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All I want for Christmas


Dear Santa,

This Christmas please don’t let lawmakers do anything silly and unhelpful in response to the latest statistics about America’s opioid addiction epidemic (brought to you by Purdue Pharmaceuticals).

I also would like a unicorn that craps rainbows.

Between 2013 and 2014, the age-adjusted rate of death involving methadone remained unchanged; however, the age-adjusted rate of death involving natural and semisynthetic opioid pain relievers, heroin, and synthetic opioids, other than methadone (e.g., fentanyl) increased 9%, 26%, and 80%, respectively. The sharp increase in deaths involving synthetic opioids, other than methadone, in 2014 coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl, a synthetic opioid; however, illicitly manufactured fentanyl cannot be distinguished from prescription fentanyl in death certificate data. These findings indicate that the opioid overdose epidemic is worsening. There is a need for continued action to prevent opioid abuse, dependence, and death, improve treatment capacity for opioid use disorders, and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl.

(The CDC includes suicide and adverse effects in its overdose counts. An adverse effect means the patient took the drug as prescribed, and something bad happened. E.g. patient croaked.)

This is the opposite of surprising. The people who became hooked on opioids in the form of a prescription pain medication did not stop being addicts when the local pill mill was shut down or their doctor got cold feet and changed or cut their prescription without accounting for the fact that they were now dependent on the drug. Withdrawal without treatment goes something like this. So naturally people sought replacement drugs.

I checked out the latest guidelines on prescribing opioids (it seems the CDC has been dropping these things monthly), and one of the problems is right up at the top:

primary care providers say they receive insufficient training in prescribing opioid pain relievers.

Right. So two possible solutions that could make life a little better for providers and patients and keep a bunch of besuited morons who just see DRUG ADDICTS USING DRUGS SKREEEE! from passing some disaster of a law that takes the War on Drugs 2.0 to the national level and pleases no one save the United Cocaine Heroin Producers, Smugglers, Pushers, and Affiliated Scum:

1. Before a doctor (or nurse practitioner or physician assistant) puts his patients and his DEA license at risk, get some training. I know providers are very busy people, but continuing education is part of the job. And it beats what happens when the local DEA agent gets bored and starts sniffing around the practice.

2. If training isn’t an option, the PCP sends the patient to a pain management specialist. Getting a consultation could be easiest for the patient. But referring the patient to another provider: “Here, you take care of this one, I can’t,” is sometimes the best option. Perhaps the patient needs a treatment that doesn’t involve opioids, and the PCP sure won’t want to stick needles into a patient’s spine. And if there are no PMs close enough, the friendly state or national pain management society is a phone call or email away.

But it’s probably way too late for that and we’re going to get some nightmare of a federal law because DRUG ADDICTS, SKREEE!

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  • Murc

    Christ on a bike, I really hope they don’t tighten up restrictions on prescription opiates further.

    I know far too many people who can’t get the medication they need because their doctors are far more concerned with attracting DEA attention than they are with providing proper pain management. My own father openly admits he often prescribes downward from what he knows his patients actually need because he’s spent thirty years building his practice and would prefer not to have it all whisked away because someone doesn’t like the number of vicodin pills flowing out under his signature.

    (Dad is a podiatrist, and has a lot of patients with real pain management issues because, you know… feet. It’s not really possible to not put stress on your feet short of being confined to a wheelchair, which is just not possible for most of his patients.)

    • Steve LaBonne

      But isn’t it best for both him and his patients if he refers them to a specialty pain management clinic?

      • Murc

        How does that alleviate the problem, though?

        Dad isn’t above referring people to specialists who need them, because HE is a specialist himself; most of his patients were sent to him by GPs, after all. He has a bunch of people who have problems with their feet relating to their diabetes, and he doesn’t attempt to treat their diabetes at all, he just deals with the foot stuff. So with people experiencing unusual pain in their feet (often but not exclusively post-surgery) he’ll of course refer them to a pain management specialist.

        But there are two problems with that. The first is he shouldn’t have to refer every single patient there; Dad has been dealing with peoples feet for thirty years and has a pretty good idea about what most usual cases that happen down there require.

        The second is, what makes you think pain management specialists are operating under less fear of having the boom lowered down on them for overprescription than he is? Those guys are under EVEN MORE scrutiny than him because that’s basically all they do and if their prescription rights were revoked their careers become nonexistent. That in no way solves the problem of “I’m afraid to prescribe when I think this person needs because I don’t want to have to defend myself in a potentially life-destroying inquiry.”

        • Steve LaBonne

          It’s better because, in addition to shielding him from the DEA, pain management really is a very complex, specialized area, and one practitioner can’t do everything.

          • joe from Lowell

            Yes, this.

            Murc frames this as if getting better treatment for patients and avoiding the DEA are contradictory goals. What you and the OP are talking about looks better by both metrics.

            • Murc

              What I have legit no information on is… who shields the pain management specialist from the DEA? I mean, I don’t know any (I know a lot of doctors because they’re my dads friends and colleagues, but I don’t think any of them are pain specialists) but wouldn’t the precise same incentives re: prescriptions apply to them as opposed to other doctors?

              Although it would of course be true that someone who does nothing but pain management would be better at it than someone for whom it is merely part of their regimen.

              • joe from Lowell

                I figure the police and DEA probably give them a little more benefit of the doubt, too.

