What do you take when you hurt?
Back in the good old days of herbal medicines and no antibiotics, Osler quipped you could throw out all the medicines in the pharmacies except for opium, and the patients would be better for it.
(Get all your medicines in a box, then) Throw out opium… throw out wine, which is a food, and the vapors which produce the miracle of anaesthesia, and I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind – and all the worse for the fishes.
That’s not true nowadays (my husband Lolo would have died of a stroke 20 years ago if we didn’t have modern medicine for high blood pressure), yet Osler had a point.
People often only see a doctor when they hurt, and they want the hurt to go away.
So when the headlines might cry about a “300 percent increase in drug deaths” from opiods,  (narcotic pain pills), you might want to take a look at what the problem is before you insist all docs are evil because they are causing the problem.

CDC report on the problem:

Results: In 2010, a total of 15,323 deaths among women were attributed to drug overdose, a rate of 9.8 per 100,000 population.

That is all drugs, and it doesn’t say how or why they overdose.

Deaths from opioid pain relievers (OPRs) increased fivefold between 1999 and 2010 for women; OPR deaths among men increased 3.6 times.

In 2010, there were 943,365 ED visits by women for drug misuse or abuse. The highest ED visit rates were for cocaine or heroin (147.2 per 100,000 population), benzodiazepines (134.6), and OPR (129.6). ED visits related to misuse or abuse of OPR among women more than doubled between 2004 and 2010.

So a lot of folks are overdosing, but again we need to know who is overdosing, and why.

Note the large number from illicit drugs (cocaine and heroin), meaning these were druggies wanting to ge high.

But how many of the Benzodiazepam (tranquillizer) and pain pill ( problems were from those prescribed and taken correctly, or were they from diverted pills, either bought from the street, gotten from doctors because they lied, or gotten from the small number of pill pushers who use their medical license to make money by selling narcotics (such as the abortion doc in Philly, who got away with murdering newborns for years, but was caught because he also was making money by selling narcotic prescriptions).

But stressing the percentage, we get an inaccurate picture: a 300 percent increase sounds horrible, yet the actual numbers are small:

In 2010, a total of 15,323 deaths among women were attributed to drug overdose, a rate of 9.8 per 100,000 population. Among these, a drug
was specified in 10,922 (71.3%) deaths.

So were the deaths all from pain pills? We don’t have information on almost one third of those dying, or why they took the pills, or if they got the prescriptions for a valid reason or from the black market, or if they stole Grandmom’s pain pills, but never mind. It’s the doctor’s fault.

So the headlines only use statistics to imply docs are causing a huge increase in people dying because the stupid docs give out narcotics to people who hurt.

So yes, there is a problem, but if we want to solve it, you have to find the facts.

How many of these were from accidental drug overdose? Or from suicide? or from taking them to get high? Each of these scenerios would mean a different approach to prevent the problem.

Alas, the article admits they don’t know.

information on the motivation for use might be incomplete; some ED visits might have resulted from suicide attempts.

Uh, if they were suicide attempts, you need to diagnose depression and treat it, or else the person may try again.  Why wasn’t it documented in the Emergency room record?

But then we have this dirty little secret: Those writing the article weren’t looking for abuse or diverted medicines as the cause of the problem either.

Finally, distinguishing between drugs taken for nonmedical and medical reasons is not always possible, especially when multiple drugs are involved.

Uh, why not ask the patient or their family, or check the bottle of medicine?

The increase in using opium type medicines to get high is now more common because for years, people suffered in pain because docs were told not give out narcotics, for fear of causing “addiction”.

This idea has changed, for two reasons: One,  Dr. Kavorkian.

You see, despite the cheerleading press that made him a “hero”, the dirty little secret is that Kavorkian’s murders were rarely of those dying: Most of his so called “patients” had inadequate treatment of their pain, and were depressed.  In other words, if he had offered them proper pain relief,  a lot of them would be alive today.

The second reason is that we now have long acting narcotic medicines that let you remain pain free without the “see-saw” effect of either being zonked out or in pain due to the short half life of narcotic pain medicines.

A wag said that Rush Limbaugh was the poster child for using oxycontin for pain, and there is a lot of truth in that, because when properly used, oxycontin, MSContin, methadone, and fentanyl patches let our patients function normally and be pain free with only a minimum of side effects.

(I must note one problem however: the long acting medicines can sneak up and affect even people using them correctly…I had to stop Fentanyl patches on two old ladies with COPD, chronic lung disease, because the slight decrease in respiratory rate from the medicine was too much for them when they developed lung infections.)

