American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tuesday, November 8, 2011

Don't blame doctors for prescription drug overdoses

The overdose death rate from prescription opioids, referred to as "narcotics," has reached "epidemic levels" in the U.S., according to a report just released by the Centers for Disease Control and Prevention (CDC). The report further states that the intentional misuse and abuse of popular opioids such as OxyContin, Vicodin, methadone and others now cause more deaths than those caused by heroin and cocaine combined.

Dr. Thomas Frieden, CDC Director, told reporters that "Narcotics prescribed by physicians kill 40 people a day." He continued by stating, "Prescription painkillers are meant to help people who have severe pain. They are, however, highly addictive."

The report states that increased prescribing of pain medications by doctors is a significant cause of this growing number of deaths. However, the situation is far more complicated than this report presents. Poor pain management and prescription drug abuse has become a catch-22 in the U.S.

On one hand, the Institute of Medicine estimates that 116 million American adults suffer daily from chronic pain. This is considerably more than all the people with heart disease, cancer and diabetes in the U.S. combined.

The medical community has recognized the devastating consequences of unrelieved pain, and is taking steps to treat this enormous medical problem. Opioids are a valuable treatment option in the management of chronic pain, so it unsurprising that increasing efforts to treat this problem has resulted in increased use of all analgesics, including opioids. Having more opioids in circulation increases the risk of abuse and diversion, hence the catch-22.

The CDC report shocks the reader with statistics: 40 people in the U.S. die every day from opioids (over 14,000 a year). However, we know that approximately 17,000 people die every year from nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) or naproxen (Aleve) and others. The inappropriate prescribing of any medication can lead to adverse consequences, even death.

Where are the people who use a prescription pain medication for a non-intended use getting them from? The 2010 National Survey on Drug Use and Health questioned persons aged 12 and older in 2009-2010 and got the following responses:
--55.0% obtained free from a friend or relative
--11.4% bought from a friend or relative
--4.8% took from a friend or relative without asking
--4.4% got from a drug dealer or stranger
--7.1% some other source
--17.3% prescribed by one doctor

Less than 20% of pain medications used in some unintended fashion are prescribed by one doctor. The reasons for the increase in deaths from pain medications is due to many factors, not just increased prescribing by doctors. In our zeal to curb this alarming problem, let's not throw the baby out with the bathwater, leaving legitimate pain patients holding the bag and suffering needlessly.

What can we do to turn this trend around? Let's look as some possibilities:
--First, doctors do need to develop skills to help detect adults who are not legitimate pain patients, or who are at risk for pain medication abuse or diversion. There are screening tools doctors can use to help predict people likely to use the pain medication in a manner other than intended.
--Doctors can prescribe opioids in "abuse-deterrent" tablets and capsules designed to make it harder to crush or chew.
--If states find doctors that are writing prescriptions for pain medications simply for profit, they should be dealt with in the legal system.
--Many states have a prescription monitoring program where doctors can see all the prescriptions written for an individual in the past by any prescriber. These state monitoring programs should include all controlled substances, not just opioid prescriptions.
--States and communities need to develop efficient "take-back" programs for medications no longer needed, most especially for pain medications.
--Education is critically important for prescribers, other health care providers, and patients, families and caregivers. Dr. Lynn Webster suggests the following six steps to protect yourself and your family from opioid misuse:
1) Never take a prescription painkiller unless it is prescribed for you.
2) Do not take pain medication with alcohol.
3) Do not take more doses than prescribed.
4) Use of other sedative or anti-anxiety medications can be dangerous.
5) Avoid using prescription painkillers to facilitate sleep.
6) Lock up prescription painkillers.

To learn more about these tips and other information to help curb the misuse and abuse of prescription pain managers, visit the American Pain Foundation website to learn about the PainSafe Alliance. Last, your community pharmacist is in an excellent position to review all your medications to make sure they are safe to be taken together, and that the best pain medications have been selected to treat your pain.

We need to take the competing problems of chronic pain and prescription pain medication misuse seriously, and to not worsen the plight of legitimate pain patients in our zeal to reduce the abuse of these medications.

This post by Mary Lynn McPherson, PharmD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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