                • Feathers

                  Not true. Lazy ass drug warriors go for the low hanging fruit – pain specialists. Apparently someone will show up saying how “Your Pain Prescriptions are way above the average.” Replying that you are a pain specialist is apparently proof that you are a wise ass.

        • ThrottleJockey

          How well documented is this fear of “DEA will destroy Doctors for prescribing opates”? I can think of just a couple of cases in the last 5 years of where this has happened, and one was so flagrantly outside of normal bounds that it was obvious. There are public lists of doctors who “over” prescribe opiates and to my knowledge few, if any, have been prosecuted. The article says just a dozen of the top 20 prescribers have been investigated.

          The No. 1 prescriber Shelinder Aggarwal of Huntsville, Ala., with more than 14,000 Schedule 2 prescriptions in 2012 — had his controlled-substances certificate suspended by the state medical board in March 2013…

          It took a complaint from pharmacies near Aggarwal’s office to alert the Alabama Board of Medical Examiners to his unusual prescribing habits, said Larry Dixon, the board’s executive director. Board investigators subsequently made undercover visits to the doctor’s office and videotaped him prescribing drugs without an exam.

          “If you paid $1,200 in cash, they would put a VIP stamp on your medical records and you didn’t ever have to have an appointment,” Dixon said.

          • Halloween Jack

            It’s not just about prosecution; doctors can also be threatened with a revocation or suspension of their license, and even a temporary suspension can cost them patients and make a big negative impact on their finances (especially for new doctors, who can have hundreds of thousands of dollars’ worth of student loans); this is particularly true of primary care providers, who are often paid much less than specialists in the first place and also have big malpractice insurance bills.

            • ThrottleJockey

              Yeah, and a lot of real, courageous, red-blooded, gun totin’ Americans are scared of Syrian refugees. Being scared of an event isn’t the same as there being a high incidence rate of an event. Some fears aren’t well founded–or get over emphasized.

              It could be that the media is under reporting how many doctors are being investigated or otherwise hassled, but there’s not many stories that suggest that the government or state medical boards are going after doctors much.

              • joe from Lowell

                So let me get this straight: Murc’s father’s decades of experience in the field get tossed aside, and his perception treated as irrational, because you came up with an insulting analogy for his perception of how his profession operates?

                • sparks

                  I try not to engage TJ in any thread having to do with drugs. I don’t think he knows much about diabetic neuropathy.

                • ThrottleJockey

                  Joe–Everyone’s opinion and gets interrogated here, including, frequently, mine. That’s one of the reasons this site is so informative, no? How many doctors are/were afraid of Obamacare? Do I just do like the GOP and say, “Well, doctors are afraid so…”? There might be any number of reasons why Murc’s father’s perspective is true of his specific situation, or even his geography, but not generally true across the nation. Widespread hassles of doctors by the DEA should be a readily quantifiable thing given the political sway of the AMA.

                  Sparks–What would you like me to know about diabetic neuropathy? My 83yo father suffers from it. He also suffers from 4 bulging discs and cervical spinal stenosis. He got hit by a car before I was born and as long as I’ve known the man he’s been in constant pain. And he, out of an abundance of caution, declines opiates. I’ve always thought he’s had a high pain tolerance, so other people may need opiates more than he does. I’m not suggesting that people don’t, but that the risks of addiction are very serious.

          • JR in WV

            My family doctor once had a ‘patient” who on her first visit complained of chronic intense pain. She was accompanied by a “relative” who had a briefcase, which she kept pointed at the doctor.

            Who did not prescribe pain pills that the patient begged for, but instead referred her for physical therapy for her condition.

            I know this because I’ve been a patient of the doctor for more than 30 years, and am a chronic pain patient who spends a lot of time seeing physical therapists.

        • Halloween Jack

          The other horn of that dilemma is the rise of social media-type patient ratings of doctors.

          • jim, some guy in iowa

            “social media-type patient ratings of doctors”

            *that* will provide all sorts of useful & thoughtful information


            • ThrottleJockey

              What’s the downside of rating your doctor? Its not obvious to me…Before I see a new doctor, I try and read everything I can about them…There are doctors I’ve warned people to stay away from…if that was in a website somewhere–Yelp for MDs, say–what’s the problem?

              • nkh

                Well, patient satisfaction does not correlate positively with successful health outcomes. Catering to the patient means over-prescription, improper prescription (‘I want antibiotics!”), unnecessary testing, etc. But that doesn’t stop hospitals from using patient satisfaction as a metric for healthcare providers. It’s essentially the reason we don’t really want to open up healthcare to market competition. The consumers, errr… patients are generally not sufficiently informed about the product. I’m not saying that you, or any other particular individuals, are doing a poor job of research, but in general, what makes patients happy and what makes them healthy are not the same thing and this makes it easy to skew these kinds of ratings to promote improper care.

              • joe from Lowell

                The same problems that make health care uniquely unsuited for market-based solutions (mainly the inability of patients to make informed decisions in a field in which “informed” requires a graduate degree) makes them poor sources of information about doctors’ performances.

                I mean, if you want information about wait times and office decor, I’m sure Yelp for MDs could be useful, but not actual medical information.

