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.
Yikes! You might want to take a pass on that one.
I have been on percocet or oxy since 1994. I started on percocet 5 x90 a month. In 2011 I was bumped to 10 mgs. Then they bumped it to 120 a month. I asked to go back to 90 a month. In addition to the 90 a month I take Hysingla 40 mg which is a 24 hour dose.
On good days I might skip one percocet or Hysingla. When I skip one I hurt. He’ll I hurt most of the time since June of 87 when I had a parachute accident with full combat equipment and a WECI Bag.
I have never copped a buzz. I D not understand how someone can get high off pain pills. Maybe I hurt too much.
Now when I skip one, I feel a type of withdrawal tiredness, followed by pain.
I might skip 8-10 Hysingla in a month. Or I might skip 8-10 percocet a month. However I generally have a day here or there where I take an extra.
The real sad part is they give you 30 days at a time. Then the pharmacy may go a week or two before they can fill the prescription.
The doctors and or pain management don’t care if you can’t fill the prescription or not. They don’t care if you are in pain. IT IS ALL ABOUT THE INSURANCE PAYMENTS.
I imagine the fyntenal crisis us fueled by the supply chain lack of medications.
Suing the drug companies only made shortages worse.
Lots of people buy percocet from India where 700 bucks get you a thousand 10 mgs percocet. But those people get spam calls from the other 1.5b scammers in India.
Tramadol does not work at all to stop pain.
Sometimes people do have real pain and it is nasty to give someone something that does not lessen the pain.
I would classify it as a placebo.
I imagine the problem for you is not getting high but the risk of having to increase the meds over and over again as your body adjusts to the meds thus making your body more dependent on them until it is taking too much and starts overdosing. That is the way I have to look at it since most of these type of drugs do nothing for me as far wow I am getting high feeling.
Genetics plays such a huge role in the way you process any drug and most doctors don’t seem to know how to deal with it. My doctors didn’t even catch it despite me saying things like oxy doesnt work on me.. I had to find out myself. And now that they know...it still doesn’t help that they know.
When I am prescribed any drug now I have to look at how it is metabolized. If I say okay I am defective in that enzyme so how do we adjust they are dumbfounded.
Metabolization is a factor. My now passed friend had pretty good information and advice having been a federal doctor.
His methods for using percocet and oxy was that 90% of medicine is metabolized in the stomach. Thus, a person can break off a small piece and hold it under their tongue and get about 4 doses from one.
Sometimes you skip a week and your body resets. That’s probably the positive with the disruption of supply these days.
It is routine to hurt and as I have learned to mitigate pain my best days are those going to the spa and hitting the steam, sanu , hot tub and then actually swimming for 30 - 60 minutes.
“Another drug listed is gabapentin. It doesnt work on me for whatever reason but it is just as well because that is another drug that people get hooked on for the euphoria it gives you.”
“None of these drugs give me euphoria. When I was taking Oxy after a surgery I couldnt figure out what the big deal was”.
Gabapentin makes me dizzy all day. When I asked for an increase, I couldn’t stand the dizziness and returned to the original dose of 300MG. (RLS, peripheral neuropathy).
Tramadol and oxycodone seemed only to MASK the pain—everything connected with kidney stones AND post-knee surgery still hurt.
Morphine in the hospital worked fine after knee surgery AND it was self-administered!
Ever bit down on a bullet?
:-/
I’m hearing “trank” is a readily-available street drug.
When I had shoulder surgery a few years ago the doctor prescribed 90 oxycodone, 3 separate times. As I got to the end of the end of those I had to wean myself off of them. It was pretty miserable.
.
Since I am not a clinical pharmacologist I can’t dispute what you are saying .. The problem isnt the stomach for me it is the liver enzymes.
This article lays out the mechanics of OXY
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704133/
So for me, I have no CYP2d6 and some variants in CYP3a4 that are in the ‘emerging’ category of clinical study. But what is interesting is that your post made me look up that article and in that article it talks about uridine diphosphate glucuronosyltransferase (UGT) for metabolism. There are several genes related to that so I pulled up my Nebula DNA.
Sure enough, I have a red flag in one of them that when you look it up it mentions tramadol. So this requires me to do more research into the rest of the genes and variants related to UGT and pain relievers
But I will give the under the tongue thing a try just to see what happens.
so for anyone that happens on this thread and you dont know what the heck I am talking about in respect to drugs read this article.
https://www.ncbi.nlm.nih.gov/books/NBK100662/
And this would apply to other drugs and other enzymes.
So For example, I am a poor metabolizer of Codeine. I have been given it before and it didnt do anything for me. Of course all I got from the Doctor was different people react differently to drugs. But how many times do I have to go through this before someone thinks..Oh wait...you might have a gene problem
On the other hand, an Ultra metabolizer would get the pain relief but might have side effects that are similar to overdosing.
And this doesnt even cover the drug/drug interactions.
It is a very very complicated topic. You really need to consult with a clinical pharmacologist because the average Doctor isn’t going to know what the heck to do with this. They likely will have heard of it in med school but have no practical knowledge on how to deal with it.
And they certainly don’t think to test you for it. Instead, just say meds react in different ways for different people...”let’s try another”
20 minutes or as long as possible;)
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