I believe in evidence based practice. I have noticed some patients do respond positively to reasonably dosed opioids. I have never seen non-cancer patients respond long term to high dosed opioids. With that said, there is generally a lack of evidence that long term opioids make any positive difference in outcomes or functioning (ironically there is a lot of evidence that opioids cause a negative difference in some). If I am wrong, please point me to a paper that says otherwise. It has been studied and it has not been shown to do anything long-term. For that reason, it is my opinion that long term usage of opioids for pain should be abandoned for the vast majority of patients.
Additionally the morbidity and mortality for patients on opioid therapy in my first 15 yrs of practice was 10 times larger compared to anything else I do including invasive procedures at times.
I have largely abandoned opioids for chronic pain in the last 5 years and my patients are better for it. Those who have weaned are also happier in general.
There is data that a lot of patients have greater pain five years later than they would have if they were never on these meds because of hyperalgesia and other reasons. I personally don't think we are serving patients well in general by prescribing these drugs for chronic pain but everyone must look at evidence and do what they feel is right.
Those articles don't change anything. The first one pertains to cancer pain. The second concludes that opioids help in first 3 months which is in the acute pain period. Your articles offer no opinions about chronic non cancer pain which is the point of my post....but thanks for posting them.
I hav 45 years of experience using very long term opioids, at times in very high doses, in literally thousands of patients with remarkable improvement in function. And the full approval of federal agencies. Doctors are generally ignorant of this use of opioids because they are forbidden to use the medication. It’s methadone and although I was primarily treating opioid use disorder, 1/3 had chronic pain and at least 1/2 had co-occurring mental health diagnoses, all of which improved with methadone. The anti-opioid doctors just do not have a clue because they have no experience. Chronic pain patients who are forced to turn to illicit opioids can ironically actually get proper care in in methadone programs. It is a travesty that they have to take this bizarre route to care.
Dr Kertecz is a real medical hero who actually does ‘get it’ and has the courage to speak the truth to power
Addicted patients are certainly not the only people who can benefit from this opioid
Thank you for your response and I appreciate your thoughts. You are correct in stating that most doctors cannot by law treat patients for addiction. It takes a separate license in many states including my own even to prescribe buprenorphine for addiction (slowly changing).
With that said, it does not surprise me that you are seeing success in treating pain while treating the patient for addiction. What you are addressing is treatment of opioid-induced hyperalgesia (OIH). As you probably know, OIH is mediated by an NMDA pathway and methadone is an atypical opioid that does inhibit hyperalgesia through NMDA blockade. This phenomenon definitely occurs at lower dosages such as 20-30 mg per day but can occur at high dosages as you are describing. Ketamine and dextramethorphan also work on the NMDA receptor. Patient are noticing less pain primarily because their OIH is being addressed ad their opioids are paradoxically causing more pain.
Methadone should only be used by skilled and experienced clinicians, like yourself, because it can have side effects such as Torsades and can be overdosed inadvertently quite easily.
I am not saying that there are a few patients who may benefit but I still don't know of any well done (or even poorly done) clinical papers that says that opioids make a difference at all long term in patients. In my 20 years of practice, I have seen many patients on high dosed regimens such as fentanyl 100 ug, MSContin 60 mg bid, Oxycontin 40 mg tid, etc etc and I really cant remember one of these patients whose pain or function had improved versus not ever being on the medications. The vast majority still presented with pain scores greater than 7/10 even while on the medication.
The real questions that I ask is:
Is there clinical evidence that these medications help with long term pain and function? If a patient rates pain as 7/10 both on and off of the medication, should we be prescribing these medications at all in this situation? Would a patient be better off if they even lived with their pain or used some non-opioid therapy vs ever taking any of these medications.
I always keep an open mind but when I examine the current literature plus examine my own patient experience (which is extensive), I am led to the conclusion that patients are better off long term if they never have seen these medications. There may be exceptions but they are few..
Thank you, Stefan. Your TED talk was so logical. When large government agencies in the name of reform bully physicians into a societal goal removing incentive to treat individual patients for their clearly stated needs, we "hurt" patients. We certainly have lost a great deal in today's medicine with an over-emphasis on guidelines and an inattention to listening. I also recommend Paul Ramsey's sentinel book of almost 50 years ago, The Patient as Person.
I think there are some chronic illnesses which chronic opioids make more tolerable. This is an unpopular view.
My employer tolerates my chronic opioid prescribing for my primary care patients, but wishes I would refer them to pain clinics where they would have another monthly appointment and copay, and an additional prescriber messing with their med list. I worry that someday I will be asked to stop. Already, I feel inhibitted about asking for things that would make my life as an opioid prescribing primary care doc easier because I am afraid my clinic will make policy changes and I will have to stop or leave.