                • ThrottleJockey

                  Yeah, I agree that healthcare offers substantial ‘agency’ risks but I think you underestimate the intelligence of your fellow Americans, as well as the type of (self selecting) people who would follow a Yelp for MDs. To be very honest, I have good reason to blame my parents’ neurologist for my mother’s death. Without reading my father’s chart for the numerous tests conducted over night the man conducted a 180 second evaluation of my father. At the end of the 180 seconds he said my father needed spinal surgery. I asked him when his opinion would be conclusive. He said, “Its conclusive now.” The surgery that he recommended is extremely risky.

                  After 2 MRIs and 3 separate opinions from board certified nuerosurgeons, the asshat was proven wrong. I’m not even going to get into his pratfalls as regards my mother’s care. I met someone recently who was being seen by this guy and I told him to run away as fast as he could. This is the type of thing that should be in “Yelp for MDs”.

              • tsam

                What’s the downside of rating your doctor?

                I’d say it’s something like the downside of me rating orbital rocket designs.

                Which is to say that rating manner and conscientiousness (perceived, of course) are fine, but rating based on actual treatment require knowledge of the indications and prescribed treatments.

              • Sly

                What the others said, but I’d just add that medicine is one of the areas of consumer capitalism where what is called “information asymmetry” thrives (it’s the actual test case for the phenomenon); you’re basically buying something you know very little about, so accurately appraising its value is exceptionally difficult. This is true even in retrospect.

                I think there are exceptions for things like “bedside manner” that can be accurately evaluated, and are extremely important in choosing a physician, primary care or otherwise, but I suspect that these criteria are probably few in number. So if a particular doctor comes off like an asshole, then – yeah – social media evaluations can be a boon.

                • The scheduling process also, too.

                  This isn’t direct contact with a provider, but if a provider employs front staff who are disorganized/overworked/rude, that tells you a lot about the provider.

                • Ahuitzotl

                  I’m not sure it does, Shakez – I’ve repeatedly in the US had the experience of an excellent primary care physician, with surly / hostile /incompetent front office staff which seems mostly to indicate to me the physician isn’t a good staff manager & evaluator of employee quality: and why should they be, it’s not what they were trained for – but it didnt stop them being excellent doctors, once you finally managed to get to see them.
                  Of course that difficulty of getting to them, caused me to switch doctors anyway, because it doesnt matter how brilliant they are if you can’t access them when you need to.

              • Feathers

                The problem is that these ratings tell you far more about the rater than the person being rated. Dirty secret of the “360 Reviews” where everybody in a company rated everybody else – there was far more correlation between the scores someone gave others than the scores they received. People get scores that are all over the place, but tend to give scores within a very narrow band.

      • mcarson

        There are not enough chronic pain clinics. Nobody sane goes into this specialty unless you like tilting at windmills. You not only have the DEA, the state boards, any patient who gets into any trouble using their contact with you as the source of their problems, car insurance companies suing you because a patient got into a wreck, other Drs. in your building becoming “concerned” that your prescribing habits might reflect on them (people have been thrown out of buildings over this – We don’t like it when the Feds come sniffing around here, they harass our receptionists to get dirt on you, threatening them with personal investigations)
        Also, this is the DEA just loosing the right to play army over pot, and now saving us from Vicodin. Do you really think anyone is going to be better off after they help them?
        What would fix this problem is more pain clinics, and the freedom to prescribe what’s needed based on what other Drs. not in the employ of the DEA think.
        I know my Dr. has changed prescribing habits towards me based on conversations and records requests involving his prescriptions.
        They urge him to try to “come down a bit with your numbers, they are ‘out of range’ for your type of practice.”
        Also, it’s not the pills that are the problem, it’s the no support to deal with changes caused by chronic pain, the loss of friends, the loss of income, etc. People loose what used to get them out of their own head, and really need more meds if they don’t have the usual distractions and pleasures of life.
        In summary, anyone who thinks this is the way to go is nuts, there is going to be a whole bunch of people having their lives ruined, and a tremendous increase in suicide because of this.

    • ThrottleJockey

      My personal experience comes from the other side. I spent significant time being the primary caregiver for someone addicted to prescription opiates. They developed the addiction after they suffered a severe shoulder injury and their primary doctor placed them on a vicodin prescription for 7 years and then forgot about it. (Sometimes I want to kill that man.)

      It was nasty hard to break the addiction. One weekend I learned they had taken 60 pills. What I thought was a stroke turned out to be a bad drug crash. After I intervened with their doctor and got the prescription terminated, it took six months for their constant cravings to subside. It took another six for them to get a semblance of their health back. Over a year later they still demonstrated addiction behaviors. I stopped taking the narcotics I had been prescribed so that there was no chance that they could get their hands on my opiates.

      Unfortunately the symptoms of opiate addiction are too subtle, insidious, and easily misdiagnosed (physical withdrawal symptoms of opiates mirror the symptoms of colds and flus). I think we need to require 2nd, 3rd, and even 4th opinions for anyone taking opiates for more than 6 months, 9 months, and 12 months respectively.

    • Jadzia

      That is so sad. My mother had cancer (and eventually died from the side effects of the treatment, but not after 20 years of misery) and we had some ridiculous conversations with doctors about their desire for her not to become dependent on opioids. Our position was pretty frankly that we didn’t CARE if she was dependent, we wanted her not to be in pain, and it wasn’t like she was going to be out driving around or going to a job or anything like that, so what did it really matter? Theirs was just to parrot “We don’t want her dependent, we don’t want her dependent.” And she had pretty much no quality of life for an incredibly long time.

