It should come as no surprise to anyone that prescription drug abuse is a serious problem. As if we needed any reminder, a flurry of articles recently hit the press, showing just how serious the problem is. Opioids (narcotic pain medications like Vicodin, Oxycontin, methadone, etc) are the most widely prescribed drugs in America, according to IMS and to a recent survey by the National Institute on Drug Abuse (NIDA), and prescriptions can lead to misuse, abuse, and dependence.
Predictably, the government plans to get involved. As the New York Times reported earlier this week, the Obama administration wants to create legislation “requiring doctors to undergo training” before being permitted to prescribe opioid pain meds.
Hearing “government” and “training” in the same sentence doesn’t exactly inspire confidence. What will the “training” consist of? An online seminar? A paper-and-pencil exam from the DEA? A separate section on “managing pain patients” in our Board Certification exams?
[And didn’t we do this already? As a matter of fact, yes, we did: Back in 2000, JCAHO (the “Joint Commission” which accredits healthcare organizations) required doctors to undergo training to recognize and treat pain disorders. Back then, we were told that we weren’t treating pain often enough. Maybe the pendulum has swung too far in the other direction? Maybe we’ve done our job too well?]
With respect to the prevention of opioid abuse, I agree it’s a good idea for doctors to recognize the warning signs of addiction, to implement monitoring procedures (like random urine tests and treatment contracts), to deny early refills, and to inquire about other risk factors for abuse. Sadly, many doctors don’t take these measures and need encouragement to do so. But something tells me that simply providing government-mandated “prescriber education” won’t fix the problem.
In my opinion, there are two other important issues to be addressed before this “training” will prove to be useful.
The first is to get rid of existing inefficiencies. The truth is, most doctors already know the proper steps for prescribing potentially abusable opioids to pain patients. Some clinics (particularly pain clinics) follow these steps with all patients, simply as a matter of course. But in most treatment settings these steps are difficult to take. Regular urine monitoring is cumbersome and intrusive (although relatively inexpensive); generating a treatment contract takes time (although it’s arguably the most important “paperwork” of the appointment); and reviewing a patient’s full medication history is a challenge. Moreover, most of our non-patient-care resources and personnel are devoted to billing and data entry, rather than in these ancillary services that, in the long run, are far more important to cost-effective patient care.
[A side note: many states provide a “prescription drug monitoring” service to permit doctors to view prescriptions for controlled substances that any patient has filled in that state. However—at least in California—the application process takes 3-6 months, the data are typically delayed about 2-3 months, it does not include non-controlled drugs, and not all pharmacies participate. It still blows my mind that for the last 10-15 years it has been easier to purchase airplane tickets online or to send computer files halfway around the globe than to determine whether the patient sitting in my office has filled a prescription for OxyContin in the last 90 days. Simply improving the existing technology would be the most immediately beneficial step.]
The second—and, in my opinion, more important—item is for doctors to understand what is the goal of treatment. Not just “relief of pain,” but when (if at all) can the treatment be said to be complete? I’ve written about this before (see “When Does Treatment End?”), and I’m convinced it’s an important question not just in the treatment of pain but in the management of all conditions, even those we consider “chronic.” I believe that all prescribers need to ask themselves, “How long will the patient need this medication?” and engage the patient in this discussion, too.
I frequently see patients who have been prescribed opioid pain medications, or benzodiazepines or stimulants (not to mention SSRIs or other psychiatric meds), who have no idea how long they’ll need to take them. They just “got a script.” And because these medications are highly reinforcing (they relieve pain or anxiety, and sometimes have a pleasant psychoactive effect as well), they’ll continue to ask for more. Why shouldn’t they, since they were never told they should stop?
In any treatment setting, the patient and doctor should have a mutual understanding of the goals and likely duration of treatment. This plan can (and should) be flexible, but it should always have some realistic end point. Moreover, we should always measure our progress relative to that goal, rather than “kicking the can down the road” and letting someone else deal with the discontinuation of care later. I don’t think doctors should be in the business of denying care to patients, but if we’ve already had the discussion of when treatment might end, the issue of “no” has already been raised, and the patient understands this.
How would this minimize the abuse of addictive medication? For one thing, it would limit access to the drug because we, a priori, are refusing to provide an endless supply. In turn, this helps the patient recognize that everything is being prescribed for a particular purpose, whether for the transient relief of post-op pain or the longer-term management of cancer pain. If and when other symptoms emerge, they need to be discussed and treated separately—or a more comprehensive treatment plan should be developed, if the evolving symptoms fit a characteristic pattern.
