Re: Opioid crisis

[PlutoBoy]

A good read from KevinMD. It describes exactly how I feel about the problem. I don't think I have anything else to add. Just wanted to share. Feel free to share your thoughts. Link to the full article below.

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I would like to suggest that the root of this opioid epidemic lies far deeper than “physicians overprescribing.” The problem is that we are now a society of adults who have no coping skills. No ability to deal with the curves that life throws us. Everyone is looking for a quick fix. We have taught our children that they should never have to feel any sort of discomfort whether emotional or physical. When pain or suffering occurs, there is a quick fix for it, and it is the responsibility of someone else to provide that fix. Opioids certainly treat physical pain, but they simultaneously provide a temporary solution for things like emotional pain, sadness, and anxiety. The reward system inherent in our neurological setup provides the anxious and depressed patient a temporary euphoria when taking the drug.
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Physicians are being murdered for not prescribing opioids

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[jdh71]

Agree 100%

And I go out my way not to ever rx opiates. I only use it in a palliative fashion for end stage dyspnea symptoms. But I had a PCP clinic with my own panel during residency. So I'm not completely ignorant to the issues here.

It's clear to so many are treating their emotional stuff. It is a sad commentary on not only the lives some of our patients are living but our lack of resources to treat them. Heck even our lack of resources to be able to deal with talking about the problem or patients even being able to recognize it themselves or accept it.

 

[Psai]

I had a grown adult in the ed cry about falling off his bike at low speed. Exam totally benign. I told him to take some tylenol and walk it off but he went to my attending and demanded opioids. Of course the spectre of press ganey led to a week's supply for this manchild. Guy was older than me; it was completely mind-blowing.

 

[CatFactorial]

on the one hand I try to empathize as I personally am fortunate to be in good health and I can't say I know how it feels to be in severe pain. At the same time I follow a two tiered strategy for opioids -- wean or refuse.

If someone were to threaten me I'd just call the cops

 

[anonperson]

A good read from KevinMD. It describes exactly how I feel about the problem. I don't think I have anything else to add. Just wanted to share. Feel free to share your thoughts. Link to the full article below.

==============================
I would like to suggest that the root of this opioid epidemic lies far deeper than “physicians overprescribing.” The problem is that we are now a society of adults who have no coping skills. No ability to deal with the curves that life throws us. Everyone is looking for a quick fix. We have taught our children that they should never have to feel any sort of discomfort whether emotional or physical. When pain or suffering occurs, there is a quick fix for it, and it is the responsibility of someone else to provide that fix. Opioids certainly treat physical pain, but they simultaneously provide a temporary solution for things like emotional pain, sadness, and anxiety. The reward system inherent in our neurological setup provides the anxious and depressed patient a temporary euphoria when taking the drug.
==============================

Physicians are being murdered for not prescribing opioids

Pretty much spot on.

Doesn't help that "Pain is the fifth vital sign" stuff is perpetuated all over.

It is interesting though to see various pain coping strategies especially of patients who have immigrated from third world countries with little healthcare. They someone have very reasonable pain, even after major procedures.

 

[DrMetal]

Pretty much spot on.

Doesn't help that "Pain is the fifth vital sign" stuff is perpetuated all over.

Couldn't agree more. The pain scale is not a 'vital sign'. Vital signs are objective measures not prone to subjectivity.

Also it doesn't help that our Emergency and Surgical colleagues continue to pass out opioids. Why does a 22-yo with a non-displaced distal radius fracture, in a cast and not complaining of anything, need 20 Norco ??? The 20-yo in a minor MVC with no symptoms, you decide not to image her per no clinical indications, but you send her home with 20 vicodin? ridiculous.

 

[InvestingDoc]

I completely agree with one additional thought. The statement that the author makes: "The problem is that we are now a society of adults who have no coping skills."

I think that the statement is partially true. I'm not sure we have no coping skills, but no outlet for emotions that are too often viewed as "weakness."

There are so many ways to see the highlight of each others lives. On facebook, instagram, snapchat, twitter, TV, reality programs, or youtube we only often see or hear about the highlights of each persons lives. As a society we are basically bombarded by it. In a way we then compare our day to day with those highlight reels. No one wants to talk about failing that test, having a failing relationship, the alcoholic family member that just cant stop or other tough life events on youtube, facebok, or other social media. If there are posts on social media it seems to fall into one of two categories. It either a cry for help or someone who has already overcome a bad point in their life.

I personally think we are entering a new phase where keeping up with the Joneses is at an all time high in prevalence in our society. I witnessed my 22 year old male cousin delete a post on instagram because he didn't get enough likes in 4 hours from his friends. He literally looked depressed the next few hours that his post didn't get enough attention or wasn't special enough. It's not that he doesn't have coping skills, but hes trying to fit in and live up to the standard that appears to be persistent on social media.

I know I've focused a lot on social media, but the blame doesn't end or begin there. Combine relatively easy access to opiates, alcohol, drugs, or women/men with a numerous advertisements of others lives being better than yours and people will choose something that makes them feel better.