  • When did it first become official that doctors should care about pain management as part of their job? My memory is 2014, though I could be off by a year or two.

  • StellaB

    Here in California we are required to have nine hours of pain management training every two years. In the big cities, we also have ready access to pain management specialists for referral. It’s still really hard. I was always comfortable writing prescriptions for narcotics to patients that I knew well, but what do you do with new patients? What about patients with a history of substance abuse? A history of suicide attempts? Failure to follow up with ortho? Uninsured patients? Patients of a provider who’s out on leave?

    The state implemented a program that made it possible to access the patient’s narcotic prescription history. Providers had to jump through a number of hoops to join, but it alway seemed like a privacy or civil liberties violation to me. OTOH, when you can look up a new patient’s history and see that she is receiving 600+ Percocets per month from a dozen providers based on an creased and worn MRI report showing extensive damage, it’s easy enough to send her on her way.

    Pain is real, but it isn’t quantifiable. The choices for good pain control are limited (no, acupuncture and marijuana are not miracles, they’re closer to useless). They all have potentially serious side effects and provide imperfect pain control. There is no solution that I can see.

    • The Dark God of Time

      Sorry, but acupuncture is continuing to be investigated for possible use for more than just pain relief:

      Clinical and experimental evidence indicates that acupuncture may be a safe alternative or complement in the treatment of endocrine and reproductive function in women with polycystic ovary syndrome (PCOS). This review describes potential etiological factors of PCOS with the aim to support potential mechanism of action of acupuncture to relieve PCOS related symptoms. The theory that increased sympathetic activity contributes to the development and maintenance of PCOS is presented, and that the effects of acupuncture are, at least in part, mediated by modulation of sympathetic outflow. While there are no relevant randomized controlled studies on the use of acupuncture to treat metabolic abnormalities in women with PCOS, a number of experimental studies indicate that acupuncture may improve metabolic dysfunction. For each aspect of PCOS, it is important to pursue new treatment strategies that have fewer negative side effects than drug treatments, as women with PCOS often require prolonged treatment.

      • Philip

        Sorry, but acupuncture is continuing to be investigated for possible use for more than just pain relief

        That word, “investigated,” is doing an awful lot of work for you. Acupuncture “investigation” is a lot like, say, the GOP “investigation” of Hillary over BENGHAZI!!!1! “Acupuncture works. Therefore, we shall hold studies that prove it works. And lo! It works!” Meanwhile, real research has shown it to be bunk: the effect size is pretty much inversely correlated with the rigor of the study. Not unlike another garbage treatment sold by scam artists, where you tell people to drink water a lot and it cures their cancer because the water had cancer once. Funny that.

        Acupuncture had some tiny amount of plausibility beyond that of your average snake oil, for a few minor kinds of therapy. It was tested. It failed.

        • Ken

          Homeopathy is based on the Law of Contagion, a basic principle of folk magic. So the water has healing properties because it was once in contact with something with healing properties.

          Mind you, even if that were valid, homeopathy then goes completely off the rails by reversing both the Law of Sympathy and the Doctrine of Signatures, so even as magic it’s a load of bull.

          • postmodulator

            Does it help if we learn the cancer’s True Name?

          • Sly

            I think its a pretty good rule of thumb to assume that any proposition is bunk when it requires that everything we’ve learned about entire fields of science to be wrong.

            • Ken

              The economics discussion is up one from under, with the picture of Shkreli.

        • The Dark God of Time

          Acupuncture pain molecule pinpointed

          Acupuncture needle
          Acupuncture uses fine needles to relieve pain
          A molecule which may control how acupuncture relieves pain has been pinpointed by US researchers.

          Experiments in mice showed that levels of adenosine – a natural painkiller – increased in tissues near acupuncture sites.

          The Nature Neuroscience study also found that in mice resistant to the effects of adenosine, acupuncture had no effect.

          Pain experts said the findings may partly explain how the treatment works.

          Adenosine is known to have many roles in the body including regulating sleep and reducing inflammation, the researchers said.

          Other research has shown that it becomes active in the skin after an injury to act as a local painkiller.

          In the latest study, the researchers were looking at the effects of the molecule in the deeper tissues which acupuncturists target with fine needles.

          The team performed a 30-minute acupuncture session at a pressure point in the knee of mice that had discomfort in one paw.

          They found that in mice with normal functioning levels of adenosine, acupuncture reduced soreness by two-thirds, as assessed by nerve sensitivity measurements.

          The curious thing with acupuncture is that we seem to understand better and better how it might work and, at the same time, we have more and more reason to doubt that it works.”
          Professor Edzard Ernst, Peninsula Medical School


  • LeeEsq

    The political paralysis gripping the nation might come to some good for once and prevent lawmakers from doing anything too stupid for once. If you want good policy and law than your either going to need a better electorate or find away for the civil service to ignore the worst desires of the electorate. Democratic countries get bad laws and policies because they reflect the desires of the electorate, meaning the portion of the citizenry that actual votes in elections and make their desires known to people in office. Holding protests makes your desire known but it has to be combined with ballot the box in intra-party elections and actual elections.

    • The Dark God of Time

      When a problem affects enough middle-class white people, then it will be taken seriously.

