Posted on 03/05/2024 1:39:49 PM PST by nickcarraway
Reflections on medical policy, DEA permits, and the fentanyl crisis
Edwin Leap is a board-certified emergency physician who has been practicing for 30 years since finishing residency. He currently works as an emergency physician for WVU Hospitals in Princeton, West Virginia. Follow
When I was in my residency training, from 1990 to 1993, we were in the nascent phase of the "pain is a vital sign" madness. We were told, over and over, that we should treat pain aggressively and should not be afraid to give narcotics to patients in pain. Who were we to judge someone's pain, after all? The young man who fell onto his knees at work, with a normal blood pressure and heart rate, looking about the room, might well categorize his pain a "10/10," and we should honor that, respect it, and treat it.
As the years went on, drug reps actually gave physicians samples of opioids for their patients. (Talk about a good investment in reaching your market!) We had them in our hospitals in cabinets, before the days of computerized pharmacy systems. It was apparently no big deal.
Thanks to academic institutional policies and brilliant pharmaceutical marketing, pain pills such as hydrocodone and oxycodone (Oxycontin) were well known and much desired. Many a patient concocted elaborate tales of horrible pain, undocumented cancers, physicians out of the country, pills inexplicably eaten by dogs or spilled down the toilet. (This was before we had searchable registries for opioid prescriptions, which have been a wonderful thing.)
Much of our work as physicians was a balancing act between trying to show genuine compassion, mandated compassion, and appropriate skepticism about pain scales and the lies concocted in pursuit of drugs.
"So, just to be clear, your hangnail is a 10/10?"
"Maybe a 12/10, honestly."
"Let's go over the scale again, shall we?"
One of my very favorite patients with addiction (or perhaps just diversion, who knows) was an adult male who endlessly entertained me with stories about how his brother had beaten him and taken his hydrocodone/acetaminophen (Lortab). "Mama's in the car, you can go ask her!" He was about 40 when I knew him. I wasn't going to ask Mama.
Well, we certainly made our bed and now lie in it. We are in the throes of a horrible epidemic of illicit drugs. The healthcare system at large has done a remarkable 180-degree turn and over the past few years has basically said, "Whoa, there, we never said that! Doctors are the problem!" So now we're constantly subject to educational programs on how to prescribe opioids better and smarter, or not at all.
In fact, it's almost time for me to renew my federal Drug Enforcement Administration license to prescribe controlled substances. But this cycle I have to take a new 8-hour classopens in a new tab or window on proper prescribing habits and pain management. This, of course, in addition to the $888 fee for said 3-year license.
As one accustomed to mandates and tests, certifications and fees, I didn't think about it much. "One more class, whatever." But then I had an epiphany, which was that nobody really argues with me about pain pills anymore -- certainly not with the theatrical skill of the old days. Now we're only supposed to give a 3-day supply. We tell people that and they shrug. It's a little disappointing, really. Their hearts just aren't in it anymore.
But I think there may be a more sinister reason that nobody argues -- which is fentanyl. It's just so easy to get the stuff. It's inexpensive and it's everywhere. It's in drug houses and gas station parking lots. It's in high schools and college campuses. It's in prisons and homeless encampments. In fact, according to independent journalist Jonathan Choe, it can sometimes be found for 50 cents per dose in homeless camps.
I suspect that diverted, illegal pain pills (of the hydrocodone, oxycodone variety) are still out there. All too many people die from them. But the incredible volume, availability, and shocking fatality of fentanyl makes those old-school pills less relevant. (Frankly, a lot of the pills are probably fake pills cut with fentanyl anyway.)
So as physicians, in the last 20 to 30 years we were told to:
Give potentially dangerous drugs and don't worry. People are in pain, you medical monsters!
Then we were told:
Stop giving dangerous drugs and stop being bad doctors. You monsters!
And the beat goes on to this day.
The problem with oxycontin was recognized. Litigations and settlements were arranged (although even those are still working their way through the systemopens in a new tab or window).
However, the flood of illegal fentanyl precursors from China, which then become fentanyl and began flowing across the Southern border, continues unabatedopens in a new tab or window. Millions upon millions of doses of fentanyl cross into the U.S. regularly. And considering that we dose fentanyl in microgram doses -- that is, one millionth of a gram -- it doesn't take a lot of the stuff to put a lot of people in the ground. Or certainly addict them. (And that doesn't even scratch the surface of the cost of drug abuse to individuals and society ... I'll address that later.)
I've been trying to carefully prescribe opioids for the entire 33 years I've been a physician (counting residency, that is). I've tried to balance compassion with caution every time. And I'll take the silly DEA class, promise to be a proper physician, and continue my regularly scheduled berating as I and my colleagues are blamed for the enormous problem of opioid addiction and death. But it's all rearranging the deck chairs of the Titanic until someone gets a handle on the crisis from a geopolitical standpoint. And yes, that means dealing with the border as well.
