Saturday, March 2, 2013

Overprescribing Doctors Chase a Lost Generation of Pain

“Doctors are prescribing like crazy.” 

-Dr. C. Richard Chapman, the director of the Pain Research Center at the University of Utah.

High-strength opioid painkillers represent the most widely prescribed class of medications in the United States. And over the last decade, the number of prescriptions for the strongest opioids has increased nearly fourfold, with only limited evidence of their long-term effectiveness or risks, federal data shows.
Consider that medical professionals have been on high alert for many years about the health risks associated with powerful prescription painkillers like OxyContin, and now the alarm is extending from street abuse to an arena in which the drugs had been considered legitimate and safe: doctors’ offices where they are prescribed — and some say grossly overprescribed. Studies link narcotic painkillers to a variety of dangers, like sleep apnea, sharply reduced hormone production and, in the elderly, increased falls and hip fractures. The most extreme cases include fatal overdoses.
Many medical professionals fear these opioids are being overprescribed for the following:
* Back Injuries
* Arthritis

* All Types of Non-Malignant Chronic Pain

* Mood Disorders and Severe Stress
Data confirms that hundreds of thousands of patients nationwide are on potentially dangerous dosages. And while no one questions that the medicines help countless patients and that most doctors prescribe them responsibly, there is a growing resistance to their creeping overuse.
Experts say that doctors often simply keep patients on the drugs for years and that patients can develop a powerful psychological dependence on them that mirrors addiction.
(Barry Meier, "Tightening the Lid on Pain Prescriptions,"
The New York Times, April 8 2012)
Meier reports:
"The federal Centers for Disease Control and Prevention has urged doctors to use opioids more judiciously, pointing to the easy availability of the drugs on the street and a mounting toll of overdose deaths; in 2008, the most recent year with available data, 14,800 people died in episodes involving prescription painkillers.
"The Departments of Defense and Veterans Affairs are trying new programs to reduce use among active-duty troops and veterans. Various states are experimenting with restrictions, including Ohio, which is considering following the Washington model.
“We are trying to prepare our state for what we hope is the inevitable curbing of the use of opiates in chronic pain,” said Orman Hall, the director of Ohio’s Department of Alcohol and Drug Addiction Services."
Pain expert Dr. Jane C. Ballantyne, in charge of pain treatment for more than a decade at Massachusetts General Hospital in Boston before taking a post in 2008 at the University of Pennsylvania, in Philadelphia, said she once agreed with Dr. Portenoy, but she now finds herself in the role of former believer turned crusading reformer.
“We started on this whole thing because we were on a mission to help people in pain,” she said of the medical profession’s embrace of opioids. “But the long-term outcomes for many of these patients are appalling, and it is ending up destroying their lives.”
Want a telling sign that opioids are destroying patients' lives? 
In 2006, Dr. Gary Franklin, a state official in Seattle, Washington, found something in thousands of workers’ compensation claims. He called together 15 medical experts to discuss some troubling data found in the records. Here are the findings:      
"Thirty-two injured workers who were prescribed opioids for pain had died of overdoses involving the drugs. In addition, in just a few years, the strength of the average daily dose of the most powerful opioids prescribed to patients treated through the workers’ compensation program had shot up by more than 50 percent. The number of patients taking the drugs in large quantities had grown to 10,000."
Of course, doctors often increase opioid dosages because patients can adjust, or develop tolerance, to the drugs and need greater amounts to get the same effect. Pain specialists had argued that it was safe to increase dosages so long as doctors made sure that patients were improving. 
Yet, Franklin concluded:

"It is possible that additional prescription opioid related deaths could be prevented by more intensive efforts to educate health care providers about opioids. Two years after implementation of the 2007 WA AMDG opioid dosing guideline, only 45% of WA primary care physicians responding to a survey reported being familiar with the guideline [Morse et al., 2011]. This indicates the need for more intensive educational efforts, perhaps including special emphasis on targeting opioid prescribing education to high-frequency prescribers."
(Gary M. Franklin M.D., "Bending the Prescription Opioid Dosing and Mortality Curves: Impact of the Washingto State Dosing Guideline," American Journal of Industrial Medicine)

 So, the Washington data suggested that doctors were not monitoring patients; they were simply prescribing more and more opioids. 
Dr. Claire Trescott, the official at Group Health in Seattle, believes such practices are common because treating pain patients, who are often also depressed or anxious, is time-consuming and difficult.
“Doctors end up chasing pain” instead of focusing on treating the underlying condition, Dr. Claire said.
Before the widespread use of opioids, the University of Washington’s medical school was known for an approach to chronic pain that emphasized nondrug treatments like physical therapy and counseling. Some specialists like Dr. Ballantyne, who moved here a year ago, are now determined to revive that tradition.
“If doctors understood how hard it is to get patients off of these drugs, they would not prescribe them to begin with,” Dr. Ballantyne said.
Dr. Ballantyne once embraced the wide use of opioids to treat chronic pain. But, about a decade ago, she became a skeptic when she noticed that hospitalized patients taking high dosages screamed when they were examined — as if the drugs had increased their sensitivity to pain.
She decided to research long-term data about the drugs and published a medical journal article in 2003 with her findings. It concluded that high doses might not be safe or effective.
(Jane C. Ballantyne, M.D., and Jianren Mao, M.D., Ph.D. "Opioid Therapy for Chronic Pain."
N Engl J Med 2003; 349:1943-1953. November 13 2003)
Now, Ballantyne has little patience for those who believe that the opioid problem can be solved simply by screening out those patients who might abuse the drugs.
“I think that after 20 years of a failed experiment that there are not many people supporting this except for the die-hards and the pharmaceutical industry,” Ballantyne said.
The Food and Drug Administration indicated in 2008 that it might require that doctors receive several hours of mandatory training in the use of opioids as a condition of prescribing them. But in 2010, the agency backed away from that stance in the face of opposition from some medical and patient advocacy groups. In addition, although the Obama administration announced plans last year to introduce legislation containing such a mandate, it has yet to do so. No mandatory training is presently required.
Few programs are in place to deal with patients now on high opioid dosages who are not benefiting from them.
If the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years.
Much to the horror of pain sufferers, even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle. Considering the danger of long-term treatment with opioids, this will surely mean deaths is close to many. How does this translate to Ballantyne?
“I think we are dealing with a lost generation of patients,” she said.

Sign this online petition to request that the FDA require doctors to have mandatory pain management training before prescribing opioids:


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