      • LeeEsq

        A lot of middle class white teenagers seem to be getting busted by prosecutors over sexting and nothing is getting done to reform the laws being used to ruin their lives.

        • Philip

          If there’s one thing America loves more than middle class whites, it’s billionaire whites. But if there’s a SECOND thing America loves more than middle class whites, it’s destroying people’s lives because how dare you do the sex thing you did!

          • LeeEsq

            Just because policy choices are suboptimal or even bad, doesn’t mean they lack democratic legitimacy. A more European approach to sex education or underage sex in general would work a lot better than what we currently do in the United States but its going to go against the policy desires of a large plurality of voters from across the demographic spectrum or maybe even a majority of voters. And let us not kid ourselves and assume that it is only white Christians that are opposed to decent policy in these matters. There are millions of socially conservative people in every socio-demographic and religious group in the Untied States. European style sex education is least popular with immigrant and minority groups that tend to be a lot more socially conservative than the majority population.

            In so much as democracy is about majority rule, your going to have to allow for suboptimal policies in some instances if that is what the citizenry wants. In the end, your really only going to get a policy as enlightened as your citizenry in most cases.

            • The Dark God of Time

              A more European approach to sex education or underage sex in general would work a lot better than what we currently do in the United States but its going to go against the policy desires of a large plurality of voters from across the demographic spectrum or maybe even a majority of voters.

              Yeah, it’s not like there is a major political party that could develop a platform based on research and information and present it to the voters of this country.

              “So if you work with a biologi-
              cal drive — ?”

              “I know of none which is con-
              sistent with inhibition of fertility.”

              Barlow’s face went poker-
              blank, the result of years of
              careful discipline. “You don’t,
              huh? You’re the great brains and
              you can’t think of any?”

              “Why, no,” said the psychist in-
              nocently. “Can you?”

              “That depends. I sold ten thou-
              sand acres of Siberian tundra —
              through a dummy firm, of course
              — after the partition of Russia. The
              buyers thought they were getting
              improved building lots on the out-
              skirts of Kiev. I’d say that was a
              lot tougher than this job.”

              • joe from Lowell

                Research and information should be dominant factors in political outcomes.

                They totally should be.

                • LeeEsq

                  Ha. On a serious note, some times the electorate wants something that is bad, immoral, evil or otherwise suboptimal is a big pitfall of democracy. Its why Mencken said “Democracy is the theory that the people know what they want and deserve to get it good and hard.”

                • The Dark God of Time

                  Public Opinion is a book by Walter Lippmann, published in 1922, that is a critical assessment of functional democratic government, especially the irrational, and often self-serving, social perceptions that influence individual behavior, and prevent optimal societal cohesion. The descriptions of the cognitive limitations people face in comprehending their socio-political and cultural environments, proposes that people must inevitably apply an evolving catalogue of general stereotypes to a complex reality, rendered Public Opinion a seminal text in the fields of media studies, political science, and social psychology.


        • When enough middle class white people start defending white kids who pass around pictures of their so-called girlfriends in their underwear, and make those pictures available publicly, using the same words–“they don’t have a developed sense of judgement”–that they use to defend harsh sentences for black kids who commit minor, victimless offenses, then they will no longer be taken seriously.

        • Sly

          Top five things that America loves, ranked in order:

          1) Money.
          2) White Jesus.
          3) Guns.*
          4) White Children.
          5) White Soldiers.

          As you can see, White Jesus is loved more than White Children, and strict hetero-normative sexual mores fall under White Jesus.

          * A few years ago I would have put white children above guns, but Newtown tore off that veil right quick.

          • Ahuitzotl

            I’d have thought if they loved soldiers, they’d pay them more than povertyline wages at a minimum

    • ThrottleJockey

      The political paralysis gripping the nation might come to some good for once and prevent lawmakers from doing anything too stupid for once.

      The proper response to an industry, as we have with the health care industry, that fails to regulate itself is for the government to regulate it. That is as right and proper here as it would be if any other industry was failing to regulate itself. Why should we defend shitty industry practices because drugs?

      Opiates are too poorly regulated. People deserve better.

  • keta

    Here’s what I want for Christmas: I want the Republicans to hire Steve Harvey as the emcee of the GOP convention in Cleveland next July.

    “SURVEY SAYS!…Oh, wait a minute…”

    That would be worth a cabinet full of drugs. Christ, I’m trippin’ right now just imagining it…

  • T.E. Shaw

    I just finished the excellent book “Dreamland” a few weeks ago, and I was amazed at how far the pendulum on opiates has swung in both directions. Forty years ago, doctors wouldn’t even prescribe opiates for terminal cancer patients. Fifteen years ago, it was widely accepted that opiates had only a one percent addiction rate (an idea based on a one-paragraph letter to the NEJM in 1980, believe it or not) and that no dosage could be too high because the pain would counteract the effects of the high. By the late 90s, pain was the “fifth vital sign” that every doctor needed to treat aggressively. Now it seems we’re almost back where we were in 1975.

    As for where we are now…we should never forget that PCPs are under immense time pressures. “Dreamland” made a point of talking about how the more effective, holistic methods of diagnosing and treating the sources of pain requires far more time on the part of the doctor, time that the doctor often doesn’t have and insurance won’t fairly compensate. No amount of continuing medical education is going to fix that problem.

