Our 25-year-old nephew passed away last week. He had been fighting an addiction to prescription opiates for some time, and despite great efforts on the part of himself and his family, he died. I've written about this on my own blog.
His death has caused me to reflect on my own role in the larger problem. It has brought home an ugly issue that we all, as prescribing physicians and mothers, should reflect on.
When I first started as an attending in our small internal medicine practice, I learned to dread one aspect of the call more than any other: dealing with the requests for narcotics prescription refills.
We take a week of call at a time, and call starts Friday at 8 a.m. Friday afternoon call would roll around, and so would the requests. Not hundreds, and not always, but very commonly, one to five requests.
There was a pattern: usually someone was requesting a refill early, with a story about how the original prescription had been lost, or stolen, or left in the glove compartment of the rental car they were driving while their car was being fixed but now the rental car was re-rented and the prescription was gone (true story). Or they had used more than was originally prescribed because they had had a particularly bad flare of back pain/ knee pain/ fibromyalgia secondary to a new injury or stressful event of some kind. Typically there would also be a mention in there of a sick child, a recent family death, a failed marriage, or a lost job. Usually the prescribing doctor or PCP was not readily available, and usually the electronic medical record showed a history of similar weekend early refill requests with notes like, "Filled amount for just a few days until PCP returns" or "Rx sent with no refills with instruction to f/u with PCP". And I usually did the same. (Except sometimes when I was really peeved).
Why didn't I (and we) generally refuse to fill these? Because you could put someone into serious withdrawal if they suddenly stopped their Oxycodone 20 mg three times a day. And if the medication was truly needed for pain, it would be cruel not to provide it, and you just never really knew. In addition, to outright deny these requests could be construed as sort of a slap in the face of the prescribing PCP, my (senior) colleague, thereby questioning their medical judgment in writing this prescription in the first place. And, honestly, a huge time suck as well, as if I were to refuse, I would need to spend so much more time dealing with the mess then if I just gave the patient a few, just to get through a few days until the PCP returned or the office reopened.
Luckily, soon after I was hired, more stringent prescribing standards were encouraged, and then, within the past few years and even months, actual legislation has emerged to practically help us physicians to deal with narcotics prescriptions. Pharmacies cannot accept phone orders for refills, and patients must have a signed hard copy of the narcotic prescription. Weekend phone call refills are no longer even possible. Pharmacies' databases are now linked up so that patients cannot use more than one pharmacy to fill these types of prescriptions. We have directives from our hospital to meet with all of our patients who are on any chronic narcotics, review a Pain Medication Contract, have them sign it, and then test their urine for the specific pain drug as well as for illicit substances.
Because we are in an epidemic.
All sorts of people are getting high on these prescription opiates. I see prescriptions for #90, #120, even #180 of 5 mg oxycodone. I've seen prescriptions for more. If someone or their family member is diverting even a few of those on a regular basis, it's enough to get others hooked.
Diversion is tempting. It's a good income. A Google search right now says that Oxycodone is worth about one to three dollars per milligram on the street, so that 5 mg tablet has a street value of at least five and perhaps fifteen dollars. If someone has a bottle of 180 tablets? Whoa.
Opiates are extremely physically addictive. And lives are crushed by addiction.
Physicians have a wide range of practice habits and comfort levels. Me, especially when I first started, I had zero comfort level with narcotics. Unless a patient just had major surgery or had metastatic cancer, I was NOT going to prescribe a narcotic at all, never mind chronically, long-term.
Now, honestly, I'm comfortable with these prescriptions, under certain circumstances. Surprisingly, in my own practice, most of the people I have started on narcotics (who hadn't had major surgery and didn't have metastatic cancer) are my very elderly ladies with bad arthritis who can't take anti-inflammatories (like Ibuprofen and those meds) and are maxed out on things like Tylenol, Lidoderm patches and Capsaicin cream. And so, yes, I do have a handful of patients who take Oxycodone 2.5 or 5 mg once or twice a day for breakthrough arthritis pain. Most of them walk with a cane, and I hope that their grandchildren aren't pilfering.
Then, I inherited a panel of patients on larger doses of an assortment of controlled substances, and I am currently struggling with these cases. I'm using laws and hospital guidelines as best I can to get a handle on things... it's a discomfort zone. My gut feeling is that some, probably a very small number, of these patients are sharing or even distributing these medications. But without obvious red flags or violations of the Pain Medication Contract, such as a urine screen negative for the prescribed medication and/or positive for an illicit substance, I cannot, in good conscience, refuse to prescribe.
In my own practice, I have tried to shift people towards alternative pain management, like healthy living, physical activity and physical therapy, acupuncture, yoga, massage... I really believe that a low-carbohydrate diet and regular exercise helps to reduce overall inflammation and decrease pain perception. This is not going to work for bone-on-bone arthritis, I am aware of that. But for low back pain and fibromyalgia sufferers, I give it a hard sell.
