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

Thursday, June 18, 2015

It was not a great idea to prescribe sedatives, opiates, and stimulants to just about everybody

Lately I've had the opportunity to work in an outpatient clinic where the regular doctor is out sick for a prolonged period of time. It is a breathtakingly beautiful little community, with green hills and a crystal clear river. It is also troubled by methamphetamine and prescription drug abuse.

The little clinic in town is unwittingly a partner in this crime. Like the U.S. itself, this small community clinic has been generous with prescribing controlled substances for those who appear to need them. Sedatives in the benzodiazepine (Valium, Ativan and Xanax are brand name examples) family are prescribed for those with anxiety. Opiates, from the family that includes morphine, are prescribed for patients with back pain and knee pain and a host of other long lasting pains, and continue to be prescribed monthly for round the clock use, sometimes at increasing doses, since these long term pains rarely go away, even on medications.

Every young person these days seems to have attention deficit disorder, and many of them have found that they can study better if they take stimulant medications. These medications have been around for years, though there are newer formulations, and used to be called “speed.” In moderate doses they make pretty much everybody able to study better. They have become extremely common on college campuses at exam time, since they also allow a person to go without sleep and sometimes without much food. One person with a regular prescription for this kind of medication can supply his or her friends with drugs as needed. Side effects can include heart rhythm disturbances and erratic behavior, especially in higher doses, as are sometimes used recreationally. Some of the patients in this little clinic get ADD drugs so they can work or study, sedatives so they aren't anxious and opiate pain killers for their bad backs or other maladies. Sometimes they take them, sometimes they sell them or give them away, and often they do both.

There is no good evidence that these medications are either safe or effective when used long term. In fact there is good evidence that they are NOT safe, and quite a bit of circumstantial evidence that they are not effective. We prescribe many times the number of controlled substances now than we did a decade ago, and overall Americans are not less anxious or less in pain or better able to concentrate than they were before. Those of us who prescribe opiates to patients with chronic pain very rarely see the pain become significantly more manageable though we do see the patients become less active and more likely to ask us for ever increasing amounts of the medications which don't work very well.

We have known for years that opiates cause constipation, nausea and vomiting, sleepiness and confusion and can cause people to stop breathing at high doses. We are also recognizing that they cause low testosterone levels which results not only in sexual dysfunction but weakness and mood alterations and bone thinning. In some patients overall tolerance to pain or anxiety is decreased. Combining them with sedatives increases the risk that patients taking these medications will stop breathing and die. Most of the patients who die of these medications do so while taking the medications as prescribed though many overdose deaths also occur in people taking the medications recreationally.

I, as a cutting edge physician of my generation, prescribed these drugs with enthusiasm, glad to be able to lessen the burden of anxiety, pain or distraction in my patients. Eventually I noticed that these patients were having real problems, including emergency room visits for confusion or for increased pain, worsening of their pre-existing breathing problems, severe constipation requiring hospitalization, one died by deliberately overdosing. Others' deaths were probably hastened. More subtle has been the increasing number of people who are becoming inactive, apathetic and stuck in poverty who appear to live mostly for their prescription medications. This group of people are not being identified at all by statistics on overdose.

I have been away from regular primary care practice for years now, so have not been writing long term opiate or sedative or stimulant prescription for patients. I have also been in the hospital more and have seen more desperately ill patients whose main problem were prescriptions for controlled substances.

Now I get to be on the receiving end of what goes around which apparently comes around. There are a bunch of patients on controlled substances which will likely kill them (unless they are selling them to people, including school children, who will take them and maybe die) for whom I am asked to write for refills. HELP. Can't do it, can't not do it. Patients can have serious withdrawal syndromes if they run out of their opiates or sedatives suddenly. (Stimulants are usually not an issue, though.) If I do prescribe these medications there is a reasonable chance that I will be responsible for some bad and preventable medical tragedy. If I don't, these patients will be shocked and betrayed, since they really think they need these drugs to be happy.

If this was just my (and their) problem it wouldn't be that interesting. What is interesting is that this is just a tiny microcosm of what is happening in the whole U.S. Physicians are discovering that these controlled substances are not safe and that their patients are mostly not doing better on them than they were off of them. A small number of patients are doing better, but it's infinitely hard to figure out who those are. Stimulants may have benefit in children with attention deficit disorder, but this is rarely relevant for me as an internist who doesn't see kids. Adults appear to be overusing them in an epidemic manner.

The medical community of the United States needs to make an abrupt about face while showing compassion for the patients who have been taking these medications and probably deteriorating because of them for years. In our opiate dependent patients, we need to re-assess their pain and the causes of it and research the options that might be helpful. We have to do all this while tapering these patients off of the medications which they think they love. We have to realize that many of the things we might do to improve our patients' pain, such as exercise, meditation, non-opiate type drugs, may not be truly effective until the patients are actually off of opiates.

In my experience in trying to deal with this situation, I have found some unexpected allies: the patients themselves. In every patient who I talk to about tapering off of controlled substances I expect anger and resistance. But this is not always the case. I have met patients who seemed like they had just been waiting for someone to help them get off of these meds. It's not even all that uncommon. People don't actually like to be passive and helpless and weak and sleepy and constipated, and some of them are willing to risk experiencing pain or other discomforts in trade for not being on drugs. I see patients on the other end of the process, too. They say that after their injury or operation they were heavily dependent on drugs and that they eventually got fed up and, with the help of a good doctor or nurse or family, got off of them and intend never to take them regularly again.

Opiate pain medications and benzodiazepines are some of the most miraculous drugs physicians can prescribe, and I am not in any way averse to using them when they are needed. The opium poppy and its derivatives can abruptly change the outlook of a person who has the acute pain of a broken bone, a toothache or a recent surgery. They can make the final weeks, days, or hours of a person's life be more tolerable. Benzodiazepines can immediately relax a person whose anxiety is running away with them. These drugs are amazing. They just shouldn't be used on a regular basis except in extremely unusual cases.

I'm not positive that adult attention problems should be treated with medications. The rise in use of stimulants may be just an indication that our society expects everyone who intends to achieve financial independence to be able to focus on tasks or studies which are mostly irrelevant to them. As we've moved away from hunting and farming and manufacturing there are many round pegs attempting to pound themselves into square holes. Stimulants, with their known significant side effects and their unknown long term effects, should not be used to make people do things that bore them silly. On the other hand, the rare person who has narcolepsy (a disorder which is characterized by sleep attacks) has my whole hearted support in using stimulants on a regular basis. I will even sign the prescription.

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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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.

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.

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.

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.

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).

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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