Last week, thousands of my physician colleagues and I received a letter from the U.S. Surgeon General, Dr. Vivek Murthy. He asked us to change our behavior in prescribing pain medicines.
Around the same time, I was seeing a middle-aged man who had been admitted to the hospital for the fifth time in the same number of months for “pain.”
A week earlier another patient burst out at the nurse, “I am not taking my antibiotics until I get my pain medicine.” His skin infection did not warrant narcotic pain medicine.
And in yet another case, the nurse found a patient’s bedside drawer full of pain medications. “The drugs have a good street price,” the patient told me.
Undeniably, our nation is in the midst of an opioid epidemic, and Tennessee is at its epicenter.
Each year, the number of prescriptions written for powerful pain pills in America is enough for each adult to have their own pain pill bottle. Tennessee is ranked among the top three states in the nation with the highest painkiller prescription rate, along with Alabama and West Virginia. And the prescription rate of one drug, oxymorphone, is 22 times higher in Tennessee than in Minnesota.
Where are people who abuse prescription pain medicine getting them? A 2011 national survey found that 55 percent receive them free from family or friends and 16 percent stole or bought them from family and friends. Only a small number, 17 percent, were prescription medicines. But that is likely higher in our state. And even 17 percent amounts to a lot of addictive pain pills.
Doctors have many options to treat pain: non-opioid and nonaddictive options include Tylenol, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDS) like Aleve. There are also non-pharmaceutical options, such as massage, biofeedback, and acupuncture that may help relieve some types of pain. In contrast, opioids are powerful drugs which can be addictive. Common opioids include hydrocodone, oxycodone (formulated in Percocet) codeine, morphine, as well as heroin.
“The addiction began insidiously,” one friend told me about her husband. He began by taking a few Percocets for back pain. Over the years, he visited emergency room after emergency room and kept changing doctors in a quest to keep a steady supply of opioids. Eventually he overdosed and nearly died. This is often the case when a one-time prescription creates such a strong urge that patients seek or steal pain medicines from family or friends, demand that their doctor prescribe medicine or even buy it on the street.
The outcome is lethal. In 2014, 1,263 people died in Tennessee from overdose (the majority of them from opioids) which is more deaths than roadway vehicular accidents.
To solve the opioid addiction problem, we need to understand how we got here. For a long time, many patients suffered needlessly from untreated pain. To solve this problem, over the past two decades “treating pain” became a major priority. We even made “pain” a 5th vital sign along with temperature, heart rate, blood pressure, and respiratory rate. Meanwhile, the drug companies marketed the drugs heavily to doctors, at times even incorrectly stating that the opioids were not addictive.
The problem is that we, the doctors, lacked proper training in treating pain with opioids: when to start, when to stop, when to wean, when to recognize an addict and offer help. There was no proper database to track if patients were getting drugs from other doctors.
It’s also difficult for physicians to determine when pain is genuine. In some cases it’s clearer — the pain of some cancers or after surgery for example. But in many other cases like back pain or abdominal pain, it’s harder to know. We need to conduct detailed evaluations, or refer patients to pain experts. In addition, we should only prescribe limited number of pills, not a 30-day supply, as is commonly done.
Curbing most addictions, such as smoking and alcohol, depends on changing the behavior of patients. The opioid addiction is different. It partially depends on changing the behavior of doctors who overprescribe the highly restricted, controlled pain medications.
The surgeon general is asking us to take a pledge as explained on the website TurntheTideRx.org — so we need to educate ourselves. This week, I take a required training course in opioid drug treatment to maintain my license. Also, a controlled substance monitoring database tncsmd.com now tracks what narcotics have been prescribed to a patient.
Lastly, we must change the lens through which we see opioid addiction. This is a terrible disease, not a moral failing.
Source: Commercial Appeal