Drugs, the US solution for all the pain
By: Daniel Becker
“In the United States, the therapeutic use of opioids has exploded as witnessed by the increased sales of hydrocodone by 280% from 1997 to 2007, while at the same time methadone usage increased 1,293% and oxycodone increased 866% (5). In addition, the estimated number of prescriptions filled for controlled substances increased from 222 million in 1994 to 354 million in 2003 (5). Consequently, the milligram per person use of therapeutic opioids in the United States increased from 73.59 milligrams in 1997 to 329.23 milligrams in 2006, an increase of 347% (5). And, while hydrocodone is the most commonly used opioid in the United States, based on milligrams per person, oxycodone is the most commonly used drug with methadone use rapidly increasing the most… Consequently, Americans, constituting only 4.6% of the world’s population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world’s illegal drugs (4-6,26-29).”
“Chronic pain’s prevalence and associated disability continue to increase. Harkness et al (181), in a 2000 publication, showed that there was a large difference in the prevalence of musculoskeletal pain over a 40- year period under investigation. The results showed that overall, the prevalence of low back pain increased from 8.1% in males to 17.8%, and in females, it increased from 9.1% to 18.2%. Similarly, Freburger et al (182) reported the rising prevalence of chronic low back pain following an evaluation of North Carolina (U.S.) households conducted in 1992 and repeated in 2006. The results showed a 162% increase in the prevalence of chronic impairing low back pain over the 14-year interval, going from 3.9% in 1992 to 10.2% in 2006 and an annual average increase of 11.6% associated with care-seeking and disability.”
I prescribe the “cold turkey” therapy in all it’s applications. There was even a movie about it:
Reverend Brooks leads the town in a contest to stop smoking for a month, But some tobacco executives don’t want them to win, and try everything they can to make them smoke. If townspeople don’t go nuts, from wanting a cigarette, or kill each other from irritation and frustration, they will will a huge prize.
Oh, the bane of my existence. As an Emergency Medicine Provider, I know these patients all too well. There is certainly a link between pain medication abuse and depression. Depression is, and has been a major problem in the US. In 2001, of the top ten medications prescribed, 4 were antidepressants.
I see these patients all the time in the ED. They generally don’t like me. I have told more than one of them, that while narcotic withdrawal sucks, it will NOT kill them. I’ve been threatened, had my family threatened, and gotten several complaint letters to the administrator, but thankfully, here, they back us up.
Oxycontin SR here, goes for about 85 bucks a pill on the street. Vicodin (Hydrocodone/APAP) goes for about 45 bucks. It’s a business for some…more in the the next reply.
There are 2 more confounding factors involved in this…..
1. ER’s….are crazy, hectic, places, often times physicians and other providers would rather just give the patient the script and get them the hell out of the ED as you have bigger problems. I have been guilty of this in the past, although I certainly don’t anymore.
2. Many physicians/providers don’t want the confrontation. It is easier especially in a tough, busy, urban ED to just give em the meds.
3. Healthcare administrators make it hard as well. Why? Cause so many hospitals are obsessed with Press Ganey scores, or patient satisfaction scores. That’s not a bad thing, except when it is carried to extremes, when an administrator confronts a physician/provider about a complaint, and then makes the physician/provider feel like they weren’t doing their job by not writing the script. This make someone think twice the next time.
4. Lastly, these patients can be real problems. I had one just a few days ago ask me for a script for 300 Oxycontin tablets, when I chuckled and said that would not be happening under any circumstance, he became quite demanding, almost threatening. I gave him the number for patient affairs.
Over the past decade or two there has also been a reaction against under-medicating for pain. Thanks to the war on drugs, doctors frequently avoided prescribing pain medications because they were being monitored. Doctors who prescribed more freely would find themselves warned and questioned. (In fact, some doctors were selling pain medication prescriptions for recreational use. I knew at least one doctor prosecuted for this. He lost his license as well.)
I have a personal interest. I remember having a terrible corneal lesion and being released from the ER with way too little pain medication. I protested, but there were people with more pressing problems. Still, it was excruciating. I only got through the night by the grace of God and Remy Martin, most of a bottle of the latter. The next day my ophthamologist got me a better bandage and a prescription for percocet.
That was in the 1980s. It was even worse back in the 1960s. Doctors wouldn’t give terminal cancer patients a proper dose of morphine lest they become addicted, presumably in the afterlife. It wasn’t good news for the patients who were in terrific pain, or for their family members who had to watch them dying in agony. Some times you have to watch loved ones die. It’s much easier on you and them if they aren’t in extreme pain. We anesthetize dogs, you know.
I approve of the trend towards better pain management. Pain stresses the body and makes healing more difficult. It is a real problem, and the “if it doesn’t hurt, it isn’t healing crowd” is just sadistic. I suppose that goes for both economics and medicine.