I know this is a tall order, and these suggestions may be hard to implement in many of the places where narcotic prescribing is common (ERs, urgent care clinics, etc). But they are important measures to take. We need to take the steps we know we should take (rather than wait for the government to tell us to do so—because we know how that will turn out). And we need to think about patients as people with the power to heal, and plan for the healing process to take place, rather than give knee-jerk reactions (i.e., prescriptions) for symptoms. If we do this, patients will be less likely to take matters into their own hands and “self-medicate,” and the outcome of treatment will be better for all.
Thanks for a great post and a great topic.
A couple of additional thoughts: so much of what I’ve seen in the way of prescription of pain meds happens in the context of the growing pressures on primary care docs to manage inordinate numbers of conditions with very limited time and attention. This isn’t to take responsibility off the docs for (as you suggest) having good clinical relationships, but simply to say that I’ve often seen PCPs try to manage incredibly complex patients (with various combinations of diabetes, cardiovascular conditions, depression, a couple of other issues, and pain) in a 7-minute time slot, and it simply doesn’t work. Something has to get short shrift, and it’s typically the pain–or, at the very least, any monitoring of or discussion of pain meds.
But this leads to the other point that seems relevant: in my experience, anyway, well-intentioned physicians want to be helpful, want to offer relief, and don’t have a lot of (or any) training in managing their countertransference with pain patients, so they do what: a) makes them feel like they’re doing something helpful, or at least palliative; and, b) do what gets the patient out of the office because they have 4 more to see before lunch and it’s 11:30.
It’s unfortunate, but remediable–most of the PCPs I’ve worked with around these issues have been highly receptive to other ways to manage their own visceral responses to pain patients–as well as other ways to manage their own stress. Interestingly, mindfulness-based interventions (MBSR, etc.) seem to have a lot of efficacy for both pain patients and stressed-out helpless-feeling PCPs, and the more we can provide access to non-opioid methods for pain management (MBSR, other health psychology interventions, acupuncture, etc.) the easier it will be to manage the opioids.
(As an aside, my experience has been that patients who are truly in pain, even if they’re abusing their meds to some extent, will often jump at the chance to do an MBSR class or try some other method for managing their conditions. The patients who are primarily med-seeking often won’t follow through with other referrals. Hmm, go figure…)
I just fell, looked like I may have broken my nose. The offer in the ER was for some codeine rather than aspirin and call doc if need more (I needed nothing but I am a chronic pain patient so think I am one who has developed over tolerance to pain). Also had my sensory cortical stim. battery repleced. Again offered codeiene as first line. I think that was a mistake. however…..
treating pain patients, absent proof they are abusers or potewntial abusers, as though they are or will be by requiring urine samples or signing a contract indicating they will not get more meds if run out or lose them (it happens – to almost everyone at one time or another regardless of their meds – no more insulin for you I don’t care that you misplaced your purse with the shot paraphenalia in it. No more nitro, I don;t care your wife washed the shirt without checking your pockets first.) Pain patients are not, by and large, looking for pain meds to get them ‘high’, most do not feel good on them, even when it does help the pain, they usually feel more doped up, cloudy mouthed, slower in thought etc. They are not fun. Most do not get addicted – addiction definition requiring the search for the high and the drtug as well as craving. Some may become physically dependent, not all (I was on up to 14 grains of codeine a day for 8 years when the first implant I had kicked in. I stopped the drug the next day and had no ill effects.)
The DEA has changed the way docs see us. We are required to come in anywhere from every 6 months to once a month to get prescriptions for narcotics.
Let’s stop demonizing the patients as potential abusers. Maybe pharma needs to be provoked into coming up with other kinds of pain meds, esp for those who have chronic intractable pain.)
Some docs will sell, overprescribe, engage in illicit behavior. So too will somoe patients but, by and large, we are looking for help. There is no short term fix for many of the chronic pain disorders and no meds that help, short of narcotics. Until and unless medicine and pharma come up with better answers we are stuck with these meds that, if you talk to many CP patients, most of us hate taking.
author A PAINED LIFE, a chronic pain journey
Thank you so much for providing a patient’s perspective. Some thoughts:
In my mind, a treatment contract or a mandatory urine sample does not “demonize” a patient any more than an airport metal detector assumes we’re all terrorists. Yes, it can be a nuisance, but it’s just good, safe medicine. My argument was that the implementation of these safety measures can be made more swift and less intrusive– that was the first “issue” addressed in my post.
