When you look at the “Opioid Epidemic” in America it is like an elephant everyone looks at it from their point of view and uses their facts the way they want the elephant viewed. The Federal Government passed a Law, as did the State of Arizona stating that the maximum level of opioids should be ninety morphine milligram equivalents (90MME). They based this more on politics and the storyline of opioid crisis with people dying. The facts are right, but is the interpretation correct. The opioid is killing people.
The first thing is some people have severe pain. The Laws exempt cancer pain and dying patients. The reason, we don’t want people dying in pain. The fact is in numerous hospice patients we give doses of opioids and anxiety medications that put patients to sleep and medications let them die. This is really killing, euthanizing, dying patients. I have no problem with it, nor does society. In fact most of us consider it the proper thing to do.
The problem is living human beings can have as much pain as a dying patient. No physician can tell how much pain another individual is in. We can see a patient writhing in pain and assume the patient is in severe pain. The patient walks out the door and goes about their business. There can be stoic patient who has severe pain and you cannot tell until you perform a physical exam. Manipulation can cause severe pain, yet the patient can state mild pain. Two doctors can touch the same patient and they can disagree about the level of pain the patient is in. No physician panel or government organization can quantify pain in an individual patient. The ten centimeter bar or face bar cannot predict pain across a spectrum of patients. It defines the one patient. The treating physician and the treating physician alone with the patient should establish a baseline of pain in the patient.
The Veteran Hospital System published a paper, which is cited that people taking 80MME have a greater chance of overdose than people taking 20MME. They looked at it and said the opioid caused the people to overdose. People taking 20MME of opioid are patients where the medication works well. When patients are taking 80MME or more they are in more pain and medications are not adequately controlling their pain. The physician may have them on additional adjuvant medications to help the pain. These may include anxiolytics, muscle relaxants, and anticonvulsants. They may also be using medical marijuana. All these medications have a side effect of sedation, as they all work on the brain. Alerts have gone out telling physicians adjuvant medications may lead to more overdoses. This is true but the vast majority of patients taking adjuvant medications have been taking them for years.
The facts are you can detoxify patient off opioids and adjuvant medications. Some patients may do well dealing with the pain using physical therapy, meditation, counseling, and maybe acupuncture. Some do horrible. What do you do with this patient? There are literally millions of these patients who don’t do well after detox. There is no good plan offered to control pain in Federal or State Guidelines (which are read as Law). This is between you and your physician. In fact, pain physicians are more worried about overdose than ever before. I can report of a suicide by gunshot because a patient could not get the medication he had been on for years.
There is no accidental overdose on opioids. A physician can prescribe a dose of medication which can kill a person, but this doesn’t happen. Post operation pain medications don’t kill people when written every three to six hours. The person in pain takes more than prescribed. The accumulated dose causes the overdose in naïve patients. These patients never got ahold of their physician to see if they could take more or a safe method of taking more. For chronic opioid users it is even harder to overdose. These patients are tolerant to the medication. There are numerous times when a patient has come in stating, “I just needed more pain relief”. A long standing pain patient on opioids who overdoses has committed suicide. I have had one of these patients who could not live with the pain. I have had many patients who withered away because pain control could not be achieved.
The following is from the National Center of Health Statistics:
According to the US Centers for Disease Control, in 2016, there were 63,632 drug overdose deaths in the United States. The CDC further estimates that of those, 42,249 deaths involved any opioid.
The CDC reports that in 2016, 15,469 deaths involved heroin; 14,487 deaths involved natural and semi-synthetic opioids; 3,373 deaths involved methadone; and 19,413 deaths involved synthetic opioids other than methadone, a category which includes fentanyl. The sum of those numbers is greater than the total opioid involved deaths because, as noted by the CDC, “Deaths involving more than one opioid category (e.g., a death involving both methadone and a natural or semisynthetic opioid such as oxycodone) are counted in both categories.”
What is not pointed out is there were 21,383 overdoses by other drugs. If you search you will find the next two biggest are benzodiazepines and cocaine, each in the four to five thousand per year range. Because benzodiazepines, Valium (diazepam) and Ativan (lorazepam), overdoses they should not be prescribed with opioids per guidelines. Further statistics show alcohol induced deaths were 33,171. Prescription related overdoses were 17,087. This is not further broken down by illegally used prescription medications (there is clear data of minors using stolen drugs). The other deaths are illegal opioids (heroin and street fentanyl, carfentanil, and sufentanil). These drugs and their evaluation should not be completely bundled with prescription opioid overdoses for a headline. These are scary drugs with unknown standardized dosing; it is easy to overdose.
There were 44,965 suicides in 2016. The causes listed are gunshot wounds (51%); suffocation (carbon monoxide/strangulation (hanging)); (25.9%), Poisoning (not opioids); (14.9%); and other (8.2%). A portion of suicides are given a second diagnosis of severe depression (20%). Personally, I think it is one hundred percent, because if everything were good in your life why would you commit suicide. Chronic pain patients may not be able to retain a job (financial stress) or maintain personal relationships (become isolated). It is amazing none of the opioid overdoses were considered suicides. If we allow cancer patients to pass away peacefully on opioids and benzodiazepines; then why wouldn’t patients in the mental mind to commit suicide not decide this is their preferred method.
