I doubt there is anyone living in the US who doesn’t realize we have an opioid crisis here. Politicians debate the solutions to abating the high death rate that comes along with it, however, they fail to acknowledge that there are Americans in pain. Yes, we need to be sure opioids are prescribed judiciously. However, we also need to treat patients in pain.
As a doctor, it is not always easy to distinguish a patient who has real pain from one who is just looking to score a prescription for their own addiction or for diversion. A big problem that is not acknowledged by those in DC is the fact that there are not many effective pain medications out there. Additionally, services that may help such as physical therapy, are often not covered well by health insurance companies and unaffordable for patients.
While the lawmakers haggle out drug quantity limitations and the easy availability of Narcan, we need better tools to treat pain. Much pain can be treated by fixing the root cause through modalities such as physical therapy. But, why would a patient pay more money to work hard when they can just get a pill to dull their pain? These tools must be made more accessible to patients.
Additionally, there are not many different classes of pain medications out there. Some, such as NSAIDs, can cause gastrointestinal bleeding or kidney disease. They are not meant to be taken on a long-term basis. Others such as gabapentin are not meant to treat all kinds of pain. Even over-the-counter tylenol can cause liver problems when taken in high enough doses. We clearly need new classes of medications available to treat pain.
What can politicians do to address the crisis other than what they are doing?
- Make insurance companies cover services such as physical therapy in a way that is affordable to most patients. Under the Affordable Care Act (ACA), preventive medical services were mandated to be made available without certain costs to the patient, such as copay. In a similar way, physical therapy services can be made available without the patient needing to pay out cash every time they go. The insurance company can foot the bill and this would indeed save costs down the road in terms of avoided spinal surgeries and joint replacements.
- Fund pharmaceutical research towards creating new classes of pain medications that are effective and non-addicting.
- Stiffen the penalties for those caught diverting these medications. If they are caught selling these drugs to minors, the penalty should be greater as we now have a crisis of opioids/heroin in teens.
- Make state registries available across state lines of all 50 states. Also, it should be made available to all working in the healthcare profession and not just physicians. In this way, a medical assistant could be doing the search while the doctor is treating the patient.
- Stop making mandates on physicians on how to prescribe. Yes, we all know there is a crisis and have to work to keep opioids out of the hands of those who truly don’t need it. However, when you make laws that doctors can only prescribe 5 days of medications at a time, you are not only making it harder on doctors but on patients as well. Imagine being a patient bedridden with metastatic breast cancer and being forced to fill your pain medications every five days. That is just cruel.
- Stop debating. We heard all your arguments. We don’t care to fulfill your agendas. Opioid addiction exists on both sides of the aisle and while the debate rages on, more people die of overdoses.
While there is little doubt of the devastating toll opioid addiction has played in the lives of many, we still are not grasping what are the key problems. Until we truly examine why this problems exists, we will not stamp it out just be limiting the way prescriptions are written. Yes, there is some drug diversion going on and it can be a profitable business for many. But we also need to solve the problem of pain.
Copyright secured by Digiprove © 2018 Linda Girgis, MD, FAAFP
What they aren’t addressing is (1) why are people resorting to these drugs and (2) Prohibition showed that interdiction not only doesn’t work, it makes things worse.
Absolutely correct. Had more than one patient, with terminal disease….HCV with hepatorenal failure…well soon to be…..some doc told him he was taking too much oxycodone…40 mg a day as I recall…so cut him off…this guy, late 50’s….was without a doc or meds for pain….started using heroin. Now that is quality health care. wb
Both correct. agree but docs need to be tough…don’t be wimps cowering (is tht how you spell that word? 🙂 ) to state/fed DEA types. Prescribe when appropriate. Don’t prescribe when not, i.e. fibromyalgia, the 25 year old with “chronic” back pain. Use opioids just like you would an antibiotic…well, maybe not the best comparison, but you get the point. Rhetorically “man up,” do the right thing mes amis. Our mission is the care of the patient, to the best of our ability….not what they want, not what Price Ganey or JCAHO says…what we think is correct and do no harm. Seen many more GI bleeds or ARF in old people on NSAID than opioid OD in same patient group. wb
I wouldn’t tell others when opiates are ‘appropriate’ – too many individual factors. For instance, you say NOT to use them for fibromyalgia, yet I have patients with that diagnosis where the only thing that works for them without bothersome side effects is a regimen that includes narcotics (along with a topical gabapentin/NSAID mixture, an oral methylation regimen (the patient also has a MTHFR SNP), Zilis hemp oil and regular sessions of physical therapy. With those plus Percocet she remains active at home, employed part-time, and raising her kids successfully. When ‘weaned’ off the Percocet she has so much pain she can barely function. So WHY exactly should I wean her off of Percocet…? Because it will ‘wear off’…? She’s been on the same dose (tapering when able, increasing with flares) for almost thirty years, with one fairly large step-down dose when we found the MTHFR issue and treated it.
