Wednesday, April 11, 2012

A Head-Scratcher

The topic of prescription drug abuse has been in the news more and more lately, although to most pharmacists it is not a new topic. All of us have seen customers descend into this hellish cycle. They keep coming in with ever-increasing dosages and quantities or more potent drug prescriptions, and each time they look just a little bit worse. I'm not talking about the "pill-mill" prescriptions -- I'm talking about legitimate prescriptions from doctors we know and patients we know -- but they have entered this cycle that no one seems to be able to stop. As a pharmacist I feel completely helpless, and unless there's something illegal going on I am often at a loss to intervene, and often my input is not greeted with much enthusiasm.

There was an interesting article in the New York Times a few days ago, called "Tightening the Lid on Pain Prescriptions" (check it out online). A couple of things stood out to me:

Quote #1:

“If doctors understood how hard it is to get patients off of these drugs, they would not prescribe them to begin with".

I tend to agree with that, and I've often looked at someone's first Oxycontin prescription with great trepidation (Doc, are you SURE you want to do this?). I'm not a physician and I can only imagine how hard it is to see a patient with chronic pain who answers every drug name you suggest to them with the words "doesn't work." But I also question starting someone on powerful narcotic medication without a plan. How are we going to get them off it?

Quote #2:

"The long-term use of opioids to treat chronic pain is relatively new. Until about 15 years ago, the drugs were largely reserved for postoperative, cancer or end-of-life care. But based on their success in those areas, pain experts argued the medications could be used to treat common kinds of long-term pain with little risk of addiction."

WHAAAAAA????????? Little risk of addiction???? Here's where I'm scratching my head. Can someone explain how chronically dosing someone with a known chemically addictive substance poses little risk of addiction? It's true that many of these drugs were originally marketed for end-of-life care (OxyContin, MS Contin) or serious pain in a hospital setting (oxycodone, hydromorphone, fentanyl, etc.) Now they have leaked out into the community and into the realm of family-practice doctors who are prescribing them for neck pain, back pain, knee pain, TMJ, migraines and a bunch of other stuff for which they are not intended.

The NY Times article concludes with this:

"If the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle.

“I think we are dealing with a lost generation of patients,” she said."


Anonymous said...

That exact thing--pain meds for real reasons turning into addictive substance--- happened in my world, ended with him completing suicide in Feb 2012. The meds and the failure of 'the system' to counsel, treat and evaulate him, along with his inability to SEE it happening.... all of it frustrates me. He was a good soul, generous person with massive back issues from military service. It's amazing how 'end of life care meds'...did exactly that.

lasermed said...

When they first started marketing some of these drugs to physicians, they said we were undertreating pain. They also said that there would be no problem getting patients off them.

Wrong on both accounts. Now look where we are.

Patients expect stronger and stronger narcotics without the understanding that they will have these problems.


Debbie said...

NP here--agree with lasermed's frustration! I also think we have a population who cannot tolerate any pain--at all. They expect narcotics. When I suggest NSAIDS combined with exercise, ice and/or heat, etc., they look at me like I have lost my mind.

Now, I do believe there are good reasons, especially in older patients, that if NSAIDs can't be used or are ineffective, and tramadol is ineffective, AND their chronic pain is not operable/correctable, AND PT and other modalities have failed...chronic use of narcotics might be needed. We ARE still in the business of relieving pain. I'm thinking of little old ladies with spinal stenosis, severe arthitis, etc.

Anonymous said...

Addiction and dependency are two different things. Many chronic pain pts are fully dependent on their meds but NOT addicted.

Anonymous said...

Sounds like some of these commenters have never suffered with pain or are sociopaths without a sense of empathy.

What say you when NSAIDs, tramadol, exercise, heat/ice, rest, TENS, PT, etc... haven't worked, what's your plan then?

What about a young lady with the stenosis and arthritis and many other painful conditions?

FroRyder said...

I have seen this issue from both sides of the fence, as a Pharmacist seen many people slide down the slope of addiction. Last year, I hurt my back, to the point where more than once I thought I was going to have to call 911 to get out of bed, the pain was so severe I could not move more than half an inch. Days it would take an hour of focused effort to get out of bed. The tramadol, flexeril and PT were never going to fix it, once I got past the ARNP gate keeper, my MD put me on narcotics, went through orthopedist, neurologist, nuero surgeon before I could get a referral to a pain specialist. Never received a single script from the pain specialist but he cured my back pain. Pain Management docs get a bad rap because of the pill mill docs. Had I been able to get into to see him 3 months sooner, that would have been 3 months less pain, 3 months sooner I could stop the narcotics (from the Start my PT told me I was wasting my time with her, that I needed to go the pain doc first, once he fixed me she could help prevent future injuries). Pain sucks, dependence sucks, addiction sucks, luckily for me there was a solution for the pain before dependence and or addiction kicked in.

Unknown said...

I suffered for years. I have a somewhat rare autoimmune disease that went untreated for over 20 years. I will now die of this disease, although it could be many, many years. For me it's about quality of life. I am taking these meds to go out and live my life, not to be stoned and escaping from life.

Before starting I knew dependence would happen but I was willing to go forward because I had no choice. Either lay in my bed all day with unmanagable pain or take some meds and go out, travel, have fun. I choose life as most pain patients do.

It's easy for all these healthy people to say oh pain meds are bad. Well until you have walked a day in my shoes, some people have no idea the devastation pain can cause.

I will be on many meds for the rest of my life, most of them will do way more damage than the pain meds.