Sunday, March 3, 2013

"Let Go of My O": The Story of Opioid Prescription and the Disfunctional American Medical System

"As recently as the early '90s,
a patient would have to present with cancer
or a painful, terminal illness before physicians
would write a prescription for ongoing opioid pain medication.
Although these drugs were commonly used
for short term, acute pain connected to a procedure,
surgery or injury, prescribing them long term was considered a bad idea."

"For example, in 1992, a physician survey found only 12% of physicians believed that giving patients opioids for chronic pain was a “lawful and generally acceptable medical practice.” In other words, almost 90% believed it was unacceptable. How that changed is a fascinating tragedy."

(Richard Juman, PsyD, "The Irony and the Agony of Our Prescription Opioid Problem,", February 3 2013)

Juman continues...

"It’s almost unthinkable that in an era preoccupied with “evidence-based” medicine and “best practice” advice, one of the worst drug problems in the United States flows right out of our health care system. Unlike other major epidemics such as those connected to methamphetamine, crack cocaine or other illegal drugs, our prescription opioid problem is full of irony and agony, because it has been fueled, to a certain extent, by the actions of well-intended medical doctors."
The Story of Pain Relief
  • The public health disaster began when physicians, wanting to help their millions of chronic pain patients, used powerful opiates for treatment -- arthritis, bad knees and backs, despite the risk-benefit analysis being considered a losing proposition. Good thing? These pain relievers worked.
  • As more and more doctors became more concerned about adequate pain management as a cornerstone of good practice because the profession broadly encouraged them to take their patients’ reports of pain more seriously, “pain relief” became a subject that deserved the most robust treatment possible. As Dr. Anna Lembke noted in a recent article published in the prestigious New England Journal of Medicine (2012), “In contemporary medical culture, self-reports of pain are above question, and the treatment of pain is held up as the holy grail of compassionate medical care.” Compassionate? Of course – as long as substances didn't hurt more than they helped.
  • At about the same time, as Dr. Lembke points out, a paradigm shift was also happening in the larger culture. It has become more and more accepted globally that there is a pill for any ailment or discomfort, and that all less-than-optimal situations, difficulties or disturbances can and should be alleviated pharmacologically. So the pain pill epidemic should also be viewed in this “prescribe the pill” context. And, so America became a land where over 20% of American women are on an antidepressant and many millions of men, women and children can’t live without their daily Xanax, Ambien, Adderall or other forms of pharmaceutical life-support
  • So then money and greed played their parts. The patient became no longer just a “patient” but a “health care consumer” bombarded by television commercials for an array of pills that can fix any problem – shyness, sleeplessness, fibromyalgia or chronic pain. Having felt they have done their adequate research by viewing advertising, patients now typically walk into their physician’s office now with a culturally validated expectation of relief.
  • And, what about docs who refuse to deliver pain relief, even if they are doing so in the best interest of their patient – possibly to safeguard them from deadly addiction? These doctors know their average patient rating on will take a hit, since these ratings frequently include questions about how well the doctor responded to the patient’s reported pain. As Dr. Lembke notes, “health care providers have become de facto hostages of these patients, yet the ultimate victims are the patients themselves.” In fact, patients began demanding certain medications for their ills and pains. What was a doctor to do to pay his expenses? I think you know.
  • And, just leave the other necessary element in the pain medication debacle to big-profit-minded Big Pharma. The development and marketing of opioids and opioid research by drug manufacturers was unbelievably well-received not only by physicians but also by the Food and Drug Administration.
  • As described in a recent Washington Post article, drug manufacturers, particularly Purdue Pharma, the maker of Oxycontin, and the researchers that they hired, put out a variety of scholarly articles that seemed to alleviate many of the concerns that the medical profession had long accepted as common knowledge. The effect of such misleading claims is still being felt in the killing fields of drug abuse.
  • Their research, which was published in the most prestigious, peer reviewed journals, including the New England Journal of Medicine, indicated that there were “inconsequential” risks of addiction, dependence or withdrawal symptoms from the long term use of opioids with true pain. The FDA-approved labeling for Oxycontin included the following language: “The development of addiction to opioid analgesics in properly managed patients with pain has been reported to be rare” (the language was removed from the label in 2008).
  • Physicians were told that patients with legitimate pain wouldn’t experience, and crave the euphoria that opiates can generate because the pain interferes with the euphoric response to the drug. Oh no, this is not fiction – it is much, much stranger and dangerous fact. Drug companies and drug reps gripped the balls of physicians and the FDA, so they all began to lie to the public. Soiled figures networked, and unholy schemes were hatched all in the name of good old “pain relief” the equates to dollar bills for all. You can't make this up. The prescription drug epidemic now threatens our national health and homeland security.
  • And, at last, the “take home message” that was inculcated into the physician community was essentially that people in legitimate pain, under the proper care of a physician, will not develop the same kind of addiction problems that other people taking the same drugs inevitably would.
    Illogical as it sounds, and untrue as we now know it turns out to be for millions of patients, the message took hold, and the mantra of the profession shifted.

It Can't Be That Bad, You Crazy Old Man

As you know, addiction has been a major problem for a long time. “Addiction is the largest preventable health problem in the United States- affecting 16 percent of the population- more than heart disease, cancer or diabetes”, says Susan Foster, CASAColumbia’s Vice President and Director of Policy Research. But, now add into the addiction continuum the misuse of multiple substances and frequently prescribed opioids.

Here are the “crazy” facts about how “bad” prescription abuse really is...
  • Vicodin and Oxycontin are the two most misused prescription drugs in the country.
  • More people are addicted to prescribed opioids (somewhere between 2 million and 2.4 million) than to heroin and cocaine combined.
  • Prescription drug misuse “remains the fastest-growing drug problem in the United States,” according to the Centers for Disease Control and prevention.
  • More people die of drug overdoses than by any other cause of accidental death, with the majority, about 15 million people, dying each year from prescribed opioids. For the first time since records have been kept, more people are dying of accidental drug overdose than in car accidents.
  • Opioid addiction, pound for pound, is the most dangerous addiction. Setting aside the sheer number of opiate-addicted citizens, the risk of death to any one user is higher than for any other drug. People who are addicted to opiates are almost 6x more likely to die than they would be if they were not addicted to opiates- making opiate addiction more dangerous than addiction to methamphetamine (#2) and other drugs and alcohol.
  • The number of infants born dependent on opioid painkillers and diagnosed opiate withdrawal upon delivery has tripled in the last decade, to 13,000 in 2009.
  • Certain regions of the country, Florida is famously one, parts of Appalachia another, are simply devastated by frightening rates of addiction to pain medications. In these regions, up to ten percent of infants are born addicted to opiates. In Florida, in 2009, death by overdose of prescription drugs was about four times that attributed to illegal drugs.

(Richard Juman, PsyD, "The Irony and the Agony of Our Prescription Opioid Problem,", February 3 2013)

Please read the entire Juman article here. Click it:

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