, a patient has pain from an injury, an illness, surgery, but almost always, the pain is invisible to an emergency room physician who is in too much of a hurry to move on to the next uninsured patient. Becuase most chronic pain patients have pain so severe they are no longer able to work and most have gone through their savings, their 401k or their pension trying to survive because they have been denied social security two or three times before finally being approved for their benefits. By then, they are devastated because everyone they know has been pushed away because the individual is depressed, broke and uninsured. They usually have spent a good portion of their income on pain relief. They often are told that their physician won't see them anymore because they need stronger pain medication. This is when they end up in the ER in a pain crisis. The ER doc gives them a shot and a couple of days worth of prescription. After the prescription is used up, they are back in the ER again. After a while, they are labeled as a drug addict.... and no one wants to help. This article is absolutely disgusting!

wifeofCPpatient
wifeofCPpatient

My husband has Chronic Pancreatitis. NSAIDS and Tylenol are not enough to do anything for the pain of this disease. However, because of rubbish like this article, it takes just less than an act of Congress to get his pain meds filled. His GP won't prescribe, his GI won't prescribe, the Pain Clinic keeps trying to push him into treatments that DO NOT WORK for his disease. I would like each of these docs to experience, just once, an acute flare of his disease. Just once. They would change their tune in a heartbeat. Phsysiologically, he is probably addicted to the meds after almost 4 years. BUT...it's a small price to pay to keep him reasonably pain-free and able to live something close to a normal life. As it is, his disease has taken his career, his health, our home, and threats of litigation for him to get the long term disability benefit from his employer.

It's bad enough he has a disease that is commonly thought of as a result of heavy alcohol use (not the cause of his disease per diagnosis), but to add insult to the injury, he is being denied the very medication that enables him to do something other than lay curled in a ball, screaming incoherently from the pain. For heaven's sake...take a GOOD LOOK at your patient before you deny pain meds.

LarryLangley
LarryLangley

I love how so called 'Medical Experts' talk about conditions they never suffered from as well as what proper medication 'IS', as if it's the same for each and every person. The statement about enough pain medication prescribed in America to properly every American around the clock. What are you basing this on? What is the dosage and which medication are you using to make that statement? Also every patient is different in age, weight and many patients get little to no relief from some of those medications. Also generic medications are NOT 100% duplication of the original Brand name. It''s been proven although some in the Pharmacy and Medical world will tell you different due to their lack of keeping up with their education in their field properly, while others that do this because they don't care, it's a job. This article is just another hype job that will harm many people who will suffer at the hands of this magazine and it's Authors of this article.

TJ68
TJ68

For all that you've said here? I can tell you without a doubt that there are several ERs out there that do the exact opposite of what you've said here. In other words, a migraine patient will show up, have taken both doses of triptan meds for a 24 hours period, the max dose of anti-emetics and the max dose of NSAIDs for  that same 24 hour period and be near status migrainosus and the ER staff will still stand around and pretend like opioids don't exist and it's okay to let the patient lay there in pain and that it's not, you know, dangerous.  They'll throw a few benedryl at them. Maybe some IV Reglan and send them home with an ice pack and bill them for $4000. 

Prescription drug abuse is a problem but let's not throw the baby out with the bath water and act like all issues can be treated with NSAIDs and Tylenol. They absolutely can't. We already know that migraines absolutely cannot be treated in this manner and that triptans fail. Please, for the love of God, do not give these sadists in their ERs any more ammunition.  Refusing real treatment for acute pain? My god.

foghamar
foghamar

I hate opioids.  They make me loopy and then I pass out.  I get better pain relief from NSAIDS, unfortunately, can't take them anymore - but tylenol usually does the trick.  

....
....

This article also fails to mention doctors receive tons of money to promote different drugs that companies are experimenting with or attempting to mainstream. Doctors are not perfect people and tend to use a one size fits all approach to treating people.

Unfortunately stupid, overweight, or elderly people tend to become willing guinea pigs for this...

bojimbo26
bojimbo26

In the UK , only 32 tablets can be bought over the counter ( save committing suicide ) , on prescription , 100 tablets .

HopperRox
HopperRox

@EDDoc  and I Quote, as the Doc looked down on me with a look of disgust,  "Not only do you probably not have pancreatitis, it's rare, and I doubt you have ever had it!  Just another person looking for narcotics, who would tell you such a thing?"  My reply was, "the Chief of Surgery at this hospital".  Service and attitude improved right away.