I'm curious to hear what are the thoughts and experiences of other physicians on this issue...
So sorry to hear about the passing of your nephew. It's always so devastating when young and otherwise healthy people lose their lives to addiction.
ReplyDeleteThere has been a lot of attention given recently to the growing epidemic that is prescription drug abuse. In TN where I live and practice, there have been some new state laws enacted to try and curb prescription drug abuse. I'm not sure what the effect will be, but it will surely make providers more skittish about prescribing narcotics and probably also leave more people in pain.
I've had my own learning curve with this issue. When I first started practice straight out of residency, my patient census was bombarded with drug seekers. These would be the ones whose med lists only included: Lortab, Soma and Xanax. They would maybe come with x-ray reports or films. They always smelled of smoke but would never use alcohol or drugs. They would have already tried multiple non-narcotic meds for pain, including Neurontin, Lyrica, TCAs, NSAIDs, and would have already tried and failed many different anti-depressants for their anxiety. Initially I accepted some into my practice and started prescribing them their controlled substances. Eventually though I just became so jaded, because just about every person I thought was "legit" was either failing their UDS or having some kind of inconsistency to make me suspicious. This included a "little old lady" who was I think in her 60s with what seemed like very legitimate reasons to use pain meds, and as it turned out, she had been seeing pain management the whole time she was seeing me, and double dipping with the controlled substances (this was in a state without a controlled substance database). After many such instances, it just became too draining emotionally and I realized I was quickly burning out. I couldn't trust my patients anymore and would never believe them. Anytime I opened a chart and their med list included a controlled substance, my heart would sink, my anxiety would increase, and I would dread the conversation I was about to have with them about their controlled substances.
Gradually I became more confident about MY own limits and comfort zone. For example, I had a patient who'd suffered a work related injury years ago and was on massive doses of narcotics - if I recall right, he was taking something like 80mg methadone a day on top of oxycodone. Finally I told him I was no longer comfortable writing these massive doses of controlled substances and had to see a pain specialist. And even right now in my practice I only have 2 patients I see for monthly Lortab (now Norco). The rest of them go to pain management. Of course this means that some patients who have been used to getting their pain meds from their PCP will choose to find a different PCP willing to write their meds for them that they just "have to have", but I'm a happier doctor to them because of that. I will also always tell patients that I will never write them chronic daily BZD. There is so much BZD abuse, and it always amazes me how patients can take 2-4mg of Xanax a day and yet be afraid of taking an anti-depressant. Have they even looked at the side effect profile of Xanax?!
ReplyDeleteI know that pain management isn't necessarily always a good idea, and some of them seem more like pill mills than anything else. However, when they are seeing the pt for pain management the risk is theirs, and besides, the pain management folks receive training on these types of high risk meds, and have better knowledge of the nuances of pain management.
I do see folks for treatment of narcotic addiction using buprenorphine or naltrexone, but that is a different situation, and the rules are very strict with those. e.g. dismissal for multiple failed UDS, no shows, etc.
Keep in mind that patients may be miserable with narcotic withdrawal, but they won't die from it. It's BZD withdrawal that's really the issue. Use clonidine, non-Soma muscle relaxants, NSAIDs, etc. for treatment of the withdrawal symptoms as needed.
The bottom line is that we all need to be more judicious about the use of controlled substances. I do UDS on pretty much everyone getting controlled substances, even stimulants, and also frequently check the state controlled subst database. But the most determined addict will find a way around all of it. The rest of it is your own comfort level and figuring out what you are and are not willing to do.
This is a well written blog post but one thing you fail to note the difference is in 'dependence' and 'addiction' - the former being the patient will need to slowly withdraw from a med to avoid withdrawal side effects (isn't just opioids, also occurs w anti-depressants and many other classes of meds) and the 2nd being the illicit use of a medication in order to get a high or some other un-intended affect from it.
ReplyDeleteI see a Pain Mngmt dr monthly and have no problem doing this despite the drive (all of my many specialists are 45mins-1hr away) bc I know these meds (low dose, a long acting and a short acting along w a neuropathic med in addition to other cardiac and enzyme related meds I take daily and weekly) give me a reasonable, productive life. I feel for drs but I also really feel for ALL of the many pts who cannot get access to Pain Mngmt drs and/or another dr willing to help them get back to a more reasonable life. Due to many people abusing the system and as well a sheer lack of training in med school around pain mngmt for drs and better education for pts. there is a large problem with chronic pain that is inadequately or not at all treated. =/
Something needs to change both for Chronic pain pts and for drs so more pts aren't left to suffer needlessly due to some people's ruining a good thing.
Erica
www.rarelydefined.blogspot.com
And I beg to differ withdrawal can be fatal for some legitimate chronic disease pts if not done properly.
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