Thank you Purdue Pharma and the Sackler family.
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.
They put on the brakes way too hard for prescription opioid pain killers. They helped chase people to fentanyl. My 78 year old mother should be able to get all the pain meds she wants, as long as she agrees to give up driving.
There is no common sense anymore.
on the flip side....Drs are so freaked out about opioids that dealing with pain is a problem for people who have genetic problems with drugs.
I have lost track of the times Drs treated me like I was a drug addict when I would say NSAIDS dont work on me and neither does Oxy or percocet.
I finally got the official genetic test put in my records and the STILL treat me like a drug fiend.
I have Eagles Syndrome. Screw the whole medical profession that doesnt even know what it is and once they do they dont want to give you medicine to deal with the crazy pain.
For example, tramadol is one of the drugs used for this. I can’t use tramadol. I also cant use tricyclic antidepressant that are used for pain.
There are some people in the world that actually do need help with pain.
Thank you Purdue Pharma and the Sackler family.
Tramadol is the most worthless painkiller on the market. I often wonder why it is even a controlled substance. I call it the pain killer that is based on the placebo effect.
and btw, a pharmacologist said Fentanyl should work for me. Put aside the addiction issue... I laughed out loud. No Doctor is going to prescribe that for me. Again, they are freaked out about addiction.
Interesting to read a view from the other side of the “fence.” To add some levity to such a serious topic “Beer is good food!” My favorite being Abita Amber Lager...delicious!
That is because the government interference has made it too difficult for patients who are truly in pain to get the medications they need. Too many patients were cut off cold turkey from their physicians from pain meds that helped them to have a productive life, and thus forced to get their pain prescriptions on the black market. That is one reason we are seeing more fentanyl overdoses in elderly people. They think they are getting opiods but instead are getting fentanyl.
“Drug overdose fatalities among US older adults have quadrupled over 20 years, UCLA research finds”
https://www.uclahealth.org/news/drug-overdose-fatalities-among-us-older-adults-have
one of the drugs listed for Eagle Syndrome is “gas station heroin”. I forget the name of the drug but they arent going to prescribe that either.
When you read the stories about what people go through with Eagle Syndrome I feel lucky that mine is not that bad yet.
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.
I love these posts. its fun to see all the reasons people need they oxy.
Screw pharma. Be a man. Smoke pot and drink whiskey like most of us for the pain.
WHAT is the “opens in new tab or window” several times in the article? Apparently to do with ads. How did it get in there? It’s not in the article at the link. Strange.
Otherwise, good article. Has to be irritating to the medical profession.
Opioids are fine for short term use. I presently have a broken knee cap (dog walking leash tangle) and received oxycodone 5mg for 30 tabs a couple of times.
They helped immensely that first couple of weeks, however I was very careful with them and only for most severe pain. Now I just use NSAIDs or acetaminophen
“Gas station heroin” is tianeptine, an antidepressant that was approved for medical use in the far east.
If you take about 20 times the dose used for depression it’s supposed to make you feel something. Obviously this is not a big drug of choice, otherwise nobody would use fentanyl.
Back in the 1980’s kids used to smoke banana peels to get high which probably did as much as tianeptine does.
I had a friend who doctor shopped for opioids using his old medical records and X-rays. Would go all over town going to different doctors. A couple years later a guy I hired out of Indiana who became addicted thanks to this guy ended up homeless and died on his friend’s sofa one night.
My 62 year old BIL’s stomach & esophagus cancer pain was so bad, no pin killers worked except fentanyl.
Yes that is the drug and some states are outlawing it. Not sure if you can even get a prescription in those states.
It wasn’t approved for sale in this country.
As I said outlawing tianeptine is kind of pointless. If it was really fun to use it would be more popular.
This kind of my dilemma. I don’t want to end up addicted like Matthew Perry but I have to have something to deal with pain if they are going to saw off my bones..let alone the daily crap I have to deal with as far pain.
What do you do when NSAIDS dont genetically work on you right...and as you go up the line the only thing that works is Fentanyl or Morphine. I am putting off two major surgeries because I know dealing with the pain is going to be a nightmare.
You are right. I just looked. So it was useless for me to even put on my list of drugs to look at for Eagle Syndrome. I guess Eagle Syndrome people in Europe can use it.
I actually would like to try it just to see if it would work for pain.
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