Speaking of those without power, people who are prescribed chronic opioids are often treated badly by pharmacists, emergency departments, doctors, etc. They usually do not wish to advocate publicly bc of fear of being called a drug addict and fear of being a crime victim. They are certainly disregarded by the medical system and society at large.
To me and many other long term pain patients like myself, you are heroic, you are our lifeline.
We’re stronger together-reach out if you ever feel the need to enter into community with patient advocates & physicians organizing, working, sharing, and supporting each other to restore pain care and put out the opiophobia forest fire set by some very unethical addiction psychiatrists & class-action lawyers (like RFK jr.).
As a current patient taking opioids for restless leg it’s nice to see this. When my hip was broken by cancer in 2022 I was prescribed extended release morphine tablets. I was terrified to take it because I thought morphine was the strongest opioid (LOL). It also made me feel like total crap. Ended up with 40+ tablets that I disposed of after they expired in 2023. I transitioned to oxycodone for acute pain when I could walk again and then after my hip replacement (I was 31, btw, not 80 so this was by no means “normal” with age). When I completely stopped taking them my restless leg suddenly got so bad. I had it prior to all of this but after my stint with high dose Yervoy my body was hit hard. Tried all 5 recommended drugs prior to being put back on oxycodone as all of them gave me horrible nausea, swelling , headaches, dizziness or didn’t work at all. It took a lot of googling to find the studies supporting the use of select opioids for RLS. I hate having to take them, but we’ve tried all but iron infusions (which I’m going to ask for next week) and I’m just hoping something else works. I hate being treated like a drug addict by nurses, doctors, and pharmacists. My current palliative care NP is fantastic and genuinely trying to help me instead of giving up.
I also know some people with chronic pain (one was crushed by a horse when younger) and they have the same issue. One of my previous palliative care doctors had a resident who I met with for the first time told me I would be tapering off starting that day and the plan was to get me completely off and I totally freaked out. That was while I was still in pain from cancer issues and it made no sense! My actual doctor came in afterwards looking confused and asked if I had asked to taper. When I told him what happened he was like “that makes more sense, if you’re still in pain you’re not ready to taper.” Thank goodness for doctors with an actual head on their shoulders.
It *can* be connected. But they don’t really understand all of the potential causes so everyone has different responses to treatment like that. For some people an iron supplement or magnesium supplement “cures” them. Then some others just massage their legs and take hot baths or exercise. Some take Gabapentin or dopamine agonist (I may be saying that wrong) and it works. Then people like me on opioids, (but not just any opioid, oxycodone seems most well established in studies) 🤷♀️ a big mystery overall since those are all so different.
I believe that Joint Commission played a big part in over prescribing. They were relentless in their insistence that we were letting patients suffer from pain, and went way overboard in monitoring notes and charts to push for more treatment.
Thanks for this interesting and thoughtful post. I agree that, while overprescription and fraud has been a problem, it is probably not the primary driver of the opioid crisis in the US. The medical profession has allowed politicians to demagogue and scapegoat physicians and Pharma over this problem. And despite major prescription reform, the public health problem of opioid overdose keeps getting worse.
The primary driver of the opioid crisis was the patent for OxyContin. Without the patent and the money that goes along with the patent…nobody in the pharmaceutical ecosystem has motive to push the opioid. Opioids have been around for thousands of years and everyone knew they were very addictive prior to the OxyContin patent. Btw, everyone knew cigarettes were addictive and the cigarette produced such huge profits that a new great American university could be established in Duke. And keep in mind Duke is the newest great American university and so if Silicon Valley has been making profits like cigarette companies then why haven’t Big Tech oligarchs endowed a new university with a $20 billion endowment along with a bucolic campus that would cost several billion dollars to develop??
So once the reason for the crisis has been established—$$$$—then cracking down on prescriptions ends up looking counterproductive because opioids didn’t cause the problem….greed caused the problem. And greed caused people to lie about cigarettes for decades.
Speaking as a recent patient, I feel there needs to be more nuance around this topic rather than blanket policies. I was recently hospitalized for blood clots including one that caused the majority of my spleen to be infarcted. It felt like I was being stabbed under the ribs. They gave me morphine in the ED and then oxy after I was admitted which was ultimately switched to Percocet because the oxy gave me a headache. The doctor explained that the pain could last a week or so. When it came time to discharge home, in addition to Eliquis, a 7 day supply of Percocet was ordered. When I arrived at the pharmacy they had readily filled the Eliquis but not the Percocet. I was told I would have to reach out to my doctor if I wanted it filled. I was tired, in pain, and just wanted to go home. I tried to manage with extra strength Tylenol but that wasn’t cutting it at all. I couldn’t sleep. I was finally able to get it filled and only ended up needing to take it twice. It was a week’s supply for an acute problem. I would have greatly preferred not to have had to jump through hoops and not to have been unnecessarily miserable for an extra day.