I think a lot of the difference in prescription rates is in changing attitudes, but he rise in lower back pain is suggestive. How much of it is related to obesity? I have a sneaking hunch.
Also, Cold Turkey was a great movie and much underrated.
If I were a political sort, I’d say that it’s all people like Rush Limbaugh’s fault with those nasty conservatives making prescription drug abuse socially acceptible and blah blah blah.
I sure can relate to Michael Halasy’s experience. (Lucky me I’m out of this circus now!) The ER frequent flyers can be a royal pain. The extent to which they can fake disease to get their fix is amazing: I’ve had a patient chipping away pieces of his own teeth to make believe he had just “passed” a kidney stone!
However, we could do much better to effectively treat addiction in this country instead of mindlessly criminalize everything.
In the old days (before prohibition) a lot of folks drank a lot, in fact in the late 1700 consumption per person was 3 to 4x what it is now. Ethanol is of course another way of escaping as noted in an earlier post. Emerson noted “the mass of men lead lives of quiet despairation” and the trend noted here may just be a reflection of this. As life gets apparently more despairate one may wish more and more to withdraw.
Now the other option is that people are just following an updated version of the comment in Isaiah 22:13 Let us eat and drink for tommorrow we die. One today might say eat , drink and do drugs…
Of course life in 1800 was a lot harder than it is now, in particular lots of young kids died, making life more depressing. Perhaps an alternative is now that instead of religion being the opium of the people (according to Marx), people have decided to go for the real thing.
My years managing orthopaedic centers gave me some insights into the pros and cons of these meds.
The biggest problems these days are “pill mills” where the number of scripts are just astounding and defy any reasonable medical judgment.
I can certainly appreciate the need for pain control. There is no reason to leave a person in pain. In RI, we actually have a law on the books dictating what pain control is to look like and act like.
Yes, there are certainly people shopping doc’s just to get the pills.
However, neither of these explain: …”Americans, constituting only 4.6% of the world’s population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply,”
This is beyond medical necessity.
The other fact was 2/3 of the worlds illegal durgs are used by US. Knowing the history of the human race to use some type of mind/mood altering substance in great quantities, I just wonder what this says about the economic assumption of the “rational consumer”. Or, is the “invisible hand” dependent on which dimension of reality one is in?
If the rational consumer is not maximizing utility but maximizing pain relief (which could be tied into avoidance of death), then our policies of focusing on the efficiency of money are wrong.
Kaleberg
thanks for reminding me of the other side of this question.
my own experience has been with doctors “pushing” anti depressants and anti anxiety meds. not because they are bad people, but because they are told the meds “work”, and their own experience seems to support that. but i think the short term fix (pun not intended) is bad for the patient in the long term. there are… for most people, i think… better ways to deal with depression and anxiety, but they require life style or life situation changes. hard for a doctor to prescribe that.
i think the same may be true for minor pain and even symptoms of allergy… don’t claim to be a doctor here, or even a typical patient. just have found myself that the medicine seems to prolong the problem. and, for example, careful exercise will do more for back pain than pain medicine.
but, absolutely, the problem is not that simple. and people in real pain should get medicine for it. i think we can deal with any addiction problem later. that’s just another pain, isn’t it?
I’m just a user of the medical system, not a member of it. My experience is that when the diagnosis can be checked in a box, I’m showered with pain killers (dental, ortho surgeries and back pain). But get off the checkbox grid (I have a unique neurological problem) and you have to beg and jump through hoops to get pain meds.
Agreed.
Apparently the DEA has just about won the war on drugs, because they have been focusing some of their resources on hassling nursing home nurses and physicians.
Typically a nursing home order works like this:
1) the physician gives an oral order to the charge nurse
2) the nurse writes up the order and faxes to the pharmacy and the physician
3) the pharmacy fills the order
4) the physician signs the order and faxes it back for the chart
This has to work because the physicians are only rarely in the nursing home.
In the nursing home two licensed nurses count every narc (pill, patch, liquid) and sign off three times a day.
Well, the DEA, apparently not understanding that nursing homes are not just minature hospitals. wanted to change this system so it wouldn’t work.
To its credit, when confronted with reality, the DEA backed off and agreed to something workable.
It is good to hear the other side. Myself, I came to dread seeing the doctor. He seemed to consider himself a pharmacist, searching, searching, for a script to write. I don’t like pills.
