Monday, June 13, 2016

The back and forth pendulum swing of narcotic pain-killer use.

The story of Prince being found to have died due to an overdose of fentanyl is reflective of narcotic pain killer use in our country.

I say our country because the U.S. represents less than 5% of the world's population but uses over 95% of its narcotic pain-killers.  I think it's unlikely that we have 95% of the world's physical pain.

Not long ago, pain-killers such as morphine, Demerol, Dilaudid, Percocet or Vicodin were pretty much only used right after a surgery or in people dying of cancer.  Prescribing these medications for long periods of time was very much frowned upon and could result in doctors coming under investigation or prosecution for over-prescribing them if complaints arose from families, pharmacies or other doctors.

Some time in the late 1990's, the pendulum swung fully in the opposite direction.  The above link does a pretty decent job of describing it.  In California, doctors were required to take a course covering this change: pain was "the fifth vital sign", pain-killer addiction was rare, tolerance to them uncommon, and patients reporting more pain were to be assumed to be suffering a worsening in their condition (as opposed to narcotic pain-killer tolerance or addiction).  Along with this, there were a number of laws, regulations or legal precedents requiring doctors to prescribe the perfectly right amount of narcotics or risk sanctions and lawsuits.  Doctors got found against for over-use and also for under-use, or for not referring patients to doctors who would prescribe pain-killers.  A surgeon on a widely read medical website shares his recollections of these times, too.

At this point, it is fair to say that this didn't work out as intended.  And mind you, intentions were good.  Chronic pain not related to cancer exists, and no one liked to see people suffering with it.

It was certainly a tipping point when Purdue Pharma developed and heavily marketed OxyContin.  I remember  a pharmacist from a big hospital center in Seattle giving a presentation on it to doctors at Marshall right after the FDA approved it.  It was touted as being a slowly released, long acting, abuse-proof non-addictive 12-hour narcotic pain killer.  It was sold as being insoluble with water so could not be injected, and providing good pain relief with only two doses a day.  Turns out, none of these statements are true.  It didn't take long for people to realize that injecting it for a fast high was impossible, but smashing it and snorting it worked just fine.  Worse yet, the pills in no way lasted 12 hours; more like 8 hours.  Worst of all, Purdue Pharma knew this, but lied.  They knew that doctors would be a lot less likely to prescribe a medication that had to be taken every 8 hours to work.  Only now are they admitting to this fraud.

Certainly, narcotic pain medications have a role in the treatment of acute and chronic pain.  It is simply time for the pendulum to swing back to a reasonable point somewhere in the middle.

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