Here is a solution that is sure to inspire a lot of emotional response. Eliminate prescription drugs. Any adult can purchase any drug they choose. They may choose to consult a physician or not. This is not a random thought that just popped into my head. I have held this opinion through 40 years of medical practice and stand by it today. We had a "noble experiment" with legal prohibition of alcohol a hundred years ago and that worked out so badly that it had to be repealed. We have had a war on drugs for at least the last fifty years. How has that worked out for us?
Love starting over from scrap instead of trying to fix unfixable things.
Here one problem is that prescription also serves to manage the cost to patients of very expensive drugs.
Something which states could not afford if anyone could buy them at low prices. Though this could be easily fixed by transforming the prescription into such discount, approved by a physician.
The main problem is the externalities though.
We could subsidize addiction (in Switzerland they tried it, if I'm not wrong), but it doesn't look like a great project, neither ethically, nor economically in the long term.
Sorry to say that I don't understand what you are proposing here. Surely it is obvious that requiring a prescription raises the cost of drugs to consumers. Allowing people to obtain drugs without a prescription at market prices doesn't subsidize anything. The chief externality of drug legalization would be a very marked reduction in the crime rate---a positive in my opinion. Opting for individual liberty is always a good idea; both ethically and economically.
1) Simplifying rules is good. Eliminating bad rules is best.
2) Prescription allows necessary drugs to be covered by insurance which is important for poor people to afford necessary medications.
3) You could eliminate the barrier to access and still keep the discounted price option via a repurposed prescription.
4) But the main problem is that of the externalities: in particular if I had free access to legal opiates I'd like to have a trip every now and then, but others would end up becoming addicted which IMO is an induced pathology. I don't see any individual or societal benefit as relevant as this downside.
5) I'm for drug legalization but in a very specific & regulated way. Your expectation that allowing access to drug is simply going to improve crime rates is ill-advised: in many countries and areas there is practically no enforcement for drug crimes and yet crime rates are high. To decrease crime rates related to drug addiction you have to subsidize it, which isn't ok.
6) "Individual liberty" as a general principle ("always") is naive from many points of view. The main one: laws and liberty are in conflict; when is one more important than the other?
We would have to make it illegal for big pharma to advertise. They are there to convince everyone that they need their drugs for everything real and pretend. They would use their propaganda to influence poor choices for profit.
Advertising is not mind control even though trial lawyers love to claim we-and even our physicians-are too stupid Or spineless to resist its hypnosis.
Not that I disagree with your premise pharmaceutical companies should not be advertising. It’s ridiculous we treat this like it’s rocket science and we’ve never chosen to limit who may advertise or not before.
All advertising is propaganda. There is little hope for those naive enough to take it at face value. Violating free speech starts us down the steep slope to tyranny as we have seen over the past few years.
Somehow, that suggestion doesn't seem rational to me! Our specialty is understanding medicines, how to dose, watch for interactions, etc - that is a complex proposition. To have people go on autopiolot doesn't make much sense. There is probably a whole host of medications that could be completely OTC - but certainly not all. And as people age and poly pharmacy comes into play, self prescribing makes even less sense. Trying to equate prescription drugs with alcohol or drugs of abuse also doesn't make much sense.
If anyone wants to see what happens when we "decriminalize" street drugs, see what has happened to Portland, OR. did not go well.
That is why I wrote "They may choose to consult a physician or not." I don't see a link between the happenings in Portland and the legalization of street drugs. People on street drugs cannot even organize a trip to the bathroom much less a full blown riot. What they actually do is commit crimes against innocent victims in order to get the money to afford drugs that are massively overpriced due to their illegality. Didn't the police stand back and watch one of their stationhouses get torched? I think the problems in Portland go way deeper than drug legalization.
I knew we were in trouble when in 1994 the California legislature mandated for the first time a specific topic for all physicians’ continuing education. That topic, of course, was pain management. Many or most of the instructors for these courses were shills for Purdue pharma. The lectures could have been written by their marketing department. We have paid the price for this disastrous legislation.
