opioids.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5906a1.htm

http://www.dopl.utah.gov/licensing/forms/OpioidGuidlines.pdf

http://health.utah.gov/prescription/

http://www.cdc.gov/nchs/data/databriefs/db22.pdf

Ballantyne, Jane C. MD et al. "Efficacy of Opioids for Chronic Pain: A Review of the Evidence." The Clinical Journal of Pain

2008 Jul-Aug;24(6):469-78.

Ballantyne, JC et al (2003 Nov). "Opioid therapy for chronic pain." New England Journal of Medicine 2003 Nov 13;349(20):1943-53.

Eisenberg, Elon et al (2005 Jun). "Efficacy and Safety of Opioid Agonists in the Treatment of Neuropathic Pain of Nonmalignant Origin. Systematic Review and Meta-analysis of Randomized Controlled Trials." JAMA. 293(24), 3043-52.

Martell, BA (2007 Jan). "Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction." Annals of Internal Medicine. 2007 Jan 16;146(2):116-27.

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As a philosophical debate, this is a very interesting topic.

I attended a lecture today that was discussing the use of chronic opioids to treat chronic pain syndromes.. This topic always fuels my mind.

The data (or lack of) about the complications, abuse, misuse, unknown efficacy, and unintended deaths from opioids is staggering. I find it particularly fascinating that, after looking at and having concrete data on the topic, that there are no regulations on who and what and how long we are allowed to prescribe these dangerous medications.

I am looking at this from the perspective of a family doc.. My training is very broad, but also very shallow. I find myself having to decide about what to do by grabbing on to my own anecdotal experiences or the limited training I have received from 1 hour lectures here and there, my own personal self-directed education, electives, or just plain "guessing" about what is the right or appropriate thing to do. I am allowed to prescribe narcotics at my own discretion after 4 years of medical school and 1.5 years of residency training. You might argue that this is sufficient training, but I would argue not. The reason I argue not is that it is a very time-intensive process to decide who and what and how long to treat a subjective chronic pain condition, and you have to do this process over and over throughout the course of their treatment... And most of us, including myself, do not have the time allocated to do this appropriately. My argument is that, perhaps if we do not have the time or training to prescribe these medications with the appropriate screening, counseling, and supportive services available, THAT MAYBE WE SHOULD NOT BE PRESCRIBING THESE MEDICATIONS SO LIBERALLY to TWENTY PERCENT of our population for a SUBJECTIVE COMPLAINT with no evidence to support that it may even SUBJECTIVELY HELP their chronic condition for fear that they may have to deal with some pain!! This is insanity.

Now translate this argument to the fact that mid-level practitioners are also allowed to prescribe narcotics at their discretion. Theoretically, they have "a physician" over-seeing their work. But practically, these mid-levels are independent providers making independent decisions. Again, this is both a time issue and a "revenue generator" issue that I believe is wrong unless this provider has the appropriate training! I like PAs, and beyond that, I think their integration is basically essential into our medical system to fill an enormous gaping hole in affordable and accessible primary care offered in our health system, but we are also talking about people who have completed between 18 and 36 months of education in medicine... Many of them in primary care do exactly the same thing I do. This is a whole other topic, but if I am questioning whether I should have the authority to liberally prescribe chronic opioids, it naturally leads to the question of whether mid-levels should have this authority.

I started forming my opinions on this topic during residency, perhaps because in Utah, or in particular residency clinics in Utah, chronic pain is such a ubiquitous problem.. And the complications from over-prescribing are also infamously ubiquitous. Perhaps this is also in part because as my unique training experience as a family doc, I am able to observe patients in a variety of settings via rotations. For example, anecdotally, I feel like I see just as many patients in the ED who have overdosed on opioids that were prescribed by a physician as patients in clinic who are being prescribed them for a chronic condition...I have also had the opportunity to work with patients in both med school and residency who are recovering from prescription pain med dependence and addiction.. At this point, I think I have had a wide breadth of exposures in this particular subject... I have been involved in the role of prescribing, denying, treating serious and dangerous life-threatening complications in the ED, and also observing life-changing implications in the form of recovering addicts who lost decades of their lives to that disease..

Besides that, when we are providing informed consent about these meds and describing the "risks," we should include that all of these risks come with the caveat that we do not have the appropriate pool of or access to resources to deal with any unintended or predictable complications from the use or misuse of the drug except via the ED (a place intended to treat emergencies, like, for example, heart attacks, broken hips, strokes)..... and yet there are always a significant percentage of patients in the ED requesting their chronic pain meds, benzos, and/or with serious and predictable complications related to overdose of these meds...

This is absurdly ridiculous, and I just have to vent about it.

An ironic point brought up at the end of the lecture was that physicians have to go through intensive training to be able to prescribe Suboxone, a drug designed to help people ween off of opioid addiction.... This drug has been designed so that it is impossible to abuse and difficult to overdose on.... Anyone else think this is IRONIC??!!!!!!! And in a room of I'm guessing about 50-100 family med docs and mid-levels, NONE were certified to prescribe this medication... Nor did anyone have a reference of someone who was certified to prescribe this... and yet, I am sure we have all prescribed opioids for chronic pain at some point.

