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Tuesday, April 15, 2014

The scourge of prescription pain medicine abuse

Opioids are a family of pain medications chemically related to opium and heroin. They include morphine, fentanyl, codeine, hydromorphone and others. Opioids have unique properties that make them both indispensable for pain management and extremely dangerous.

Unlike virtually any other family of medications, opioids have no maximum effective dose. If any dose, no matter how high, is ineffective at controlling pain, a higher dose can give more pain relief. Most other medications don’t work this way. For example, if 800 mg of ibuprofen doesn’t bring relief, it’s very unlikely that any higher dose will. This property makes opioids a mainstay for treating severe acute pain, such as from fractures or after surgery.

But the risks and side-effects are substantial. Tolerance (diminished effectiveness with repeated use) is a common problem requiring dose escalation to maintain the same pain relief. Withdrawal symptoms are miserable (but not dangerous) and addiction is very common. The most serious risk is that opioids decrease the drive to breathe. In patients who are dying and short of breath, this is a welcome benefit, not a side-effect. Opioids are essential in hospice care because of their ability to eliminate the sense of shortness of breath. But that same effect in an overdose can stop breathing entirely. Philip Seymour Hoffman is only the most recent well-known victim of this property of opioids.

When I did my residency in the mid-90s the philosophy I was taught about opioids was simple. Opioids were for acute pain. If you broke a bone or had a documented kidney stone you could have a prescription that would last a week or so. Patient requests for more prolonged treatment were met with suspicion. The exception was for dying patients. If you had chronic pain form a disease that was going to kill you, you could have all the opioids you wanted. But if you had chronic pain from arthritis, or chronic back pain, or anything else non-fatal, then opioids were simply off the table. You had to make due with other medicines.

Sometime thereafter, we went through a revolution in our attitude. I’m not a pain specialist, so I don’t know if the revolution was supported by any scientific evidence or was simply a change in philosophy. The new teaching was that pain should be treated seriously, and that doctors had been negligent in providing their patients adequate pain relief. Since pain is an entirely subjective experience, there is no test or objective measurement for pain, and the patient’s report of pain should be accepted at face value. The use of opioid analgesics for chronic conditions became acceptable when other options failed.

What followed was an explosion of opioid prescriptions, opioid addiction, and overdose deaths. In 1999 in the U.S. 4,030 people died from overdoses of opioid prescription medications. In 2010 that number had more than quadrupled to 16,651. Since 2003, more people have died from overdoses due to prescription opioids than due to heroin and cocaine combined.

This month the American College of Physicians issued a policy position paper about prescription drug abuse. It was much more of a description of the current dilemma and a recommendation for future research than a guideline for prescribing physicians. The latter is what is desperately needed.

Adding fuel to this fire is the FDA’s decision this week to approve Zohydro, a new extended release formulation of hydrocodone. This decision has received much criticism from physician groups (see links to news articles below) who warn that the potential for abuse and overdose is enormous and that the need for another opioid analgesic is nonexistent.

Has our new more lax prescribing philosophy allowed some chronic pain patients to achieve adequate relief? Is the epidemic of addiction and overdose deaths simply a terrible but acceptable price to pay for the benefit of a far greater number of people who use opiates responsibly? I honestly don’t know. I would love to hear from a pain specialist if any rigorous studies exist on the topic. The societal problem of opioid addiction may have no solutions, only trade-offs. It would be nice if those trade-offs were informed by data.

Learn more:

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic(Morbidity and Mortality Weekly Report)

QuickStats: Number of Deaths From Poisoning, Drug Poisoning, and Drug Poisoning Involving Opioid Analgesics — United States, 1999–2010 (Morbidity and Mortality Weekly Report)

Is Zohydro, The Super Potent New Opiate Painkiller, Just Too Dangerous? (Forbes)

New pain pill’s approval: ‘Genuinely frightening’ (CNN Health)

Potent New Painkiller May Prove Lethal for Addicts, Critics Warn (NBC News)

Prescription Drug Abuse: Executive Summary of a Policy Position Paper From the American College of Physicians (Annals of Internal Medicine)

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. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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1 Comments:

Anonymous Anonymous said...

I'm sick to death of health care professionals treating chronic pain patients as if they are addicts seeking a drug high. Because of headlines like this one, the medical profession continues to slam people like myself who MUST use narcotics to manage life long pain.
The author could have said ANYTHING other than the "scourge of prescription pain medicine abuse" to get his point across.
When I have medical professionals treat me like I'm an addict I tell them to go and bash their thumb repeatedly each and every day for a month and then they will understand more how a chronic pain sufferer feels.
What matters worse is some of the same medical professionals I came into contact with while working as a paramedic are the very ones who treat me like I'm an addict. An ambulance wreck ended my career when it tore my right shoulder and back up. I've had NINE right shoulder surgeries including a total joint replacement. I've had 2 back surgeries and I'm waiting on a call back from my neurosurgeon's office to schedule yet another surgery.
PLEASE stop treating everyone as an addict and stop pushing the drug abuse nonsense. The vast majority of people using narcotic pain medicine do so as instructed.

May 13, 2014 at 1:19 PM  

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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 Iowa City, IA, 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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