    One last thing: People were already moving from opiates to things like black tar heroin before the pendulum swung the other way, because the latter provides more bang for your buck (heroin dealers have been known to recruit at methadone centers, too, so wide availability of methadone isn’t a panacea). So it’s not entirely fair to blame this recent development exclusively on government laws.

    • sparks

      Amusingly, pure heroin is safer than methadone, which has heart-stopping side effects in some people which heroin doesn’t have.

      • Got a reference for that? I prescribe rather large amounts of various narcotics in my ICU practice, including methadone, and I’ve never seen anything about that.

        I do hope they don’t make fentanyl more difficult to use. For several reasons it is the most useful ICU narcotic compared with most others.

        • sparks

          People with long qt syndrome can have cardiac arrest while taking large doses of methadone. Most of the literature on this is from Europe.

          • Long QT has a lot of drug related issues. You’re supposed to look at an ECG (which shows the syndrome) before prescribing many agents.

            • sparks

              You’d think so, wouldn’t you? Unfortunately, it’s rarely done.

        • Halloween Jack

          Under “Adverse effects” in Lexi-Comp, they list the following (under “frequency not defined”):

          Cardiovascular: Bigeminy, bradycardia, cardiac arrest, cardiac arrhythmia, cardiac failure, cardiomyopathy, ECG changes, edema, extrasystoles, flushing, hypotension, inversion T wave on ECG, orthostatic hypotension, palpitations, peripheral vasodilation, phlebitis, prolonged Q-T interval on ECG, shock, syncope, tachycardia, torsades de pointes, ventricular fibrillation, ventricular tachycardia

          Also, here’s a PubMed search on methadone/adverse effects and heart arrest.

          • sparks

            Good job, I know one person who arrested and died on methadone, and another who arrested twice while on methadone(luck was with him) and ended up with a defibrillator/pacemaker.

            I get the feeling those who steer addicts to methadone clinics really don’t care if they die.

            • j_doc

              Methadone is the most dangerous (risk of death) opiate not because of long QT but because of its pharmacokinetics. It has a very long duration of action and unusually variable effect on different people. So it is very, very easy to increase doses too fast so that they stack before reaching peak effect, and you die of an overdose days later. It should takes weeks or months to titrate, not hours or days.

              Methadone can be a very useful drug for chronic pain, but it requires particular care and supervision in how it’s used.

          • Quite a laundry list, and not really clinically useful for those of us in the biz. It’s typical for Lexi-Comp, which puts in everything ever reported without any screening of importance or actual relevance. Several things on that list are mutually incompatible, for example, or shared by other narcotic agents.

            But still, methadone is a powerful drug. I prescribe it all the time to wean people off chronic physiological dependence on fentanyl and morphine. We commonly use it, for example, for infants born to addicted mothers.

  • DrDick

    This is what happens when de-industrialization and concentration of wealth collide with medical care. Synthetic opioid abuse is skyrocketing among former working class and rural whites (aka Redneck America) for the same reason opiate use has long been high among the inner city poor.

    • postmodulator

      There’s another vector amongst the rural whites aside from the usual misery and boredom of poverty; work-related injury. Most people seem to accept that it’s not a coincidence opioid abuse is a problem in coal country, in people who spent a thirty-year career slouching down to get into a mine shaft.

      • DrDick

        That pretty much applies to most rural occupations, especially farming, which has the highest rate of occupational injury and death of any occupation.

  • tsam

    1: Shakezula: You and I must have come up listening the same music. Always dig your selections.

    2: Always dig opiates and opioids. If I didn’t have so much to lose, I’d be one of those statistics. It’s not the body high, it’s a natural anti-depressant for me. They don’t mix all that well with my prescribed ADs, though, so I really have to behave myself with them.

    • postmodulator

      I never liked them. Lucky break; I had enough problems with the things I did like.

  • Dr. Ronnie James, DO

    Ideally, PCPs are supposed to be the quarterbacks of patient care: they don’t make every play, but they know what everyone on the team is doing, and how it all fits together (because if they don’t do it, no one will). Instead, a lot of them refer/ consult and “get out of the way.” It’s understandable: the only way that can work is if PCPs have the time and attention span to do so, and frankly we don’t have enough PCPs right now to do that adequately as it is, for several reasons. The largest of which IMHO is compensation (specialists make more than PCPs because we typically pay doctors more for tests and procedures than office visits and preventive care…and that calculus absolutely informs the choice of med students who are on the fence and terrified about paying off a quarter mil in debt). You get what you pay for. The ACA takes some big steps away from “pay for doin’ stuff” towards “pay for outcomes” where you get paid for how healthy your patients are as a group, how cost-effective their care is, and how few mistakes you make. But we’re nowhere near there yet, and the problems are still here. Medicare pays for nearly all medical residencies in the US and could in theory exert a lot more influence in steering students and hospitals to primary care. ACA also led to an explosion in the use of electronic medical records and e-prescribing, which could theoretically help track patient prescriptions better but a lot of the systems aren’t inter compatible yet [shakes fist at capitalism], though some progress is being made. Groan.

    One sad aspect about the CDC opiate guidelines is that the FDA is openly criticizing them, and CDC sniping right back. If I were Obama, I’d be calling Sylvia Burwell and using a lot of WTFs.

    • The ACA also contains provisions to encourage non-physician providers to fill the PC physician gap. Personally, I’m a fan. But different states have different laws about what an NPP can do.