“Demonization” is in the eye of the beholder. Unfortunately, some doctors assume all opioid/benzo users are addicts until proven otherwise; similarly, some pain patients assume all doctors have labeled them as addicts. My desire is to eliminate those labels/assumptions from both parties.
Your comments also correctly point out that most pain patients are not looking to get “high.” I agree. By the same token, most doctors (certainly most good ones) can detect who’s a legitimate patient and who has ulterior motives. (See Michael‘s comment above for just one simple way to do this.) Certainly, we can be fooled. But we’re much more likely to be fooled when we just proffer the Rx to get the patient out of our office and go to lunch, than if we sit down and try to understand the patient, develop a treatment plan and mutual understanding of treatment goals, etc. That was the second “issue” of my post.
Finally, and very specifically, if I understand you correctly, you’re complaining that “we are required to come in anywhere from every 6 months to once a month to get prescriptions for narcotics.” Frankly, I just think that’s good medicine, regardless of what’s being prescribed.
I am not sure how less intrusive it can be made. The analogy does not feel quite right to me, yes terrorists have killed and all of us are made safer by having detectors. Because some people abuse their meds all of us, as a society are not protected by making sure a patient is not abusing their meds.
I am lucky my docs have never had issues with me. so it is my umbrage rather than experience that makes it feel like demonizating.
I agree with you and Michael, those of us in pain are usually willing to try almost anything, and would happily use mindfulness, etc rather than a pill.
Sadly the time issue, esp with HMO’s etc seem not to allow for much sitting down and spending time with a patient. It is definitely easier to write and then send us on our way.
The complaint wasn’t re docs requiring more app’ts but that this is from the DEA. For many patients. having to get out to go to a docs office, or often anywhere, is pain inducing. Those who used to see the doc maybe every 3, 6 mths now have to endure more pain. (My doc told me at first meeting ‘there is nothing I can do for you. If you want me to write for your meds I can do that but that is all I have to offer you.” In those days went once a year. For me is now only every 6 mths so not a big hardship but if my pain was body pain instead of face and eye it would be a hardship, and worse if every 1, 2, 3 months.) It is of course good medical practice to see patients more but it should definitely come from the doctor and not the government.
leejcaroll says: “it should definitely come from the doctor and not the government.”
Little in medicine today seems to come from anywhere but the government. I require quarterly visits for patients who would probably be happy with yearly because of malpractice risk, monthly visits with buprenorphine patients because of DEA. It’s in the doc’s financial interest to increase the frequency of patient encounters, but who wants to (or is able to) pay for them? For patients like leejcaroll perhaps videconferencing offers a less painful way to “see” the doc, provided the government will allow it.
It’s been an uphill battle to get my residents to review charts each time a patient comes in for a med check, so they know how long patients have been on particular drugs, how many past episodes of, say, depression, patients have had, and whether anyone has ever tapered their meds off to see if they still needed to take them.
Docs seem to have multiple incentives to put pts on a med and then leave them on it forever, and you are right, usually no one has discussed with patients how long they will need to be on meds, or if some other treatment (like psychotherapy) might help them to eventually get off meds.
If the Obama administration were serious about the prescription opiate problem it would encourage treatment, an approach conspicuously absent from the “action” plan. Instead, DEA agents routinely harass physicians who prescribe buprenorphine, gratuitously refusing to schedule audits and thus disrupting practices, compromising the rights of patients, and discouraging physicians from using this effective form of treatment. In fact, wider prescribing of buprenorphine for pain, because the drug is so much safer, would probably save lives in itself.
I absolutely agree with the necessity of discussing the end point of prescribing from the outset, but patients also need to know about SSRI abstinence syndrome and the difficulty of stopping benzos and opiates. In fact I do not prescribe benzos, and I refuse to accept new patients who already take them in part because of this problem.
Records of prescribing of all medications should be made available to all doctors in all states immediately. We have the technology now.
DEA has no interest in treatment of prevention. DEA employees depend on an active black market in drugs for their jobs. No illegal drug trade means no need for DEA.
Save a DEA job. Stop prescribing buprenorphine.
moviedoc: “Save a DEA job. Stop prescribing buprenorphine.”
Perhaps a little harsh, but not without merit:
“Records of prescribing of all medications should be made available to all doctors in all states immediately. We have the technology now.”
Moviedoc is right for 2 reasons; the one in discussion but also I hear many stories from folks who move and cannot find a pain doc. The easy transfer of this information would help doctors quickly avail themselves of the truth about a patient’s narcotic med history, making it easier to decide who might and might not be a liar or faker and who is truly in need of pain management and possible continuing opiod meds.
