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

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Thursday, December 6, 2012

Creating dependency: Is that what we do for a living?

Lately, it seems, I have been treating quite a lot of people who end up in the hospital as a result of prescription drug abuse. Most of them have chronic pain and have been generously prescribed long acting opiate medications such as methadone and morphine by doctors of various types, have taken excessive numbers of these medications or mixed them with other medications and have ended up being unable to breathe for themselves.

In the beginning of the last decade there was a well-intentioned movement to recognize that pain was a real issue and should be treated. Pain is not visible, usually, and can often be ignored. Having lots of pain for a long while or intense pain for shorter periods is bad for us. It causes depression, anxiety, leads to post-traumatic stress disorder, and just generally hurts a lot.

Humans view torture, deliberately causing another being to have pain, as vile and unacceptable. Conversely we regard the relief of pain as a great gift. In 1999 the Veterans Administration started a campaign to make a rating of pain the "5th vital sign." That means that, in addition to measuring blood pressure, pulse, respirations and temperature, nurses were encouraged to rate a person's pain on a scale of 1-10. This tended to cause doctors to be more aware of their patients' discomfort and perhaps to offer pain medications.

As a doctor, I always find a pain scale difficult to interpret since, unlike blood pressure, it is very subjective. Not everybody is a number person and not everybody has experienced a truly redline pain level on which to base their 1-10 scale. Also some people recognize that stating a pain number above 5 will result in getting really delightful injectable opiate medications. Opiates are not delightful for everyone, in fact some people absolutely hate them, throw up, hallucinate, get hideously constipated, feel out of control. Still. Some people feel SO much better with opiates. They feel warm inside and nothing bothers them. Anxiety goes away and the world becomes a beautiful place.

Since pain became a major focus in medical care, the use of really potent opiates has increased nearly exponentially, and along with that so has prescription pain medication abuse, overdose and unintentional death. Between 1997 and 2007 prescription of opioids increased more than 600%, and that increase has (as far as I can tell) not slowed significantly. In 2007, 27,000 people died of unintentional drug overdose, the majority of that due to prescribed medications.

In our kindness and empathy we as physicians offer increasing doses of long and short acting pain medications that kill tens of thousands of people and, possibly more tragic, make hundreds of thousands more just-on-the-edge-of-high-all-the-time people dependent upon us for refills. I have been such a physician at times in my many years of primary practice. I would see a patient, know that they had a legitimate reason for opiate pain medications, definitely they hurt and had been taking these pills for years with some improvement, and refilled or even increased the intensity of the medications prescribed. And I was practicing in a way that was encouraged by experts in the field of internal medicine.

If a person needed opiates regularly, they should be on long acting ones, and should have short acting ones for breakthrough pain. To offer less was unkind and old fashioned. Sometimes this approach made my patients more functional but surprisingly often there was no dose of opiates at which the patient was truly happy, functional or their pain was actually tolerable. Occasionally, after trying everything I could think of, opiates, anti-anxiety medications, anti-depressants and anticonvulsants I would be forced to admit defeat and let my patient know that they needed to find help elsewhere because I could no longer ethically offer them refills of pills that I knew were not good for them and which were evidently not actually helping. I would offer these patients supervised tapering of the medications, but it was very rare that they were willing to actually get off of the medications completely.

And even with all of this said, I believe that the products of the opium poppy, in all of their glorious diversity, are some of the greatest remedies that the field of medicine has to offer. For post-operative pain, for a toothache, for a kidney stone, for cancer pain there is just nothing like an opiate. Codeine, a low potency opiate, is one of the most useful drugs I can prescribe, relieving stomach cramps, stopping diarrhea, quieting a cough and gentling a headache.

There are pains that have no visible cause but are just as intense as a drill press, and opiates can make these tolerable, sometimes. But, as I remember it, the world of 1997 did not include more people who were miserable than the world of 2007 when there were 600% more opiates prescribed. Regular use of opiates changes people. This is not something I know because I read a study, but because I have treated so many of them. They are less motivated, more foggy. They are tied to the schedule of my office because they feel very unwell when they don't get their medications. Their memories are worse. Their bowels are usually slow, which becomes an issue in itself. Occasionally they overdose and die. Many patients prescribed opiates share them or sell them which leads to dependency in a whole host of other people.

There have been many government- and medical profession-based responses to this problem, including closer observation of our prescribing habits, efforts to keep patients from getting huge numbers of pills by seeing multiple physicians, pain medication contracts to make explicit the risks of taking the medications and our expectations of the patient for whom we prescribe them. Pain medication prescribing has become big business and many areas have clinics who advertise themselves as treating chronic pain, but really just write prescriptions for patients who are willing to pay for cursory visits. These clinics are being scrutinized and shut down in many places. All of these are good ideas, but I am seeing no decline in the number of patients who are on opiates and who show up with grave consequences of opiate use and abuse.

The problem is that prescription pain med dependence is just the tip of an iceberg of overall increasing dependency on the medical profession due to inappropriate use of medical technology. Physicians generally have ethical motivations, but regardless of our (mostly) good hearts, it benefits us economically to make sure that our patients continue to need us. We have increasing numbers of patients on hemodialysis, whose kidneys have failed. They absolutely require several hours of artificial filtering of their blood at least three times a week at the cost of close to $100,000 a year. They are some of the sickest patients we see in the hospital because hemodialysis is not as good as having functional kidneys and they are at least a little bit sick all the time.

We do increasing numbers of orthopedic procedures which often are associated with complications including life threatening infections and failure of hardware. These procedures can be wonderfully effective in the right patients, but they are becoming more standard for patients who are at extremely high risk of complications. Our intensive care is more and more effective at making the very sick survive, but they are not, thereafter, well. They have continuing needs for multiple medication an procedures.

Most people don't like dependency. I have heard people say for years that what they dread most is becoming a burden on others. Often what we offer people is the opportunity to become a burden. When we discuss the risks of procedures of medications, I think it should be standard to bring the concept of increasing dependency into the conversation.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

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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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