Skip to main content

More on the epidemic of prescription opiate use and abuse

 Facts (from the Centers for Disease Control Health report, 2013) :
  1. The consumption of opioid pain medications (like morphine, hydrocodone an oxycodone) increased 300% between 1999 and 2010.
  2. The death rates from poisoning by opioid pain medications more than tripled during that time.
  3. The greatest increases in deaths from opioids were seen in non-Hispanic whites and American Indian/Alaskan native populations, who showed a 4 fold increase in deaths.
I have written several blogs on this, most recently talking about the experience of working with a large group of outpatients who are habituated to these drugs and are experiencing side effects, including addiction, along with small improvements in pain that are clearly not worth the devastating consequences of taking these drugs long term.

"What is so devastating?" you may ask.

Here are some stories* (names and details changed for privacy):

  • Crystal is 43 years old. She was diagnosed with fibromyalgia, a painful condition of muscles without a clear cause, 20 years ago. She was started on pain pills 15 years ago and has been on them ever since. The doses have gradually increased and she is no longer able to work because of the sleepiness and confusion that goes along with the pain pills. She has been started on laxatives to treat the constipation and muscle relaxants which make her mouth drier than it already was with the pain pills, and takes an anti-anxiety pill to sleep and to calm down during the day. She still feels terrible and can barely get out of bed, so she has gained 40 pounds. She lives on disability. People ask her if she will sell them her drugs when she comes out of the pharmacy. She has had her car broken into on several occasions by people looking for pills. She can barely afford rent and food and doctor bills on her disability check.
  • John is 50 years old. He hurt both of his shoulders doing drywall installation 10 years ago. He found it difficult to sleep and so they gave him pain pills to take at night. He had his right shoulder operated on by an orthopedic surgeon but it still hurts, as does the left one. He now takes the pain pills all the time so he can do a little work around home. He has been disabled for work for several years. He has gained a lot of weight from being inactive and he feels useless and depressed. His weight has caused him to have knee arthritis and so it hurts when he tries to go out for a walk. He's hoping he can get a knee replacement so maybe he can be more active and lose the weight. His chronic opiate use means that his chance of a successful outcome from knee replacement is substantially poorer.
  • Bill fell off a horse when he was young and has had a tricky back ever since. He used to get prescriptions for pain pills every so often when it acted up, but since it was acting up so often he has started to get a prescription every month, for 240 hydrocodone pills, so he can take 2 of them 4 times a day. He tells the doctor he has to take them all the time or else the back is so bad he can hardly stand it. He has been selling or bartering most of his hydrocodone for several years. Sometimes he takes it for pain, sometimes recreationally and with his girlfriend. If he gets caught, this is a felony. It is also his main income.
  • Nancy has multiple sclerosis. She uses crutches and has back and arm pain. She is on muscle relaxants and pain pills. It is clear to any doctor why she would need these medications, so they are refilled monthly. She lives with her boyfriend and his grown kids. She doesn't take the pills herself. Her boyfriend and his kids use them or sell them. She is vulnerable due to her disability and they threaten to kick her out if she doesn't bring home the pills.
What seems to be happening here is that people get injured or sick, physicians put them on controlled substances in the mistaken thought that it will make them better, and because of the addictive potential and side effects of the medications, they continue to take them and become progressively poor and marginalized. They find relief only in the drugs and end up unable to perform at work, which results in either job loss or being unable to excel and rise in status and income. They get depressed and anxious, often, and are put on more medications. The pain pills can actually make them depressed, but this is rarely obvious to the patient because of the little bit of euphoria that often comes with each dose. They are hassled for their pills. Sometimes they sell them because they are poor, and then they are outside of the law and have a secret that further separates them from people who might help them, such as their doctors. They often smoke, and sometimes drink. The smoking gives them lung disease which puts them at increased risk of death from the respiratory depressant effects of their pain medications. Combining their medications with alcohol can kill them. They get put on medications which lead to obesity and this increases their pain, disability and lack of self confidence.

Turning this process around is going to be hard, but so very worth it. Patients are addicted, but so are we, that is the whole healthcare system. Drug companies make lots of money on these medicines and the medicines used to treat the side effects of the medicines. Doctors get to provide a quick fix and make patients (temporarily) happy just by writing a prescription. Return visits for these patients keep clinics busy. Eventually, though, increasing demands for controlled substances crowds out our ability to see other patients and to provide care that might actually reduce disability. Our opiate using patients burn physicians out because, with rare exceptions, they will never get well. Not writing these prescriptions in the first place or developing alternative strategies that get patients off of them is important work. It will help build healthy communities by reducing the supply of illegal substances. It may even help bring these people back to a place where they can move beyond their identity as chronic pain patients and get on with their lives.

*I am not presently telling the stories of the few patients for whom chronic opiate therapy is a good thing. They do exist, but they are uncommon. They are also usually on low doses and don't take them all the time. I am also not talking about patients with acute pain from injuries, illnesses or surgeries that will resolve. They, too, can have terrible consequences of opiates, but can also benefit a great deal from using them cautiously.

Comments

Popular posts from this blog

How to make your own ultrasound gel (which is also sterile and edible and environmentally friendly) **UPDATED--NEW RECIPE**

I have been doing lots of bedside ultrasound lately and realized how useful it would be in areas far off the beaten track like Haiti, for instance. With a bedside ultrasound (mine fits in my pocket) I could diagnose heart disease, kidney and gallbladder problems, various cancers as well as lung and intestinal diseases. Then I realized that I would have to take a whole bunch of ultrasound gel with me which would mean that I would have to check luggage, which is a real pain when traveling light to a place where luggage disappears. I heard that you can use water, or spit, in a pinch, or even lotion, though oil based coupling media apparently break down the surface of the transducer. Or, of course, you can just use ultrasound gel. Ultrasound requires an aqueous interface between the transducer and the skin or else all you see is black. Ultrasound gel is a clear goo, looks like hair gel or aloe vera, and is made by several companies out of various combinations of propylene glycol, glyce

Ivermectin for Covid--Does it work? We don't know.

  Lately there has been quite a heated controversy about whether to use ivermectin for Covid-19.  The FDA , a US federal agency responsible for providing unbiased information to protect people from harmful drugs, foods, even tobacco products, has said that there is not good evidence of ivermectin's safety and effectiveness in treating Covid 19, and that just about sums up what we truly know about ivermectin in the context of Covid. The CDC, Centers for Disease Control, a branch of the department of Health and Human Services, tasked with preventing and treating disease and injury, also recently warned  people not to use ivermectin to treat Covid outside of actual clinical trials. Certain highly qualified physicians, including ones who practice critical care medicine and manage many patients with severe Covid infections in the intensive care unit vocally support the use of ivermectin to treat Covid and have published dosing schedules and reviews of the literature supporting it for tr

Old Fangak, South Sudan--Bedside Ultrasound and other stuff

I just got back from a couple of weeks in Old Fangak, a community of people living by the Zaraf River in South Sudan. It's normally a small community, with an open market and people who live by raising cows, trading on the river, fishing and gardening. Now there are tens of thousands of people there, still displaced from their homes by the civil war which has gone on intermittently for decades. There are even more people now than there were last year. There is a hospital in Old Fangak, which is run by Jill Seaman, one of the founders of Sudan Medical relief and a fierce advocate for treatment of various horrible and neglected tropical diseases, along with some very skilled and committed local clinical officers and nurses and a contingent of doctors, nurses and support staff from Medecins Sans Frontieres (Doctors Without Borders, also known as MSF) who have been helping out for a little over a year. The hospital attempts to do a lot with a little, and treats all who present ther