      As for e-prescribing, what a cluster of fucks it was getting the DEA to allow it for controlled narcotics.

  • creature

    I watched the whole ‘methadone is the cure for heroin addiction (problems)’ back in the late 60’s/early 70’s. The whole concept of treating dope fiends with dope didn’t make sense, back then, and even now. now that the pharma companies have new and better ways to deliver opioid relief, the junkie quest to extend that envelope grows, too. Using heroin is a short step anymore, from a serious Oxycotin habit- especially when the legit source gets curtailed. Never fear- Drug Replacement Therapy will solve the problem (again!?). The new methadone, Suboxone, will slake the junkie’s thirst for dope and allow them to become responsible, productive members of society, so they can get jobs, and pay their new connection for the elixir of a new reality.

    I’ve been clean for over 36 years, I never went on Methadone. I have become a responsible, productive member of society – and I see the ravages of heroin use (among other things) and the folly that Suboxone is a ‘better’ way to be addicted. Changing connections is not a ‘cure’, it is a different sort of management. It is a chemical ‘ankle monitor’, and pain control is not the primary concern. Addiction is a disease, and treating it with substances that prolong it is just as criminal as the illicit drug trade is. I noted that every so-called medical ‘cure’ or ‘solution’ for addiction involves a drug with similar characteristics of the drug it replaces. And that new drug is peddled by the pharmaceutical companies as safe and reliable and less expensive. The truth seems to be that it’s not safe, reliable or cheaper. More OD’s, more confusion for the medical community and increased costs to society. We used to ‘follow the money’ back to some drug cartel- now the trail goes to the medical community.

  • MikeJake

    My stepdad has had 3 knee surgeries, has a herniated disc in his back, and recently had surgery to repair his rotator cuff. He has genuine pain management issues. He is also genuinely addicted to pain meds and sleeping pills.

    How should a person like that be regarded? Is he a bad person because he needs pills? Should he have to be weaned off of them? How much daily pain should he be expected to routinely endure?

    • ThrottleJockey

      First, make sure your stepfather is really addicted. Does he suffer withdrawal symptoms when he doesn’t take them? Is he regularly increasing the amount he takes? Is he always jonesing for them even when he appears to be physically fine? Does he otherwise suffer from depression or anxiety?

      You may be in the unenviable position of having to decide which is worse, letting your stepfather live in substantial pain, or letting your stepfather live with a substantial addiction. I know how hard it is to be in this situation. I spent a couple of years trying to determine if a dependent was addicted to vicodin. I was their primary caregiver. Even after I concluded that they were, it was many months later before I decided to do anything. As long as the downside risks of addiction were ‘manageable’ I declined to take action. Once I thought the risk of death was high though–having learned that they took 60 vicodin in a weekend–I decided to take action.

      For me, at least, what helped most was thinking about this as an exercise in “risk management” as opposed to trying to fix the problem. I learned this from a friend whose grandmother was dealing with the same issue. She was in her late 90s. Serious injuries and surgeries kept her in immense pain. Various pain meds–tramadahl, oxycontin, flexaril–kept her a zombie. The family had to choose between an alert matriarch, or a zombie matriarch. They chose zombie matriarch, concluding that she had lived a rich, full life, her husband and closest friends had long since passed, and her kids were themselves in their 60s and 70s, and that she didn’t have long to live anyways–so why suffer?

      In my case the person had many full years, decades really, ahead of them, so I came to a different conclusion. However you guys decide, God bless. If they’re amenable to counseling–and many older people aren’t–get them some counseling. Emotional withdrawal from opiates is harder than the physical withdrawal (which is plenty hard by itself).

      • Murc

        You may be in the unenviable position of having to decide which is worse, letting your stepfather live in substantial pain, or letting your stepfather live with a substantial addiction.

        Or maybe his stepfather should be the one making that goddamn decision.

        • sparks

          Indeed. I’ve done a lot of work with elderly people and the one thing they want more than anything is control over their lives.

          • ThrottleJockey

            Sometimes, older people rely on younger people to care and help them. I have power-of-attorney for my father. Its not about the person ceding control as much as it is about them needing help.

            When my father was getting shitty care from his hospital I escalated things to the Chief of Staff. The Chief of Staff told me, “The people who do best are the people who have advocates looking out for them.” That’s because health care for elderly people is an incredibly complex task and there are a lot of things to manage and if the doctor spends 15 minutes talking to you that’s 10 minutes too long. As he also told me, “Ask 3 doctors what they think and you’ll get back 4 different opinions.” Having an advocate who understands everything that’s going on, and who also understands the person’s wishes is vital.

    • He should be treated like a patient who has a number of medical conditions, including chronic pain and addiction.

      It’s not easy to manage either condition, but lots of medical conditions are hard to manage. It’s one reason specialists get the bigger bucks.

      • DrDick

        Frankly, in cases like this I am inclined to say that the addiction is not really a problem, as long as it is managed by a knowledgeable physician. Why should people suffer just because we have stigmatized dependency on some drugs and not others. Why should we consider this any different from a diabetic’s dependency on insulin?

        • That’s what I’m saying: Both conditions should be managed. You wouldn’t ignore the addiction any more than you’d ignore depression or high blood pressure.

          Unfortunately, the public perception of addiction and to a large extent, pain is that they aren’t “real” medical conditions like diabetes. (“Tough it out!”) Addiction especially is seen as something people do to themselves and therefore should be punished.