Pain as a vital sign is still very much alive in hospitals, so much so that nothing will get a nurse fired faster than a patient complaining their pain wasn't addressed fast enough, or eliminated. Managers chart daily patient pain scores and their 1 hour intervention reassessment, and inadequate pain control is a "black mark" on performance reviews. Even a patient you have to sternal rub to get them awake and states their pain is a 10 must have their pain addressed. Patients accustomed to the medical regime have come to expect a totally pain free existence, and the chase to achieve it. Our pediatrician's office used to have a sign that read, "you have a RIGHT to have your pain addressed". No idea if it is still there, my kids are grown now.
Once JCACHO/CMS stops mandating a perfect 0 on patient's self reported pain scores, it will go a long way toward achieving a decrease in opioid use..
Good point. Pain focus is still there, but now we've added asking everybody about depression and anxiety, with the medical "establishment" telling medical providers that people now have a right to have these issues addressed and controlled.
* What happened to the WHO ladder of pain management? Starting out with NSAIDs is best practice, but at some point those NSAIDs become adjuvants when opioids are introduced
* How are the FLACC and numeric scales for deducing pain levels of any value? Aren't we taught pain is subjective and it's whatever the patient says it is? I know I cry (somewhat exaggerated) when I get an ingrown toe nail and my daughter doesn't flinch after having total top teeth removal surgery). Don't ask me what my pain level is via numbers, you won't understand it.
* I haven't known a pain clinic yet that can manage pain any where near as well as a hospice medical director and his nurses.
* I rarely hear of anyone getting "rebooted" on their pain management. After years-long dependency on opioids due to chronic back pain, don't the medications lose some of their efficacy? Was it once or is it still a practice of medically removing all analgesics and starting again?
* Stand up for what you believe or know to be true despite who is offended. I've always done that and it has cost me dearly over the years - but I sleep well at night.
Fully agree. And I am from a generation that gave outpatients an oral narcotic only if the patient was dying of a very painful cancer. They’re lousy pain pills. But once one is eniured to them you’re choices are limited.
My long termers are model patients. Some a bit of a pain but better me than a pill mill or the street.
Those articles don't change anything.
One article looks at cancer pain. The second concludes that opioids can help for 3 months which is still in the definition of acute pain.
Those studies offer no implications on chronic non cancer pain which was the point of my post....but thanks for posting them.
OIH: Myth vs Fact
https://drive.google.com/file/d/1AXEzdihxeRku3htooF8RUDLXVrp2PVAw/view?usp=drivesdk
I believe in evidence based practice. I have noticed some patients do respond positively to reasonably dosed opioids. I have never seen non-cancer patients respond long term to high dosed opioids. With that said, there is generally a lack of evidence that long term opioids make any positive difference in outcomes or functioning (ironically there is a lot of evidence that opioids cause a negative difference in some). If I am wrong, please point me to a paper that says otherwise. It has been studied and it has not been shown to do anything long-term. For that reason, it is my opinion that long term usage of opioids for pain should be abandoned for the vast majority of patients.
Here’s 2:
https://www.liebertpub.com/doi/10.1089/jpm.2023.0251
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5939920/
Additionally the morbidity and mortality for patients on opioid therapy in my first 15 yrs of practice was 10 times larger compared to anything else I do including invasive procedures at times.
I have largely abandoned opioids for chronic pain in the last 5 years and my patients are better for it. Those who have weaned are also happier in general.
There is data that a lot of patients have greater pain five years later than they would have if they were never on these meds because of hyperalgesia and other reasons. I personally don't think we are serving patients well in general by prescribing these drugs for chronic pain but everyone must look at evidence and do what they feel is right.
Just do no harm...
Those articles don't change anything. The first one pertains to cancer pain. The second concludes that opioids help in first 3 months which is in the acute pain period. Your articles offer no opinions about chronic non cancer pain which is the point of my post....but thanks for posting them.
I hav 45 years of experience using very long term opioids, at times in very high doses, in literally thousands of patients with remarkable improvement in function. And the full approval of federal agencies. Doctors are generally ignorant of this use of opioids because they are forbidden to use the medication. It’s methadone and although I was primarily treating opioid use disorder, 1/3 had chronic pain and at least 1/2 had co-occurring mental health diagnoses, all of which improved with methadone. The anti-opioid doctors just do not have a clue because they have no experience. Chronic pain patients who are forced to turn to illicit opioids can ironically actually get proper care in in methadone programs. It is a travesty that they have to take this bizarre route to care.
Dr Kertecz is a real medical hero who actually does ‘get it’ and has the courage to speak the truth to power
Addicted patients are certainly not the only people who can benefit from this opioid
Dr John McCarthy
Assistant Professor of Psychiatry
University of California Davis
Dr. McCarthy,
Thank you for your response and I appreciate your thoughts. You are correct in stating that most doctors cannot by law treat patients for addiction. It takes a separate license in many states including my own even to prescribe buprenorphine for addiction (slowly changing).
