Our 25-year-old nephew passed away last week. He had been fighting an addiction to prescription opiates for some time, and despite great efforts on the part of himself and his family, he died. I've written about this on my own blog.
His death has caused me to reflect on my own role in the larger problem. It has brought home an ugly issue that we all, as prescribing physicians and mothers, should reflect on.
When I first started as an attending in our small internal medicine practice, I learned to dread one aspect of the call more than any other: dealing with the requests for narcotics prescription refills.
We take a week of call at a time, and call starts Friday at 8 a.m. Friday afternoon call would roll around, and so would the requests. Not hundreds, and not always, but very commonly, one to five requests.
There was a pattern: usually someone was requesting a refill early, with a story about how the original prescription had been lost, or stolen, or left in the glove compartment of the rental car they were driving while their car was being fixed but now the rental car was re-rented and the prescription was gone (true story). Or they had used more than was originally prescribed because they had had a particularly bad flare of back pain/ knee pain/ fibromyalgia secondary to a new injury or stressful event of some kind. Typically there would also be a mention in there of a sick child, a recent family death, a failed marriage, or a lost job. Usually the prescribing doctor or PCP was not readily available, and usually the electronic medical record showed a history of similar weekend early refill requests with notes like, "Filled amount for just a few days until PCP returns" or "Rx sent with no refills with instruction to f/u with PCP". And I usually did the same. (Except sometimes when I was really peeved).
Why didn't I (and we) generally refuse to fill these? Because you could put someone into serious withdrawal if they suddenly stopped their Oxycodone 20 mg three times a day. And if the medication was truly needed for pain, it would be cruel not to provide it, and you just never really knew. In addition, to outright deny these requests could be construed as sort of a slap in the face of the prescribing PCP, my (senior) colleague, thereby questioning their medical judgment in writing this prescription in the first place. And, honestly, a huge time suck as well, as if I were to refuse, I would need to spend so much more time dealing with the mess then if I just gave the patient a few, just to get through a few days until the PCP returned or the office reopened.
Luckily, soon after I was hired, more stringent prescribing standards were encouraged, and then, within the past few years and even months, actual legislation has emerged to practically help us physicians to deal with narcotics prescriptions. Pharmacies cannot accept phone orders for refills, and patients must have a signed hard copy of the narcotic prescription. Weekend phone call refills are no longer even possible. Pharmacies' databases are now linked up so that patients cannot use more than one pharmacy to fill these types of prescriptions. We have directives from our hospital to meet with all of our patients who are on any chronic narcotics, review a Pain Medication Contract, have them sign it, and then test their urine for the specific pain drug as well as for illicit substances.
Because we are in an epidemic.
All sorts of people are getting high on these prescription opiates. I see prescriptions for #90, #120, even #180 of 5 mg oxycodone. I've seen prescriptions for more. If someone or their family member is diverting even a few of those on a regular basis, it's enough to get others hooked.
Diversion is tempting. It's a good income. A Google search right now says that Oxycodone is worth about one to three dollars per milligram on the street, so that 5 mg tablet has a street value of at least five and perhaps fifteen dollars. If someone has a bottle of 180 tablets? Whoa.
Opiates are extremely physically addictive. And lives are crushed by addiction.
Physicians have a wide range of practice habits and comfort levels. Me, especially when I first started, I had zero comfort level with narcotics. Unless a patient just had major surgery or had metastatic cancer, I was NOT going to prescribe a narcotic at all, never mind chronically, long-term.
Now, honestly, I'm comfortable with these prescriptions, under certain circumstances. Surprisingly, in my own practice, most of the people I have started on narcotics (who hadn't had major surgery and didn't have metastatic cancer) are my very elderly ladies with bad arthritis who can't take anti-inflammatories (like Ibuprofen and those meds) and are maxed out on things like Tylenol, Lidoderm patches and Capsaicin cream. And so, yes, I do have a handful of patients who take Oxycodone 2.5 or 5 mg once or twice a day for breakthrough arthritis pain. Most of them walk with a cane, and I hope that their grandchildren aren't pilfering.
Then, I inherited a panel of patients on larger doses of an assortment of controlled substances, and I am currently struggling with these cases. I'm using laws and hospital guidelines as best I can to get a handle on things... it's a discomfort zone. My gut feeling is that some, probably a very small number, of these patients are sharing or even distributing these medications. But without obvious red flags or violations of the Pain Medication Contract, such as a urine screen negative for the prescribed medication and/or positive for an illicit substance, I cannot, in good conscience, refuse to prescribe.
In my own practice, I have tried to shift people towards alternative pain management, like healthy living, physical activity and physical therapy, acupuncture, yoga, massage... I really believe that a low-carbohydrate diet and regular exercise helps to reduce overall inflammation and decrease pain perception. This is not going to work for bone-on-bone arthritis, I am aware of that. But for low back pain and fibromyalgia sufferers, I give it a hard sell.
I'm curious to hear what are the thoughts and experiences of other physicians on this issue...