Doctors are of course part of the problem, but I would like to think my colleagues have the integrity that I believe they have to say no to obvious inappropriate prescribing of narcotics. I know there are a few bad apples out there. However, as a whole I think our profession stays true to the oath that we all took when we started this journey. Do no harm.
/rant

 

[Crayola227]

Couldn't agree more. The pain scale is not a 'vital sign'. Vital signs are objective measures not prone to subjectivity.

Also it doesn't help that our Emergency and Surgical colleagues continue to pass out opioids. Why does a 22-yo with a non-displaced distal radius fracture, in a cast and not complaining of anything, need 20 Norco ??? The 20-yo in a minor MVC with no symptoms, you decide not to image her per no clinical indications, but you send her home with 20 vicodin? ridiculous.

I don't really see that sort of prescribing as the problem. In fact, there are studies that support that aggressive treatment of acute pain from trauma like surgery or injury is correlated with LESS chronic pain and chronic opiate use down the road.

The theory posited relates to central sensitization to pain and pain "threshold" or "gate" theories. It goes, if I don't control your post-op pain (and keep in mind how many surgeries are not the sort of insult one would expect one to survive in the "wild", hence one could argue the pain mechanisms we have are not evolved to cope with that level of stimuli), that high level of pain stimulus essentially overwhelms the mechanisms for attenuating the pain signal, basically, I break the system and leave the switch in the "on" position.

OTOH, there does seem to be a cohort of people for whom their opioid addiction essentially begins with the first exposure. Unfortunately, as it stands, the only predictors we currently have for who will go on to experience chronic pain or opioid addiction seems to be a family or personal history of either.

Now, you could say you could send folks home with nada and if they develop pain later, to seek out a provider and get some analgesics. If I had to estimate, the number of people who suffer in some form and then DON'T seek care, and then develop other problems as a result, really stands out to me as higher than those with opioid addiction. Sounds nuts, but as you might expect, one population is more of a squeaky wheel than the other.

Chronic pain is a bigger problem than opioid addiction, in my mind. I have numbers somewhere that back this up. People with chronic pain end up not working, with mental health issues, family problems, other addictions, unhealthy lifestyle behaviors, less exercise, the list of comorbid fallout goes on and on. This happens to opioid addicts but the number of chronic pain sufferers is just greater.

In any case, I don't take issue with some of the prescribing, like for short term injuries that even without complaint on presentation, might reasonably lead to pain levels where opiods might not only be beneficial, but possibly preventative.

Granted, those might be the narcs in the medicine cabinet that college kids are getting into, drinking with them, and dying. Which are most of the deaths, most of the opiod deaths are not in the habituated chronic PITA users. OTOH, I hate for what idiots do illegally, who may or may not be even able to access my patient's medication, to have that much affect on my prescribing habits for pain, especially for short term pain control, where I might be preventing the development of chronic pain.

It might be jacked that I don't care if people die, because by golly, I'm treating this guy's post MVA whiplash pain. You could argue we should let people suffer NBD pain to save so many others. But I have very little sympathy for people breaking the law and killing themselves idiotically. I'm not sure why my patients should have to suffer for them.

Most often I see your chronic low back pain people drinking themselves to death.

 

[Crayola227]

I don't talk about it a lot on the forum, but I have chronic pain and it's not something I take opioids for. I would basically rather be unable to walk than do the whole chronic narcs thing.

In any case, I'm pretty well aware of what such a life of chronic pain without opioids is like. And yes, I know just how far APAP and NSAIDs take you (sometimes to the hospital for UGIB if you're lucky). and other stuff, too.

So I'm a little torn when it comes to the issue. Part of me looks at some of these people and think, "if I can live without them, why can't you???"

Then again, I know people who would frankly be far better off with as much opiods as they can swallow than whatever else they're doing. I'm pro- "harm reduction" models.

I'm a big fan of looking at if the drugs actually have appreciable QOL affects, as evidenced by how you carry out your ADLs as opposed to more amorphous measures of the "pain scale."

People definitely need better coping skills.

 

[PlutoBoy]

I personally think we are entering a new phase where keeping up with the Joneses is at an all time high in prevalence in our society. I witnessed my 22 year old male cousin delete a post on instagram because he didn't get enough likes in 4 hours from his friends. He literally looked depressed the next few hours that his post didn't get enough attention or wasn't special enough. It's not that he doesn't have coping skills, but hes trying to fit in and live up to the standard that appears to be persistent on social media.

I know I've focused a lot on social media, but the blame doesn't end or begin there. Combine relatively easy access to opiates, alcohol, drugs, or women/men with a numerous advertisements of others lives being better than yours and people will choose something that makes them feel better.

