Monday, May 11, 2015

Some thoughts on overuse of sedatives, opiates, and stimulants

A recent article over at the Why is American Health Care So Expensive blog discussed the patterns in overuse of sedatives, opiates, and stimulants, noting:

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.

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.

Ok, that sounds like the problems that can come from a single doctor treating a patient.  But the problems can be compounded when a patient is seeing more than one doctor.  A 2014 BMJ article by Anupam Jena and colleagues reviewed the frequency and characteristics of opioid prescribing by multiple providers in Medicare.  They found:

Concurrent opioid prescribing by multiple providers is common in Medicare patients and is associated with higher rates of hospital admission related to opioid use.

Some doctors are bucking the trend, but it takes a concerted effort, patience, and thoughtfulness.  I note this piece from NPR on treatment of migraines, where Dr. Carolyn Bernstein notes:

"The majority of [desperate patients] have really been suffering a number of years and they're really miserable with the pain," Bernstein says. They say, " 'I hope you have a magic pill,' and of course there is no magic pill."

... [P]atients receive a thorough medical history that includes headache patterns, disability and mood assessments. Then the center works with patients to try to identify what triggers their headaches and how they can avoid those triggers in the future.

Some people find relief through exercise. "I write an exercise prescription probably as often as I write a prescription for medication," Bernstein says. She acknowledges it's sometimes difficult to encourage a patient with cracking head pain to get up and exercise. But even a little can help, and according to Bernstein it doesn't have to be jogging for miles and miles. It can be yoga, tai chi or even just a little stretching.


nonlocal MD said...

The prescription drug addiction epidemic is not getting the press which it deserves, and unfortunately it is aided and abetted by even conscientious physicians prescribing opoids like candy. And then these often serve as gateway drugs to heroin, which is cheaper. We need to do better, much better.

Anonymous said...

What follows is a letter I have written to my state's Board. I am a former nurse and patient who has benefitted greatly from I am writing in response to recommendations the Board is making to physicians based on PDMP Reports that patients on higher doses of opioids should have their doses lowered. It is my understanding that this recommendation is made solely on morphine equivalent dose without evaluation of the individual, their medical records, or consideration of factors including cytochrome p450 studies and malabsorption issues. I’ve been a patient of a very responsible and knowledgeable physician since February 2007. In the six months preceding my first appointment I had been off all opioid medications by choice though I had initially started treatment in 2000. I was always conflicted about using these medications due to the values instilled in me as a child. I had bilateral derotational osteotomies at the age of 13 that resulted in MRSA osteomyelitis and wound complications. Despite all this, I only received ibuprofen and a few doses of ketorolac. I’m not a person who simply cannot tolerate pain. I have primary generalized dystonia (though as I a child I was originally diagnosed with mild spastic diplegia and eventually dystonia that was secondary to that). As things progressed and multiple blood relatives including my father were diagnosed with Parkinson’s disease, it was decided that I had Primary Dystonia of non-DYT1 /DYT2 origin. I had an intrathecal pump inserted at 18 with complications leading to an atonic bladder, chronic CSF leak, neuropathic pain in my legs, and actual spasticity and plantar flexion that produced toe walking (as opposed to dystonic tone that develop in the weeks following surgery). I never really derived benefit from the intrathecal baclofen and developed additional problems as a result.
At my first appointment with my current doctor, I had been dependent on a power wheelchair for just over a year. As I had tapered down slowly from 480mg of OxyContin per day my dystonia symptoms steadily worsened and my weight dropped from around 120 pounds to 85 pound despite the fact I was getting an average of 6000 calories per day on a medical diet designed for weight gain. I was in the worst physical state of my life by far. My fingers were contracted and essentially useless. I had severe rigidity with intermittent episodes of myoclonus. Spasms made it impossible to sit up straight with it appearing as though I had a severe case of scoliosis (though once on medication again it was evident that it was predominantly muscular torsion with only a mild bony curve). My legs were extremely tight and myoclonic jerks and extensor tone made it very difficult to sit without support. Despite all this I was still living on my own refusing to leave the house I lived in. Looking back I really don’t know I managed this at all. It couldn’t have continued much longer. Getting off of the medication made one thing very clear. Yes it had been prescribed for pain which it certainly helped. Beyond this the opioids, by whatever means, had a primary effect on the dystonia that was far more than any of the myriad of traditional treatments I’d received (baclofen, tizanidine, dantrolene, trihexyphenidyl, benzotropine, leva dopa, dopamine agonists, and tetrabenzine via compassionate use protocol). I’ve had all these in high doses for sustained periods. Most were helpful to some degree. Many had side effects that were intolerable including elevated liver enzymes. Botulinum Toxins A and B had little effect or I developed resistance quickly respectively. I am aware of deep brain stimulation but it is not something I wish to pursue due to repeatxed infections harbored in hardware
these drugs.