So I wouldn’t agree that one should never use a narcotic for fibromyalgia – it depends on the patient.
As we are taught…never say never. My point is that we (docs) should use drugs/opiates in this case, appropriately and not be fearful of using them correctly. My, subjective of course, perception based on observation is that many of our colleagues are afraid to prescribe CII (which now includes vicodin) when it is appropriate. Too many suffer in pain ….which, frankly, is one of the few things we can actually treat. Bottom line…treat appropriately. My point on Fibromyalgia…rather multifactorial often with functional issues as well…so treat appropriately. wb
They also fail to acknowledge the pharmacologic reality that ‘opioids’ are NOT inherently ‘unsafe’, and many of the ‘safer alternatives’ they urge us to substitute are NOT ‘safer’.
Opiates are absolutely dangerous IF recreationally used, where they are used in multiples of the prescribed dose (i.e. not the granny who accidentally takes three per day instead of two, but the abuser who takes twenty four at once), and along with other drugs (prescribed, ‘street’, or both). SO WOULD ANYTHING WE PRESCRIBE – imagine if someone took twenty four lisinoprils, or diltiazems, or any number of other things we consider ‘safe’.
When used AS PRESCRIBED, the ‘safer alternatives’ are FAR more likely to cause a myriad of unpredictable and often not-dose-related side effects – including arrhythmias, liver damage, hallucinations, GI bleeds, renal damage, seizures, and so on. When used AS PRESCRIBED, opiates cause……….constipation. And in a fairly linear dose-response manner, sedation often appears. Opiates are pharmacologically very ‘clean’ drugs, in that they are predictable, and do little outside the realm we are intending to affect.
So the REAL problem is that we need to reduce the number of people who use those drugs recreationally. I wholeheartedly agree, and some things like educating patients on safe storage of medicines (so far the legislators haven’t interfered with that), safe disposal of medicines (many of the laws actually make that MORE difficult), and minimizing the amounts on-hand at any given time (that’s an area the legislators have made things MUCH WORSE), but denying legitimate patients legitimate treatments because abusers are out there is morally and medically wrong….!
Opiates are going to be available on the ‘street’ NO MATTER WHAT. They are available IN PRISONS, for goodness sake, where everyone is frisked, wanded, inspected, and so on. This is the phenomenon of an ‘inelastic demand curve’, and no amount of wishful thinking will change that.
Just as a for-instance, the shift of Norco to schedule-2 now means that I can’t prescribe a dozen for the sprain, where I’m unsure of the patient’s tolerance/need, and would have given them #12 for 1-2 TID, with 2 refills, and “if you need that second refill, call, because something isn’t right”. Refills not allowed. OK, so I could tell them to call if the first dozen fail, and hope the phone-tag doesn’t leave them in pain awaiting a response, but no – telephoned Rx’s are also illegal now. So……I give them #36, knowing that there is a good likelihood half or more will remain unused, when prior to the ‘improved’ regulations, the most the patient would likely have unused would be a half-dozen tablets.
Good Morning Dr. Girgis:
The insurance cos. & big pharm own the politicians.
Nothing will change in Washington until the “old guard” is replaced with new blood with fresh ideas. People that have been in Washington for 30 or 40 years have long been set in their ways and are not good at accepting change even when change is what this country needs most right now.
The public in general doesn’t seem to grasp the fact that by way of their vote, they could change the way things are done.
If one doesn’t like how things are going in their home state or in Washington just vote’m out & let someone new with fresh ideas try to make a difference.
One’s vote is the most powerful tool the public has to force change where change is needed.
Regards,
Raffie