Doctors are of course part of the problem, but I would like to think my colleagues have the integrity that I believe they have to say no to obvious inappropriate prescribing of narcotics. I know there are a few bad apples out there. However, as a whole I think our profession stays true to the oath that we all took when we started this journey. Do no harm.
/rant

I know what you mean about social media. It is ridiculous. I only signed up for Facebook when I graduated medical school just so I could keep in touch with the group. But I have refused to sign up for any other platform: twitter, instagram, snapchat, etc.

Getting back to the topic at hand, I think that most inappropriate prescriptions come from a lack of knowledge or understanding, not malice. We need to find a way to bridge the gap somehow. Not all cases of acute pain need narcotics and when you do need to prescribe them often a three to five day course will suffice.

This is important because as @Crayola227 mentioned above, a lot of addictions originate after a single exposure.

 

[visari]

This all falls back to the recent trend that healthcare is just another form of business where consumer satisfaction (i.e patients in this case) is one of the most important endpoints. our job as doctors should be to treat patients and not just to make them happy. most of the time these two go together, but sometimes they don't. and if the success of the "business" would require hospital administrators to do "everything" to make their consumers happy, they really couldn't care less how many opioid pills end up being sold on the streets. And this's exactly what's happening.

 

[DrMetal]

I don't really see that sort of prescribing as the problem. In fact, there are studies that support that aggressive treatment of acute pain from trauma like surgery or injury is correlated with LESS chronic pain and chronic opiate use down the road.

I wasn't really talking about major surgeries, nor about patients with chronic pain syndromes and multiple comorbidities. Of course in those populations, prescribing opioids in a controlled manor might be appropriate.

But the perfectly healthy 20-yo who presents to and ED for a minor (<10 mph) MVC (she only presented b/c he work made her do so), she's completely asymptomatic with no complaints...she doesn't need to go home with 20 Vicodin.

Widsom teeth extraction....doesn't need 20 percocet. He needs nsaids, f/u if pain is unabating, then maybe give narcotics. In fact, with many minor surgical procedures, I'd rather they not be on narcotics, so that if their pain becomes worse, they can re-present to have said pain worked up appropriately. That pain might be indicative of an abscess or some other post-op complications.

 

[cbrons]

A little terminology pet peeve of mine. "Opiate" is really not the technically correct term.

Opioid = broad term for what most of you are describing, eg oxycodone, heroin, hydromorphone, fentanyl, etc. AND morphine.

Opiate = very narrow term that basically only includes opium and its natural derivatives (e.g. morphine).

 

[FutureInternist]

Pretty much spot on.

Doesn't help that "Pain is the fifth vital sign" stuff is perpetuated all over.

It is interesting though to see various pain coping strategies especially of patients who have immigrated from third world countries with little healthcare. They someone have very reasonable pain, even after major procedures.

0:40 onwards

 

[meerkat111]

This is a nasty nasty problem. A common line from drug addicts I hear "if a doctor had treated my pain, I would not have turned to street drugs". So, it is the doctor's fault?

On the personal side, I recently had a bad tooth issue, I broke a tooth, had to get a crown done. I was in pain for a month. The funny thing is- I was at the dentist 5 times during that time, I never asked for anything for pain as I believe in just putting up with it (I could not even eat properly that whole time and working my 12+ hr shifts). The dentist was so scared of the opiod crisis, he never asked me if I needed anything for pain lol. I am sure he gets his dose of white and blue collar "seekers".

 

[PlutoBoy]

This is a nasty nasty problem. A common line from drug addicts I hear "if a doctor had treated my pain, I would not have turned to street drugs". So, it is the doctor's fault?

On the personal side, I recently had a bad tooth issue, I broke a tooth, had to get a crown done. I was in pain for a month. The funny thing is- I was at the dentist 5 times during that time, I never asked for anything for pain as I believe in just putting up with it (I could not even eat properly that whole time and working my 12+ hr shifts). The dentist was so scared of the opiod crisis, he never asked me if I needed anything for pain lol. I am sure he gets his dose of white and blue collar "seekers".

Yeap. Patients have tried to blackmail me using that line. "Well, I guess that if you don't prescribe it I will have to turn to the streets..."

That almost always changes my mind and I end up writing the prescription

 

[Trogghunter]

Things felt like they were changing when I was in med school/residency, the community is lagging however. We were required to change our prescription habits at the VA and we were able to fall behind USPTF recommendations for opioid prescription which limited them to acute/surgical reasons(which I rarely dealt with) and palliative cases.

Everyone is aware of the epidemic by now, and I've used a cautionary approach directly with patients when I explain why I will not be appeasing their addiction. We also have to exercise self restraint and fight the fight.

 

[Rhandhali]

I had a grown adult in the ed cry about falling off his bike at low speed. Exam totally benign. I told him to take some tylenol and walk it off but he went to my attending and demanded opioids. Of course the spectre of press ganey led to a week's supply for this manchild. Guy was older than me; it was completely mind-blowing.

One of the nice things about my institution is a certain number of items in the problem list - such as opiod dependence, withdrawal, drug seeking and other similar categories somehow triggers something that keeps them from getting a press-ganey survey. At least that's what we're told.