I have to say the only time I have ever had trouble getting ‘off’ a med was when they tried me on methadone. I only took it for about 2 weeks. The person (in hospital setting) who prescribed it told me to see his mentor who would have no problem continuing with the script. He did and refused to write for me (nor did he tell me it was so highly addictive). I had the symptoms one associates with the tales of heroin withdrawal, achiness, nose running, etc. On my own I weaned from it, also within about 2 weeks. What I read about suboxo does not sound much better (of course I am not a med person only a patient).
And, I wonder if physical dependence as opposed to addiction, much less common from all accounts in the chronic pain population on narcotic meds, requires the severe risks of suboxo? (This is a true question not an opinion about it. Until reading here I was unaware of this drug.)
What “severe risks of suboxo[ne]”? The drug is much safer in overdose and in regular use has almost no side effects. In most patients it produces little or no “high.” The line between physiological dependence and addiction can be very fine in the chronic pain patient, but since bupe treats pain, too, it may not matter except for the legalities surrounding the need for special qualification to prescribe the drug for detox/maintenance. My pet theory is that some people like the effects of opiates a lot which increases the risk of addiction, and others (like me) would prefer to suffer whatever pain remains after max doses of ibuprofen and acetaminophen, rather than the side effects of -codones.
http://www.thefix.com/content/best-kept-secret-addiction-treatment?page=2 for info on severe risks.
Your pet theory indicates to me you have never been in chronic intractable pain. I personally know a lot of people who have suffered with intractable pain for years. I certainly do not know the entire community but I have yet to hear one person say they enjoy the feeling these drugs give them. Dopiness, cloudy mouth, sleepiness, etc are not fun or sensations that are desired or craved (as one finds in addiction). We just want whatever level of releif is possible. For many of us we are at the end of the road and there is nothing left but narcotic maintenance to keep us, hoepfully, functioning even if that only means being able to physically get out of bed.
moviedoc and leejcaroll, I just want to jump in here for a moment to say that I think the two of you are polarizing something that’s not so, umm, polarized.
Having worked quite a bit in treatment of chronic pain (as a psychologist in primary care integrated behavioral health, and as an acupuncturist in private practice–and since I’m not prescribing meds people tend to tell me the truth), as well as having worked in addiction treatment for 20+ years, it’s been my experience that there’s a huge range between the two poles. There are indeed folks who fit moviedoc’s pet theory (as well as those who are more extreme, who are entirely med-seeking) and there are those who fit leejcarroll’s perceptions. I’ve come across many patients who take less than the prescribed dose of the medication because they hate the side effects, and many who are in legitimate pain and who take the meds as prescribed, but occasionally pop a few extra because they had a fight with their spouse. I’ve seen patients who are well-maintained on opioids, and who don’t abuse their meds, but who are alcoholics or problem drinkers. And I’ve known a great many patients who have taken opioids long term with no problems at all, only to find that when they try to taper off the meds they’ve become more dependent than they realized–not just physically, but emotionally and relationally, because the meds do (for a lot of folks) take away emotional as well as physical pain.
It’s just not simple. And in my view, the main issue is the one I think Steve has attempted to delineate, which is that this is an issue of medical practice that’s contingent on actually having a relationship with patients–not about rules or regs or oversight, but about the PCP actually knowing who they’re treating and for what and having the time and inclination to address all the relevant issues. Treatment needs to be clinical–and I mean clinical in the sense that it’s individual, taking into account what’s happening for each person, without imposing theories or assumptions. The problem here is that opioids are simply not treatment for chronic pain. They’re palliative–they don’t actually treat the presenting condition, they just make life bearable while patients suffer with pain. And the whole issue is way more complex than can be addressed by urine screening or med monitoring software or even clinical protocols. As long as the erroneous idea that prescribing opioids is actually treating pain continues, I doubt we’re likely to see any substantive change.
Just want to clarify: when I said that because I’m not prescribing meds people tell me the truth, I wasn’t implying anything about pain patients per se, but rather was commenting on the nature of the system in which there’s so much assumption about people abusing meds that many patients are reluctant to tell their docs the truth about how they’re actually taking their meds for fear of a punitive response. (Not that there aren’t also manipulative dishonest med-seekers as well…)
I plead not guilty to the charge of polarizing. I just want to advocate for use of bupe, not just for addiction, but also for pain. But know that I claim no experience treating pain. I hope more docs will prescribe it off label (or on label for the patch) for acute and/or chronic pain because it is so much safer and probably less likely to be abused than other opiates.