Anonymous said...

More from my letter....character limit required I put it in segments.
Within an hour of resuming OxyConin at a starting dose I had very noticeable improvement. Over the coming months and years my dose has increased back (prior to discontinuing I had taken 480mg per day plus doses of short acting medication) to prior levels. Each increase has produced sustained, improvement. With hard work these gains were beyond anything I ever dreamed possible. At times I have been able to taper somewhat during periods that I was doing particularly well though I would inevitably reach a point that I could not continue without sacrificing my ability to function. The thought of being forced to lose all that I’ve fought so hard to obtain because some make poor choices that lead to the disease of addiction feels like an incredibly cruel punishment that I just cannot accept. If my condition worsened on its own it would be difficult but I would accept it and be thankful for all the relief I’ve had and things I’ve been able to do.
As things improved I was no longer a prisoner of my home and got out more and more. I started coaching youth baseball and football for inner city children from Woodlawn (which is adjacent to Crestwood where I reside) with occasional help from high school players. Then I started playing wheelchair soccer for Lakeshore Foundation myself in additional to the youth teams I coached. I was on a travel team that practiced twice weekly with frequent road trips in a nine month season. Getting to practice via the bus took most of the day. This was exhausting but I absolutely loved it. It would have been absolutely (or do you like utterly instead) impossible without medication.
My undergraduate degree was in nursing and I was over halfway through a nurse practitioner program when medical issues forced me to leave school. I’ve always had a great deal of respect for evidenced based medicine and understanding the mechanism of how something works instead of simply knowing it is effective. However throughout the history of medicine the reasons why treatments work has often remained elusive for years after something was found to be effective. I have been very fortunate to have sustained efficacy of these medications for years now without side effects. Being forced to decrease my dose in the face of worsening symptoms will be devastating to my quality of life and ability to live independently. I have always felt that if I got back to the point that I truly did not have a good quality of life that I would make decisions that would not promote prolonging life including measures like refusing antibiotics. I’m young and have so much I want to do. I don’t want to be put in this position simply because others have made poor choices. It is for these reasons that I respectfully ask that the Board to allow my physician to continue treating me as he sees fit just as he would for any other diagnosis. I know this is also the unspoken request of countless others who will be forced to suffer without a policy change.

Anonymous said...

Thanks for accepting my comment even though it was dissenting. That says a lot. Just noticing that errors with cut and paste messed up the beginning. It should have said I am a former nurse and patient who has benefitted greatly from opioid therapy. What follows is my letter to my state's Medical Board.

I am writing in response to recommendations the Board is making to physicians based on PDMP Reports that patients on higher doses of opioids should have their doses lowered...... hope that clarifies it. ;) Thanks again for posting my dissenting view. Please remember there ARE others like me! We will be forever grateful to a doctor that treats us with compassion and helps us to have a good quality of life.

Carole said...

I read every single word, your honesty touched me deeply. May God bless you and do wonderful things with you and for you.