TJ68
TJ68

@BarbaraJohnson 

My family never took it seriously. My migraine history is atypical. I suffer from them frequently. Triptans work sometimes but not always. My main trigger is weather and I live in Western Washington (crazy) but even though that's a main, there are other triggers that also prompt migraines. 

My parents have always indicated that there was nothing wrong me that having a "full time job" wouldn't cure. if I would simply get up out of bed and go to work each day, the rest would take care of itself.  Tried that. Doesn't work.  I've had fantastic jobs with creative, understanding employers who allowed flexible worktime but "structure" was not the answer. 

I need a cure but there is no cure at this time. There may be a cure in my lifetime but I'll probably be 80 when it happens. In the meantime, I don't think articles like the one above telling people to use advil and tylenol for excruciating, chronic pain are the answer. 

I know, let them eat cake?

anyway, I appreciate your comment. It's nice to see someone who works in health care who understands that not everyone who uses pain medication is an addict.

HopperRox
HopperRox

@BarbaraJohnson  Quite a knowledgeable response.  Normally I have to watch wrestling for a good "smack down".  I was suffering from pancreatitis attacks (those vague abdominal pains).  I went to my doc 2 or 3x about this pain under my left ribcage seemed rather intense and I went to Emerge 3x.  My doc thought possible ulcer, gas, etc and at emerge I was turned away with no blood work, no pain meds and no help.  After 3 yrs of this I had a bad flare up and was finally diagnosed with acute pancreatitis.  2 more years and several attacks later (including 10 days on life support), I finally started getting better treatment.  For 2yrs it didn't matter because I was labelled an alcoholic and of course not to be trusted with drugs.  Well I wasn't an alcoholic and I got sick of being treated like it and my family doc knew better, luckily he was on my side.  Today, because I always went to the same (only) local hospital, they know I have real pain and real problems, they are pretty good to get me comfortable quickly now.  It sure didn't start out that way.  I take mscontin and dilaudid for break through pain now. I never need the hospital now unless I have a flare up and we are all much happier about that!!!  As a side note, the alcohol stigma did manage to get me denied any kind of benefits for disability (I lost a good paying job(s) over my health), so I guess I am darn lucky my spouse is also a nurse and also compassionate and understanding.  Thanks for setting these folks straight in the article.  I have seen the drug seekers myself, but real pain can be determined by physical symptoms/readings (high blood pressure/rapid pulse etc) as well as the patients rating.

drabbit
drabbit

@TJ68  

For many decades patients were denied palliative care because "narcotics bad."  If I had a problem, such as a toothache, I would not ask for "something stronger" because the request would insure that I would be refused.

Rather than, as you put it, "throw the baby out with the dishwater" we need to track prescriptions to avoid abuse.  But we can do this with out prohibition. 

thearmbarkid
thearmbarkid

@foghamar No one is saying you should take them if yo don't want or need them.  However, any chronic pain patient who needs this class of medication should be allowed to get them.

Yet another case of unintended consequences of the War on Drugs.  Instead of nabbing crack dealers who sell to children, we're targeting people in pain, and the doctors who treat them.  This nation has become simply shameful.  It's time to get rid of the Controlled Substances Act.  I'm sick of being forced to play cop/gatekeeper by the government, and we actually had less drug addiction in this nation when people could simply go to the drugstore and buy what they wanted/needed without getting permission from a doctor.

thearmbarkid
thearmbarkid

@LeeGunn So pharmaceutical companies are paying doctors to write scripts?  Holy crap, just think of all the money I missed out on!  I feel like a chump for struggling with this student loan debt, since I left all of this money on the table that pharmaceutical companies will just hand me for simply writing their drugs!  My colleagues will be pissed, too!

thearmbarkid
thearmbarkid

@bojimbo26 So, opioids are available in some countries over the counter, yet their rates of addiction are actually LOWER?  Wow, that really shoots some holes in the whole "the government needs to prevent people from taking opioids, the Devil's Drug!" argument.

I like the crafty way that they skated by the fact that most opioid-related deaths are due to polypharmaceutical overdose.  That is, most people whose deaths that we chalk up to "opioid OD" also have OTHER drugs on board!  The number of people who die with ONLY a high amount of opioids in their system is much lower.  But, that doesn't fit into the writers' narrative, now does it?

The fact of the matter is, Time had to resort to talking to ED physicians, because of course an ED physician is going to mimic the opiophobic view of TPTB at Time.  Outside of Rheumatology and Neurology, Emergency Medicine is the most opiophobic specialty in medicine.