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."

It's not about the broccoli

Y'know, it was really disheartening to hear one of the current presidential hopefuls sneer that it
was 'snobbish' for the current President to encourage people to go to college (actually, all he said was that people should aspire to at least a year of post-secondary education or training.) There are some days when I am overwhelmed at the questionable level of intelligence demonstrated to me by some of my adult, fully grown-up customers. For example, the ones who know they have a large packet of new insurance information at home but don't feel it's their responsibility to open the envelope. The ones who seem unable to follow simple directions, read what is written or listen to what is told to them. They are entitled to SO many things, but don't have to hold up their end of the bargain. They don't have to study, learn, remember or pay attention. They are spectators -- it's someone else's job to do it for them. Oh, and then there are the emails from my own managers and superiors that are written at a 4th grade grammar level and full of spelling mistakes. It really gets me down sometimes.

My apologies for not posting too often lately -- I was lucky enough to take a vacation to Europe and as always, enjoyed making some observations about health care. Pharmacists are a first-line resource for health care over there, and that makes a lot of sense to me. How many people do we see coming from a doctor's appointment clutching a piece of paper on which the doctor has
scribbled "hydrocortisone cream", or "Benadryl" or "Sudafed?" There are a lot of people who go to the doctor for minor things because they simply don't know what else to do. I guess they don't trust anyone but a doctor to tell them what to take. People have to understand how expensive this is. And then there are stories like the one Dr. Grumpy linked to, where a guy called 911 because he had scabies, and the full force of the American Health Care System weighed in to the tune of a thousand bucks. It's madness.

I had a conversation with someone in Britain who needed to go to an 'urgent care' clinic for
some severe traveler's diarrhea. Yeah, she had to wait a little while (just like here), but was seen by a clinician who prescribed totally appropriate treatment, handed her the box of antibiotic tablets (no pharmacy visit involved), told her what to do and she went on her way. No money changed hands and no bill was generated. I know it's just one example, but it seems pretty simple (and a lot cheaper) to me.

What's missing in the health care debate are the voices of the people who actually work in health care. Why don't we see them on TV instead of a bunch of extremist political pundits screeching about losing their 'freedoms?' I simply can't watch it anymore without getting depressed, yet I probably have an obligation to watch. We spend more on health care per person that any nation in the world, and get poorer results when it comes to basic preventive care. How do we get that through to people who can't understand the words "THIS CARD REPLACES YOUR OLD ONE??"