I'm not blaming one political side or another. I'm just saying that if it isn't taken seriously, then the deaths will keep skyrocketing. And it won't matter how much continuing education I take, or how many times I give only 12 doses of Lortab for that fracture. Because the people who really want the high? They just don't care anymore.
btw, if you have tinnitus you should ask your dentist to check for similar issue as seen in that graphic but don’t expect all dentists to even know about it.
The doctor prescribed tramadol for me when I had both my knees replaced. Nasty stuff. Did nothing for the pain, just made me delirious. I didn't bother taking any more of it.
Yes, exactly! I pulled an abscessed tooth with a butter knife and pliars after a bottle of Jagermeister. Pain got to be too much, ibuprofen and water wasn't cutting it anymore and I didn't have insurance. Gargled with what was left of the bottle over the next couple days and haven't had any issues since.
The Sackler narrative was BS.
Purdue never had a large Market share, it was about 4% or so. .
Prescription opioids have gone down more than 60+% since peaking in 2012 but Opioid ODs are at record levels due to un- regulated illicit opioids.
Addiction rates for opioids are around 1% certainly less than 5% and less than alcohol.
The few that were addicted to prescription opioids cannot account for the record opioid ODs; this was all illegal opioids.
If prescription opioids were a major cause of addiction and OD deaths, we should have seen a drop on opioid ODs. But of course we haven’t.
People always looks for easy explanations and scapegoats. The government always will blame-shift.
sheesh...are you in your 80s or 90s...that is some ole timey remedies right there. I could never.
I had a molar pulled out about 3 weeks ago. Far back one.
Jack and I had a good night after that.
Well the Jager has enough alcohol to kill off any infection so what the hell...
They told my 80 year old mother who has been known to keep going despite broken bones that she was just "being a baby" to go home, and the pain was not "that bad".
They ran into the wrath of dad and decided that maybe they should do a check just to make sure.... Major abyss. They had drained the smaller one earlier that day and completely missed the big one.
Granted sending her home with pain pills would not have been a good solution in that case but it does show how they regard pain as not being a major symptom anymore.
The government is expert at blame shifting. In the 1980s before big pharma and the insurance companies colluded, tying physician’s hands, I was taught that patients became addicted while in ICU and part of the care was titrating and treating that as they recovered. Now, they’re just discharged to deal with it on their own mostly. I’m still waiting for terpene compounding and sane cannabis dispensing.
Oxycodone, works great for me. Without them on hand for the times when pain is overpowering, is a miracle.
It is possible you have P450 problems in the way your process drugs. Just be on the lookout for other weird reactions to drugs.
For me, I am completely missing the enzymes from both parents that would metabolize that drug. But you can have a problem even if only one parent gave you the enzyme.
Also some pain drugs are metabolized by multiple enzymes. So if you are okay with one set but are defective in another it might still cause you problems.
That is what I have to watch out for with Plaquenil.
And then there is the whole other nightmare of how one drug effects another when you have P450 problems
Acetaminophen and Codeine work great!
Eagle-syndrome is a condition associated with the elongation of the styloid process or calcification of the stylohyoid ligament, clinically characterized by throat and neck pain, radiating into the ear.
I dont know how long I have had it but I know at least 5 dentists missed it on panaromic xrays and radiologists missed it on other images. I had to have an Eagle expert radiologist at a university hospital look at existing imaging to confirm what everyone else had missed.
It was a dentist who eventually caught it.
It can compress your jugular. I have seen pictures of it doing it. One person who had surgery said the CT didnt pick up compressing the jugular and it wasnt until surgery that they discovered the compression
I am not sure yet if I have a CNS leak but many do.
And over and over and over again I am hearing Doctors tell me they have never heard of Eagle Syndrome...which apparently is pretty common medical experience of patients who have it.
Rush Limbaugh did that too when he was hooked. Talked about it on his show. I sure miss him......
here is an example of eagle jugular syndrome imagining
https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-019-1572-3
But it can press on any number of things in your head/neck..veins, arteries, nerves. Can cause so many different symptoms depending on what it is pressing on. Since Tinnitus is one that is why I tell people to at least have your dentist check your panoramic xray
Lol. I was 30 at the time, and teaching at a local technical college. I'd had enough trying to lecture through the pain. It's amazing what we can do with/to our bodies when the time comes. If it's bad enough, you'll do something about it.
btw, this is not a modern day processed food problem. they have found it Eagle Syndrome in skulls dug up for the early mankind eras...and yet it wasnt officially discovered until the 1930s and most doctors are clueless about it.
If you have weird stuff going on that doctors cant figure out look at that panoramic xray. Chances are you dont have it because it is rare but I have so many rare things “rare” doesnt mean anything to me.
i agree
one last thing on this
If you are experiencing long haul covid you definitely need to check to see if you have Eagle Syndrome.
here is a person who found out after covid
but my reasoning is that Covid may have affected your vagus nerve and what you were able to tolerate before has all become more inflamed for a variety of reasons. Depending on where your spikes are it could be aggravating the vagus nerve which operates all throughout your body.
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