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Friday, May 8, 2015

Doctors of tomorrow: please forgive us for thinking that it was a great idea to prescribe sedatives, opiates and stimulants to just about everybody

Lately I've had the opportunity to work in an outpatient clinic where the regular doctor is out sick for a prolonged period of time. It is a breathtakingly beautiful little community, with green hills and a crystal clear river. It is also troubled by methamphetamine and prescription drug abuse.

The little clinic in town is unwittingly a partner in this crime. Like the US itself, this small community clinic has been generous with prescribing controlled substances for those who appear to need them. Sedatives in the benzodiazepine (Valium, Ativan and Xanax are brand name examples) family are prescribed for those with anxiety. Opiates, from the family that includes morphine, are prescribed for patients with back pain and knee pain and a host of other long lasting pains, and continue to be prescribed monthly for round the clock use, sometimes at increasing doses, since these long term pains rarely go away, even on medications. Every young person these days seems to have attention deficit disorder, and many of them have found that they can study better if they take stimulant medications. These medications have been around for years, though there are newer formulations, and used to be called "speed." In moderate doses they make pretty much everybody able to study better. They have become extremely common on college campuses at exam time, since they also allow a person to go without sleep and sometimes without much food. One person with a regular prescription for this kind of medication can supply his or her friends with drugs as needed. Side effects can include heart rhythm disturbances and erratic behavior, especially in higher doses, as are sometimes used recreationally. Some of the patients in this little clinic get ADD drugs so they can work or study, sedatives so they aren't anxious and opiate pain killers for their bad backs or other maladies. Sometimes they take them, sometimes they sell them or give them away, and often they do both.

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.

We have known for years that opiates cause constipation, nausea and vomiting, sleepiness and confusion and can cause people to stop breathing at high doses. We are also recognizing that they cause low testosterone levels which results not only in sexual dysfunction but weakness and mood alterations and bone thinning. In some patients overall tolerance to pain or anxiety is decreased. Combining them with sedatives increases the risk that patients taking these medications will stop breathing and die. Most of the patients who die of these medications do so while taking the medications as prescribed though many overdose deaths also occur in people taking the medications recreationally.

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.

I have been away from regular primary care practice for years now, so have not been writing long term opiate or sedative or stimulant prescription for patients. I have also been in the hospital more and have seen more desperately ill patients whose main problem were prescriptions for controlled substances.

Now I get to be on the receiving end of what goes around which apparently comes around. There are a bunch of patients on controlled substances which will likely kill them (unless they are selling them to people, including school children, who will take them and maybe die) for whom I am asked to write for refills. HELP. Can't do it, can't not do it. Patients can have serious withdrawal syndromes if they run out of their opiates or sedatives suddenly. (Stimulants are usually not an issue, though.) If I do prescribe these medications there is a reasonable chance that I will be responsible for some bad and preventable medical tragedy. If I don't, these patients will be shocked and betrayed, since they really think they need these drugs to be happy.

If this was just my (and their) problem it wouldn't be that interesting. What is interesting is that this is just a tiny microcosm of what is happening in the whole US. Physicians are discovering that these controlled substances are not safe and that their patients are mostly not doing better on them than they were off of them. A small number of patients are doing better, but it's infinitely hard to figure out who those are. Stimulants may have benefit in children with attention deficit disorder, but this is rarely relevant for me as an internist who doesn't see kids. Adults appear to be overusing them in an epidemic manner. The  medical community of the United States needs to make an abrupt about face while showing compassion for the patients who have been taking these medications and probably deteriorating because of them for years. In our opiate dependent patients, we need to re-assess their pain and the causes of it and research the options that might be helpful. We have to do all this while tapering these patients off of the medications which they think they love. We have to realize that many of the things we might do to improve our patients' pain, such as exercise, meditation, non-opiate type drugs, may not be truly effective until the patients are actually off of opiates.

In my experience in trying to deal with this situation, I have found some unexpected allies: the patients themselves. In every patient who I talk to about tapering off of controlled substances I expect anger and resistance. But this is not always the case. I have met patients who seemed like they had just been waiting for someone to help them get off of these meds. It's not even all that uncommon. People don't actually like to be passive and helpless and weak and sleepy and constipated, and some of them are willing to risk experiencing pain or other discomforts in trade for not being on drugs. I see patients on the other end of the process, too. They say that after their injury or operation they were heavily dependent on drugs and that they eventually got fed up and, with the help of a good doctor or nurse or family, got off of them and intend never to take them regularly again.

Opiate pain medications and benzodiazepines are some of the most miraculous drugs physicians can prescribe, and I am not in any way averse to using them when they are needed. The opium poppy and its derivatives can abruptly change the outlook of a person who has the acute pain of a broken bone, a toothache or a recent surgery. They can make the final weeks, days or hours of a person's life be more tolerable. Benzodiazepines can immediately relax a person whose anxiety is running away with them. These drugs are amazing. They just shouldn't be used on a regular basis except in extremely unusual cases.

I'm not positive that adult attention problems should be treated with medications. The rise in use of stimulants may be just an indication that our society expects everyone who intends to achieve financial independence to be able to focus on tasks or studies which are mostly irrelevant to them. As we've moved away from hunting and farming and manufacturing there are many round pegs attempting to pound themselves into square holes. Stimulants, with their known significant side effects and their unknown long term effects, should not be used to make people do things that bore them silly. On the other hand, the rare person who has narcolepsy (a disorder which is characterized by sleep attacks) has my whole hearted support in using stimulants on a regular basis. I will even sign the prescription.


6 comments:

Paul Levy said...

Hi, I quoted you here and added some more thoughts: http://runningahospital.blogspot.com/2015/05/some-thoughts-on-overuse-of-sedatives.html

Janice Boughton said...

Thanks, good article!

Rick Bunker said...

Very compelling article. It is relevant to work we do. May I quote/post a copy of it on our web site please? www.pastrx.com is the site, if you want to take a look first.

Thanks,

Rick.

Anonymous said...

As a patient who benefits greatly from these drugs and has continued to do so for over 15 years I have make the case that patients who clearly benefit should not be punished simply because others fail to benefit or make poor choices. Right now I'm paying the price for these poor choices and have been on a two month dose reduction that will likely have to go much lower simply because others have made poor choices. After years of looking for employment, I had just found the perfect thing for my background in nursing. Sadly, I had to call back and decline after initially accepting the position. I worked to get myself in shape to drive competently again for seven years and made major sacrifices to afford it. At the present time it is essentially useless to me and will be sold if I am forced to continue. Anti-opioid hype is devastating to the quality of life of patients like me who benefit greatly from it. What follows is a letter that I am still revising for submission to my state's Medical Board. Please don't throw the baby out with the proverbial bath water.

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.
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 repeated infections harbored in hardware.

Anonymous said...

my letter to board continued.....

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 repeated infections harbored in hardware.

Anonymous said...

more from my letter to board...it had to be cut due to character restrictions.

Within an hour of resuming OxyContin 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.