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.
I dunno. I had heart surgery in June, 2020, during the height of the Covid hysteria. I was out of work for about five weeks, and in a lot of pain initially. I took Tramadol daily for almost a month, and it mostly worked. I had a prescription for oxycodone, and about 14 doses. I only took it once, when I was in too much pain to fall asleep. I thought tramadol made me feel sick most of the time, no appetite, but it did control my pain. I think between hip replacement and heart surgery, I have had two prescriptions, about 20 doses of oxycodone, and taken one, but it was effective.
I honestly do not understand the appeal of narcotics, tramadol made me feel sick all the time and I could not wait to be off it.
You know you have a real serious injury when the doctor prescribes opioids to get you through the first weeks of PT after you’ve healed over 6 weeks post op.
People should be able to take anything for pain that they want to.
I see nothing in my copy of the Constitution that says anything about the government regulating what we put in our bodies.
Chicago article about Gas station heroin. You can get it online and in Illinois
https://abc7chicago.com/tianeptine-gas-station-heroin-illinois-poison-center-opioids/14477807/
Re: “ We are in the throes of a horrible epidemic of illicit drugs. “
We have always been in a horrible epidemic of illicit drugs. Heroin, cocaine, crack, meth, ( this was a big deal when I was practicing), and now fentanyl. Who knows what’s next?
I keep a small bottle of Jack Daniels for use after a bad day at the dentist. A couple of shots and I am out.
gas station heroin has been recalled
https://www.molllawgroup.com/blog/gas-station-heroin-has-been-recalled/
Clinical Annotation for rs1799971 (OPRM1); tianeptine; Depressive Disorder, Major and suicidal ideation (level 3 Toxicity)
https://www.pharmgkb.org/clinicalAnnotation/1450935171
People should be able to take anything for pain that they want to.
I see nothing in my copy of the Constitution that says anything about the government regulating what we put in our bodies.
LOL....sheesh...yep...another drug that my genes have a problem with. Anyone that has to take risky drugs should have a full genome test just so you know what to look out for like this:
“AA Patients with the AA genotype may be at an increased risk of developing treatment emergent suicidal ideation (TESI) when treated with tianeptine as compared to patients with the AG or GG genotypes. Other genetic and clinical factors may also affect suicidal ideation in patients.”
btw, when looking at your DNA sometimes you really have to jump through hoops. I have so many variants from that gene that it was easier to look at 23andme for this gene than looking at Nebula who did my whole genome test ....and then I verified it with nebula for accuracy
Perfectly stated. So sorry about your mother.
...also keep a bullet handy so you have something to bite down on.
More specifically they are freaked out about possibly losing their licenses to practice. Check your state's list of physicians who have had their licenses revoked and the reasons for those revocations. It will usually be something to do with writing inappropriate prescriptions for addictive drugs.
I live with pain daily as do many people and on a good day 4 out of 10. I refuse to take any opioids even though it’s offered about anytime I go to orthopedics. Had to sign a refusal to take them at an emergency room visit last year after a complex torn meniscus knee issue. Bad back, both shoulders shot with massive rotator cuff tears and a couple ibuprofen is what I take and that’s usually every other day. Wife and I take no prescription drugs at all and we hit 70 this year.
So I limp, hurt, takes awhile to get moving, sleep sucks but eventually I get 1 or 2 days of good sleep and get caught up. Still hunt, hike, fish, ride the Harley, work on my cars, do yard and work, maintain the house and refuse to give up.
You deal with pain you don’t prescribe it away. Nobody makes you take opioids, fentanyl or any other drug, it’s all self choice.
That being said every now and then a few good bourbons or whiskeys helps but it’s not crutch for pain.
when you have verifiable genetic proof that all those safe drugs dont work...and verifiable imaging that says you have a problem that is causing pain ...it should be malpractice to make a patient live in so much pain they contemplate suicide.
What Eagle Syndrome patients go through in mind boggling. And yes, the pain can be just as bad as cancer pain. Thankfully not for me yet.
I actually blame the Insurance Companies for the people that got or get addicted to pain meds legally prescribed by their doctor. Sometimes you have no choice in the matter because the pain is so severe for a long time.
In 1979 after a bad motorcycle accident my doctors and I decided me being addicted to Percodan(yesterdays oxycontin) was the only course of action, at the end of 3 months I was taking 50 a day! and then it was time for my 3 week stay at the hospital for my surgery, but the First Week was to go Through Managed Withdrawls under doctors care in a Hospital Bed. This was actually planned from the beginning, but this is when doctors were allowed to practice medicine without needing approval from insurance companies.
I retired after 46 years of active practice as a PA. I’ve had a lot of problems with osteoarthritis and injures resulting in four joint replacements and other assorted surgeries. I have taken lots of opioids. I rarely take them any more. I’d rather suffer the pain than the constipation they cause. That said, when a patient was suffering severe pain I did not hesitate to order opioids because nothing works better. Our bodies have built-in opioid receptors. Gee, how did those get there? They sure didn’t’ come from the DEA!
Now the pendulum swings and they overreact to the other direction. You’re going to see people being told to do meditation, heating pad, etc. to deal with pain. When there’s an easily available product that could help them. All because of the Sackler family and DC.
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