There is an addiction problem in America to prescription medications. There are patients who became addicts on opioids because they were treated for pain with an opioid. I do not want to diminish this fact, but they are now addicts. Like alcohol or illicit drugs these people need help. But there is no way to force these people to get help. The problem is that we think the physician and the opioid started the addiction; but if they did, it was most likely not with malicious intent. There was a reason for pain. There could still be a reason for pain. This is the toughest patient to treat. They are emotional draining to office staff, time consuming, and least cost effective to general pain practitioners and primary care providers. A lot of physicians would state these patients are malingerers or have psychological issues, but do not have a reason for pain. This is the patient that gets discharged from pain practices and primary care offices. This patient is labeled rightly or wrongly medically, “an addict” and not “pain patient/addict”. The reason is a term called “opioid induced hyperalgesia”. These are patient when detoxified have no pain. This is rare, but now is described for all patients as probable with physical therapy, counseling/religion, meditation, acupuncture, and other alternative therapies. God blessed those people who could stop their opioid use and have no pain. The relapse rate is high with pain patients because moderate to severe pain is unforgiving. Even mild chronic pain depresses people.
The following is a published excerpt:
Tuesday, August 11, 2015
A new analysis of data from the 2012 National Health Interview Survey (NHIS) has found that most American adults have experienced some level of pain, from brief to more lasting (chronic) pain, and from relatively minor to more severe pain. The analysis helps to unravel the complexities of a Nation in pain. It found that an estimated 25.3 million adults (11.2 percent) experience chronic pain—that is, they had pain every day for the preceding 3 months. Nearly 40 million adults (17.6 percent) experience severe levels of pain. Those with severe pain are also likely to have worse health status. The analysis was funded by the National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH) and was published in The Journal of Pain.
If you have ever had severe pain you probably didn’t go to work that day and you did not interact well with others inside or outside the home. There is data that shows American Physicians over treat chronic severe pain more than any nation in the world. There are two sides: this is a good thing or this is a bad thing. There is no data to show how under treating the chronic severe pain problem in other countries is affecting the population except to say it is expensive. There are studies showing there is inadequate coverage for pain throughout Europe.
We also know over the counter medications thought safe have lasting side effects. Chronic over the counter (OTC) NSAIDs (aspirin, ibuprofen, and naproxen) can cause ulcers and kidney damage. Chronic or short term over usage of acetaminophen can cause liver damage (this is a horrible way to die).
Not writing opioids for a patient in pain does not make a physician a good or bad doctor, nor does writing opioids for a patient in pain make a physician a good or bad doctor. Taking an opioid for pain relief does not make the pain patient a bad person. There are databases in all States (run by the government), which monitor the patient, physician, and pharmacy. These databases are tapped by the Federal Government. This is how you can you down to bad physicians, patients, or pharmacies. When you read about the bizarre number of prescriptions in a town or state, we should question the State and Federal Government. There are doctors who lose their licenses for bad or illegal prescribing. With all these prescription overdoses, I have never heard the State or Federal Government coming into the office to educate the physician of a patient who overdosed. I have heard of them arresting a physician and closing a practice. There should be more than two extremes.
How do you teach prescribing opioids? I have thought about this question. There is no good fundamental way to teach opioid prescribing. Sure you can say you must check the prescription query; order urine drug screens (and look at the results); and submit questionnaires. Addicts know how to answer questionnaires. Only addicts who want to get caught answer questionnaires, which show them to be addicted or question an addiction possibility. Opioid prescribing is a medical art form. When you think you are good, a patient teaches you there is still more to be learned. There used to be propoxyphene (Darvocet/Darvon). Studies showed it had no effect better than placebo, but asked an old physician how it worked for a patient who trusted their physician, and they will tell you it worked great. There is a level of medication to the individual patient the physician feels comfortable with prescribing. Again, in some physicians this is none to what some physicians whatever it takes. There is also convincing the patient the level of pain will not change with more medication. Putting a ceiling on this hamstrings the physician.
There are 25.3 million Americans with chronic severe pain. There were 17,087 prescription opioid deaths. The number of prescription overdose deaths is far below 1%. There is always ways to learn and improve. The fact is by restricting the physician there will be the greatest number of opioid overdoses/suicides in the next year or two. The physician tries to explain a study that shows no benefit for the level of medication the patient is on, and the physician is required to reduce and in some physicians’ minds stop the prescribed medication. I have more patients stating they will commit suicide since the beginning of the year than in the total eighteen years I have been in private practice. Now, does a physician prescribe a patient in pain stating they will commit suicide an opioid and if so how many? Does the physician send them to an inpatient facility? You know the inpatient facility can detox, but you know if pain and depression is the problem there are other means of committing suicide. Does a patient committing suicide by gunshot absolve the physician of a role in their patient’s death? There is a problem. I can’t absolve myself by blaming the opioid or the standard ways of committing suicide.
When I first started practicing medicine patients with complicated histories and/or diagnoses were sent to a panel of physicians to discuss the case and hear recommendations from the physician. The panel could follow the recommendations, have the patient examined for agreement with referring physician, or have the patient sent to another physician. The treating physician could follow the panel’s recommendations or allow the transfer of care. The patient may not like losing a physician, but at least there was thought in what was the best approach to the patient. This is not the same as a medical director sitting in an office reading a policy manual of benefits under the insurance.