          More reasons why I really, really, don’t want a legislator-driven solution.

          • tsam

            I’m getting the feeling that you don’t trust this Congress to draft intelligent legislation. I know that can’t be true, but I’m seeing it between the lines.

          • DrDick

            The general perception is that addiction represents a character flaw and a moral failing. Pain is seen as something you just “tough out” and “deal with”. Why anybody believes that is a mystery to me.

            As to legislative solutions, what could go wrong with a bunch of semi-literate mouth breathers setting medical policy based on public polling and Iron Age superstition?

            • ThrottleJockey

              To be honest, I don’t really hear people talking like that. In fact, I can’t say I’ve ever heard anyone talk like that. I think people recognize that addiction brings certain risks, and that those risks have to be closely managed. Try finding someone outside half naked, folding clothes outside like I did once. Or thinking someone’s had a stroke because they’ve had 15 pills in a day. Its a thing.

  • The death certificates are issued by the same practitioners of the Best Health Care In The World who deliver the prescriptions, so the data can’t be taken as gospel. Are there studies that double-check?

  • nkh

    I think you’re being a little harsh of PCPs. Obviously this is anecdotal to a large extent, but my wife works as a PA in primary care. She’s extremely averse to prescribing opioids. In cases where it might be advisable, if you were to suggest that she send a patient to a PM specialist, I think her response would be something along the lines of “HAHAHAHA… yeah, and how about you go find that unicorn. It’ll take less time.” In addition, she would point out that a lot of opioid prescriptions originate with specialists who are connected to the source of pain, e.g. surgeons, and who don’t have a PCP’s broader perspective on the well-being of the patient.

  • Bugboy

    “primary care providers say they receive insufficient training in prescribing opioid pain relievers.”

    This is the natural end result of viewing healthcare as a business, with customers, rather than as a public health service with patients. There is a primary focus on making a buck, rather than delivering the service. There is no profit in continuing education! Except for the providers of said continuing education, that is…

    I have had first hand experience trying to penetrate this opaque level of awareness physicians exhibit, with mosquito borne disease, ALL of which are required by law to be reported. First of all, a great number of our imported disease cases go unreported and mis-diagnosed, unless the physician has some personal interest in it. A S. Florida Malaria outbreak in 2003? Discovered by a physician who studied it as a hobby. Our more recent Dengue outbreaks emerge from the fog of war the same way: only by the physician being alert to the presence of the disease in the area because of his personal interest. And they are too busy making a buck to pay attention or have any personal interest.

    When we started seeing Dengue here in S. Florida, I was at my doctor with high blood pressure. She asks me if there is anything stressing me out at work, and I say “Well, YEAH, our Dengue outbreak, it’s been all over the news. Haven’t you heard about it?” Her answer: “No.”

    These people aren’t doing their jobs at a fundamental level. And if it isn’t their job, someone needs to do it.

  • koolhand21

    There can also be the intersection of insurance coverages for pain management vs PCP. I had my tibia crushed just above the ankle in a motorcycle wreck and lost about 1 and 1/2 inches of bone but had great doctors who put things back together (a “benefit” of ortho surgery from Vietnam) and despite the pain got by with occasional aspirin until I developed bone infection 25 years later.
    After many attempts to fix things, I had a BK amputation. Unfortunately, being exceptional, I have experienced phantom limb pain ever since, now 11 years. I went to a pain doctor for several years and have tried the surface device Shaq advertises, acupuncture, hypnosis, the mirror box etc. but for about 6 years my pain doctor (who also did the spinal battery device) and I did fine.
    Then my employer changed plan offerings and the pain practice no longer accepted my insurance so off to the PCP I went. He’s great but his biggest issue is not giving me more than 40mg per day which is what sets off the investigators.
    Something’s better than nothing. At least I feel okay for. Few hours a day. Hope they don’t cut off my Advil.

    • Stories like this are incredibly irritating to me. It’s like hearing someone’s plan doesn’t provide adequate coverage for asthma treatments.

      For the record, I’ve never heard of a certain dosage “setting off the investigators.”

      • DocAmazing

        Work with kids on Medicaid. It’s depressingly common.

        Had a chronic pain/drug-seeking patient that I sent to a pain management clinic. They shoo’d her away like she had crabs. I haven’t been able to get authorization to send anyone else there.

  • joe from Lowell

    Those both seem like reasonable policy solutions.

  • shah8

    complementary reading, sure to annoy the creature upthread: http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment

    • postmodulator

      That article got me as angry as I got back when I used to believe in things.

  • mcarson

    Dosages very much DO set off investigations. That’s the “metrics” thing, Dr’s # of patients vs. # being prescribed opiates vs. average prescription strength. DEA, malpractice ins., other Dr’s. in same practice group, other Dr’s. in same building, zip code, patient income group, private ins. vs. Medicaid & Medicare.
    Think NYC cops stop & frisk stats that had to be met each week, even if you didn’t see any suspicious people, you needed 8 a day, or whatever the # was. Dr. changed my meds from high dose as needed to low dose daily to escape metrics, I just take lots of pills for flare ups & always refill whether I need them or not. Bonus high risk of liver failure since 3 pills is right codeine dose but Tylenol overdose. Thanks for the liver failure, DEA.

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