But the long acting medicines are especially prone to overdose when diverted to the black market: they take awhile to work, so the person takes one and doesn’t get high, so they take a couple more. Then, three hours later, the entire dose starts working, and voila, overdose.

I had a druggie overdose on some MSContin she stole from her relative dying of cancer. She didn’t get high from one or two, so took a couple more and it killed her a couple hours later.

And of course, druggies have learned how to crush and process these medicines to get the full blown high, but often misjudge the proper dose and end up dead.

So how many of these pills were “diverted” or stolen in the USA? A lot of them.

For example, our reservation’s casino had an ongoing market for Tylenol with codiene. (usual price was only 5 dollars a pill, much less than if you bought it on the street in the nearby town)….

Our old ladies would sell a few if they were short of  money, but they also knew that they could buy a few if they hurt too much and didn’t want to sit in the emergency room for a couple of hours. Go figure.

Then there was the teenager “offered” a swig of another teen’s grandmom’s morphine syrup (grandmom had died of cancer and the granddaughter found her discarded medicine in the trashcan). The second teenager, eager to look “sophisticated” in front of her friends, drank a couple of sips, and died.

So don’t prescribe medicine to those who might use them to get high, or are at high risk to divert them, right? Yeah, but in both these cases, the medicines were properly prescribed by the physician for cancer pain. The problem was a mindset in society that sees getting high as a harmless activity.

But what about those who have both substance abuse histories and severe pain from valid medical problems?

I had one such druggie with lupus. She’d come in with red swollen joints barely able to move,  and required narcotics to relieve her pain. Yet she  was unreliable in taking her lupus medicine every day.

We finally “solved” her problem  by changing her lupus medicine to a weekly injection, with a strict pain contract that would only give her one week’s worth of pills if she came in, got her blood tests and shot first.

That worked, but she had withdrawal symptoms when she developed pneumonia (a problem since her immune system was a mess). So what should we have done about her? Let her suffer?

Sigh.

So what is the alternative for those with chronic pain?

NSAIDS? (motrin/ibuprofen, alleve, aspirin?)

The dirty little secret is that we see more problems from them than narcotics (usually bleeding ulcers, but also kidney problems)

LINK emedicine

Both acute and chronic poisoning with NSAIDs results in significant morbidity and mortality. The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) system has estimated that more than 100,000 hospitalizations and more than 16,000 deaths in the United States each year are due to NSAID-related complications with costs greater than $2 billion. Gastrointestinal (GI), renal, central nervous system (CNS), hematologic, and dermatologic symptoms may ensue (see
Complications).

Yes, that innocent NSAID ( ibuprofen/motrin/alleve/.aspirin/ etc.) tablet kills just as many folks as evil narcotic pain pills.

That has led some “experts” to tell old ladies to take tylenol instead for their pain.

But the dirty little secret is that you have to take a lot of them because of their short half life.  Most folks won’t take 12 pills a day…Luckily, there are “arthritis” formulas of tylenol that don’t require so many pills, and that helps.

We docs had hoped the Vioxx type medicines would act as an alternative, until some bozo figured out they interfered with the blood clotting system so people clotted up their arteries and had more heart attacks. Sigh.

But tylenol isn’t free or problems either. The main dirty little secret is that if you overdose on it, you don’t die right away: You die a few days later when your liver shuts down. Yes, it can be treated if a doc knows about it and gives you the antidote, but often the suicidal person might not present to the ER.

Luckily, such deaths are rare:

Analysis of national databases show that acetaminophen-associated overdoses account for about 56,000 emergency room visits and 26,000 hospitalizations yearly. Analysis of national mortality files shows 458 deaths occur each year from acetaminophen-associated overdoses; 100 of these are unintentional.

Another “dirty little secret” is that, despite all the reports, that NSAIDS  work better than tylenol for some types of pain. But for severe pain, despite the dangers, morphine and other narcotics work the best. One also has to note that the placebo effect is huge here.

So should we go back to the good old days and refuse to give our patients narcotics when they hurt?

That can cause depression, obesity, and suicide.

No, I don’t have an answer for this, but I do wish that we would stop being so “non judgemental” against substance abusers who steal grannies’ pain pills to get high, while we condemn the docs for trying to help her cope with her arthritis pain.

——————————-

Nancy Reyes is a retired physician living in the Philippines. a slightly different version of this was posted to her “Heydoc” blog.

 

 

 

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