Most if not all of the hundreds of patients for whom I have prescribed buprenorphine report a euphoric effect the first time they used opiates, regardless of the indication. I can’t recall anyone who wanted to stop bupe because of “dopiness, cloudy mouth, sleepiness,” etc.
The Fix: Of course it’s addictive. Tapering the dose from the high end is usually the easy part. No “professional help” (whatever that means) is needed. You just taper at your own pace. Low testosterone? Happens with all opiates: you just rub some gel on your skin. Rotting teeth. Rare with the tablets, probably less likely with the new film, and FDA has approved a patch for treating chronic pain. Next up may be a 6 month implant. Hair loss “severe”? Anyway I’ve never seen it. Brain chemistry heal? Right.
37-hour half-life? Wrong again. Much shorter. It’s the effect on the brain that lasts which means the user is not on a roller coaster and only needs to take the drug twice a day (maybe more often for pain). A year to taper? One patient went from 32mg/day to zero in seven days. He said, “I had a bad week.” I think that meant he only worked 8 hour days.
Block all of a person’s emotions? Hogwash. Depression? He must not have heard of all the people who claim it helps their mood.
’25 to 45 times as powerful as morphine”: Shameless double talk. Drug are not “powerful.” All this means is that to get the same effect on pain for example as 1mg of bupe you might have to take 25-45mg of morphine. The correct term is potency. It’s just numbers. If bupe is so powerful, can Dr. S explain the fact that if you take enough morphine you’ll stop breathing and die, but bupe has a ceiling: increasing doses produce increasing effect up to about 24mg per day. Then it hits a ceiling. Take 240mg, 2400mg, you get no additional effect as long as you’re not combining it with something else. (Don’t try this at home.)
Someone might ask Dr Scanlan what he was smoking, except of course he’s right that abstinence is king where addiction is concerned, unless you need the drug for pain or there’s zero chance that you’ll remain abstinent.
Let’s see, death or low testosterone? Your call.
I cannot of course respond to your difference of opinion with the click. I have not researched it, as I mentioned this is a new drug for me (i.e. knowledge, not use).
Michael, you are absolutely right. There is a spectrum from the no use to the addicted. Having said that, it is palliative. I know of no one in chronic pain who believes it is curative or healing at any level.
Moviedoc -At no time, on codeine, morphine. demerol, tincture of opium, among others whose names I no longer recall, did I ever experience ‘euphoria’. You have treated many patients, I have talked with many people in chornic intractable pain. Obviously our experiences are vastly different.
I know folks who have been told there is nothing we can do for you but try to control the pain at some level. Speaking for myself I have been told, repeatedly, there is nothing else we can do for you. We do not know why the eye usage pain remains. The best we can do is try to give you some relief with narcotics.” They have offered me hydrocodone and higher levels of narcs. They make me feel awful and have never helped either emotionalloy or psycholioically. I choose to remain on only codeine and take it only when the eye pain gets away from me.
As long as there is pain with no answer but palliative there will be the need for narcotic medication.
I hear you repeatedly referring to your own concerns and not those of other patients or physicians. I can assure you that if physicians merely catered to a patient’s wishes/sensitivities/etc, and should a bad outcome occur, they would likely be considered liable in a malpractice suit, because of falling below a reasonable standard of care in prescribing such medications. I have served on malpractice review panels, and seen many a well intentioned physician fall victim to the syndrome of patient pleasing and not following reasonable practice standards. Treatment should always be individualized, but at the same time meet such standards. Try not to personalize system wide practice standards, which I think as a whole are solid and make sense.
doctorZ, I think you misread my postings. I continually refer to other patients.
“I can assure you that if physicians merely catered to a patient’s wishes/sensitivities/etc, and should a bad outcome occur, they would likely be considered liable in a malpractice suit.” I have never said a doc should cater to patient wishes. If I saw a doc who did that (sry 1st person) I would not continue to see him. His job is not to parrot me but to give me his considered opinion and treatment/plan if he has one.
My point remains, many in chronic intractable pain have no recourse but palliative care until something else comes along. I did not say how much, how iften etc but that narcotics are an essential part of treating those with CIP.
The docs you cite are not good docs, nothing to do with anything I have written, “…well intentioned physician fall victim to the syndrome of patient pleasing and not following reasonable practice standards.” Good intentions, as they say, pave the road to Hell, Neither I, nor the other patients with whom I have spoken, and continue to speak, want or do tell the docs what we need and how much. It is up to the doc and relates directly to appropriate standards of care.
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