But can I tell the other side of the Vicodin, Oxycotin coin. I was in a head-on collision that left me severely damaged. I was placed on Vicodin for awhile and the doctor later switched me to Oxycontin. When I down to 10 pills of Oxycontin, I put them aside (for possible failure) and sat there laughing at myself crying for the next two days. It only took two days, approximately. I threw the remaining pills away. The thing you guys need to understand is that many to most cases are not as much physical as psychological. For those people, I think the entire problem takes on a new dimension. This is true, also, for real chronic pain. One can overcome the drugs when the underlying need for them has gone away. When the need is still there, such as it is for chronic pain and psychological dependency, it is very hard to return to life without the pills and very frustrating for these people when the doctor “just doesn’t understand”.
I just wanted to say that I strongly support giving the pain medications to people with a need for them, especially people in severe pain. But, doctors today walk away from the patient without helping them through the weaning. In my case the doctor didn’t even warn me that stopping the pills had any consequence. I just happened to have already known this.
Like Kaleberg I had a grandmother die of cancer during the period that a dying patient was not given strong pain relief because they might become addicted. If you have ever watched someone die that way, you wouldn’t hesitate to understand how important pain relief can be.
The US uses pills inappropriately, thus the stats. This doesn’t mean appropriate use should be affected or even questioned.
Lyle,
In the old days beer (primarily) was a diet staple – sometimes being 20-30% of a persons caloric intake. Alcohol was easy to store and transport and would not spoil quickly. It also was ‘cleaner’ than the water many had to drink.
And the kids dieing young really just started changing since the advent of modern medicine (mostly vaccinations) and modern sanitation (removal of human wastes and decent drinking water). It was quite common not to name children until they were mostly certain they would live. Also farm life could be quite dangerous and almost any accident that today we look at as a minor injury used to be quite deadly. Around 1900 a broken leg was still 50% fatel.
Modern medical treatment has been outstanding in lowering the death-rates.
Islam will change
As a nurse in a burn unit, administering pain medication is a major part of my job. It is my experience that most physicians don’t really understand narcotics – timing, route, and adjuncts are all as important as dose and are highly individual. It takes a lot of time and effort to properly titrate pain medicine, something most doctors don’t have. Most patients I see are under medicated for pain. Of course, when narcotics are used to treat non-pain issues, like depression, then we have a huge problem, as has been noted above.
As a nurse in a burn unit, administering pain medication is a major part of my job. It is my experience that most physicians don’t really understand narcotics – timing, route, and adjuncts are all as important as dose and are highly individual. It takes a lot of time and effort to properly titrate pain medicine, something most doctors don’t have. Most patients I see are under medicated for pain. Of course, when narcotics are used to treat non-pain issues, like depression, then we have a huge problem, as has been noted above.
Some how the practice of psychiatry has been convinced to alter its approach to patient treatment modalities and now rarely spend any time providing therapy other than psycho-pharmacological therapy. Now it isn’t whether the Dr. practices psychoanalysis, cognitive therapy, behaviorl therapy or keeps an Orgon Box in the closet. Rather its the shelter provided by mother’s little helpers that are the chosen approach. Some discussion of the issue appeared in the NY Times recently: http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?scp=3&sq=psychiatry%20sessions&st=cse
Hmmmm…I do know this arena somewhat. I saw the article. As the mental health field is a poor second cousin to other areas of medicine, a psychiatrist would have to be willing to accept the limits on frequency of visits and adaptation of the therapy learned given the Dr.s age. It would be quite a loss of income for a doc to a phd. level and getting lower. The Dr. would have to learn new approaches. Meds. is lucrative for everyone, and are prescribed by non experts but medically licensed all the time…it takes experience and skill to be sensitive to the side effects most everyone gets. Many docs do very little history taking when prescribing anymore either.
Analysis is done but not thru insurance. Thterapy has declining ‘wages’ and restrictions galore from insurance companies. Contracts with providers in MA are changing constantly.
As I wrote in Concession to Error is not Admission of Defeat (’93), “America” is the only place in the world where you can drive down a sedate suburban street and see signs spelling out DRUGS in four foot letters. We as a society are the most chemically dependent people in the world. Ambein, Prosaic, Viagra.
The next time you hear some rightwing pundit, a bimbo bottle-blonde bobble-head on teevee, suggesting someone has “Drank the Kool-Aid” ask yourselves what they are trying to project, or as the case may be, not. Where did “Drink the Kool-Aid come from? The commonly accepted Jonestown Incident, where five hundred or so half-witted fat white christian cultists first followed a charismatic leader to a “commune” in Guyana and then to suicide?
When your Faux/CNN rightwing bobble-head is heaping scorn upon the object of their derision by suggesting said is a half-wit cultist blindly following a charismatic leader to suicide – hmmm… might have to rethink that one guys – what they’re really trying to do is distract attention away from the fact that they are all ON DRUGS – Ambein, Prosaic, Viagra. Batshit crazy stoned out of their gourd 24/7 ON DRUGS.
Doesn’t say much for the people who watch them.