I wonder why we do not have to go through intensive training or consult with an expert to dispense enormously absurd quantities, doses, and durations of opioids? To use a different example, we do not see such staggering statistics about many other dangerous medications.. for example Digoxin, a medication that is known to be potentially dangerous and that we feel obligated to consult with an expert cardiologist on its use.. I suppose it has not caused such widespread harm for a few reasons. Primarily, because it is does not give patients Euphoria, and so they are not inclined to take it or ask for it unless they are directed to do so... Secondly, it is ingrained in our minds that cardiologists should be dealing with complex heart conditions. Well, what about complex pain conditions? Am I, as a family doctor, really supposed to be fixing this problem with a 15 or 20 minute total time slot without training with the bandaid of a dangerous medication? This sounds like a set-up for disaster, which it has indeed become.

I think we, as a primary care community, have proven that we are incapable of dealing with this problem appropriately and safely.... And I think it is our responsibility to start self-regulating or/or beg for government-imposed regulation..

My own current philosophical belief system supports regulating opioids against liberal prescribing for the following reasons:

1. Chronic pain conditions are complex and I do not believe we are not fixing the problem with the prescribing of long-term opioids.

2. We are clearly, unarguably, creating huge and significant public health problems with this liberal prescribing.

3. No one is dying from pain, and lots of people are dying from opioid overdose and misuse.

4. There is no clear evidence THAT IT HELPS with chronic pain conditions!!!

What I mean by "liberal prescribing" is not clearly defined in my mind. I think perhaps providers who are prescribing these medications for chronic pain should have to go through a special certification program and that these patients should have to go to a special clinic providing services including: a certified trained physician, a psychologist, physical therapy/rehab services, and a social worker. Why do I believe this? Simply because it makes sense to me that this will do more good than harm, and the way we are doing it seems to be doing more harm than good....

I often argue against over-regulation and government imposition on various things, but it seems we have an expensive, dangerous, public health hazard because of a scenario we have created ourselves.. And we are, it seems, helpless to formulate a streamlined solution. We are all trying haphazardly to use self-derived "pain contracts," urine drug screens, DOPL reports under ridiculous time-contraints... but none of us has the time or resources available to formulate a streamlined approach to this problem. Without a doubt, this is currently the public's and the government's problem because our medical system has not yet formulated any reasonable solution. The public is footing the bill for a systems-derived problem, primarily in the scope of security/police services and ERs. As I see it -- and admittedly, I may be over-simplifying or generalizing --We can either try to prevent a predictable problem from occurring in the first place, we can address a problem after we have acknowledged its creation, or we can ignore it as it grows exponentially in our faces. I think we are doing a lot of talking.. And in the meantime, the problem is continuing at enormous cost, risk, and utilization of time and resources...

There may appear to be some irony in my belief system... specifically because my primary interest is in palliative care (aligning goals of care, providing comfort, using holistic approaches)... However, I see a clear delineation in these topics.... for the following reasons:

1. If we are trying to treat pain, let us try to treat the pain. We should be trying to identify what is the source? Why? What can be done to remedy the source? I believe that in many cases, opioids are not the solution to that question and we are using it as a gigantic bandage to cover "PAIN." For example, if someone has chronic back pain because of obesity, perhaps maybe we should be tackling that issue instead of being afraid to or feel helpless to address it. If someone has chronic abdominal pain because they were sexually abused or have uncontrolled depression, perhaps maybe these are the illnesses we should be discussing.

2. If we are trying to treat addiction or abuse, let us call it that and not pretend we are "treating pain" to make ourselves feel better about it. Because the treatment is different. Do we treat alcoholics by trying to titrate the amount of alcohol that satisfies their addiction? No, this is ridiculous. Many of us know or have a valid suspicion that our pain patients are addicts, yet we continue prescribing..

3. If I believed narcotics worked to treat a patient's pain in order to provide comfort, and that pain would be otherwise uncontrolled with no other reasonable and less dangerous solution aimed at treating an underlying source of pain, I would be inclined to do this. These scenarios exist. Some examples, acute and severe pain from an injury, surgery, or illness, "air hunger" in end-of-life care, spinal stenosis, sickle cell crisis...

But it seems obvious to me that we are inappropriately treating the problem of pain and creating problems instead of solutions by overprescribing opioids. This inappropriate treatment is creating a resultant problem of expensive, dangerous, and predictable opioid complications in our society... endorsed by physicians.

I have no intention to "under treat" pain, but rather try to look at the entire problem and scope of our definition of pain to try to more accurately and safely treat it without creating a public health disaster.

This is merely what I currently believe based on the information I have, what I have seen, and the way I feel about it...

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About morals, I know only that what is moral is what you feel good after and what is immoral is what you feel bad after.

Ernest Hemingway

All things truly wicked start from innocence.

Ernest Hemingway