With that said, it does not surprise me that you are seeing success in treating pain while treating the patient for addiction. What you are addressing is treatment of opioid-induced hyperalgesia (OIH). As you probably know, OIH is mediated by an NMDA pathway and methadone is an atypical opioid that does inhibit hyperalgesia through NMDA blockade. This phenomenon definitely occurs at lower dosages such as 20-30 mg per day but can occur at high dosages as you are describing. Ketamine and dextramethorphan also work on the NMDA receptor. Patient are noticing less pain primarily because their OIH is being addressed ad their opioids are paradoxically causing more pain.
Methadone should only be used by skilled and experienced clinicians, like yourself, because it can have side effects such as Torsades and can be overdosed inadvertently quite easily.
I am not saying that there are a few patients who may benefit but I still don't know of any well done (or even poorly done) clinical papers that says that opioids make a difference at all long term in patients. In my 20 years of practice, I have seen many patients on high dosed regimens such as fentanyl 100 ug, MSContin 60 mg bid, Oxycontin 40 mg tid, etc etc and I really cant remember one of these patients whose pain or function had improved versus not ever being on the medications. The vast majority still presented with pain scores greater than 7/10 even while on the medication.
The real questions that I ask is:
Is there clinical evidence that these medications help with long term pain and function? If a patient rates pain as 7/10 both on and off of the medication, should we be prescribing these medications at all in this situation? Would a patient be better off if they even lived with their pain or used some non-opioid therapy vs ever taking any of these medications.
I always keep an open mind but when I examine the current literature plus examine my own patient experience (which is extensive), I am led to the conclusion that patients are better off long term if they never have seen these medications. There may be exceptions but they are few..
Eric Miller, M.D.
Thank you, Stefan. Your TED talk was so logical. When large government agencies in the name of reform bully physicians into a societal goal removing incentive to treat individual patients for their clearly stated needs, we "hurt" patients. We certainly have lost a great deal in today's medicine with an over-emphasis on guidelines and an inattention to listening. I also recommend Paul Ramsey's sentinel book of almost 50 years ago, The Patient as Person.
I think there are some chronic illnesses which chronic opioids make more tolerable. This is an unpopular view.
My employer tolerates my chronic opioid prescribing for my primary care patients, but wishes I would refer them to pain clinics where they would have another monthly appointment and copay, and an additional prescriber messing with their med list. I worry that someday I will be asked to stop. Already, I feel inhibitted about asking for things that would make my life as an opioid prescribing primary care doc easier because I am afraid my clinic will make policy changes and I will have to stop or leave.
Speaking of those without power, people who are prescribed chronic opioids are often treated badly by pharmacists, emergency departments, doctors, etc. They usually do not wish to advocate publicly bc of fear of being called a drug addict and fear of being a crime victim. They are certainly disregarded by the medical system and society at large.
To me and many other long term pain patients like myself, you are heroic, you are our lifeline.
We’re stronger together-reach out if you ever feel the need to enter into community with patient advocates & physicians organizing, working, sharing, and supporting each other to restore pain care and put out the opiophobia forest fire set by some very unethical addiction psychiatrists & class-action lawyers (like RFK jr.).
🖤
As a current patient taking opioids for restless leg it’s nice to see this. When my hip was broken by cancer in 2022 I was prescribed extended release morphine tablets. I was terrified to take it because I thought morphine was the strongest opioid (LOL). It also made me feel like total crap. Ended up with 40+ tablets that I disposed of after they expired in 2023. I transitioned to oxycodone for acute pain when I could walk again and then after my hip replacement (I was 31, btw, not 80 so this was by no means “normal” with age). When I completely stopped taking them my restless leg suddenly got so bad. I had it prior to all of this but after my stint with high dose Yervoy my body was hit hard. Tried all 5 recommended drugs prior to being put back on oxycodone as all of them gave me horrible nausea, swelling , headaches, dizziness or didn’t work at all. It took a lot of googling to find the studies supporting the use of select opioids for RLS. I hate having to take them, but we’ve tried all but iron infusions (which I’m going to ask for next week) and I’m just hoping something else works. I hate being treated like a drug addict by nurses, doctors, and pharmacists. My current palliative care NP is fantastic and genuinely trying to help me instead of giving up.
I also know some people with chronic pain (one was crushed by a horse when younger) and they have the same issue. One of my previous palliative care doctors had a resident who I met with for the first time told me I would be tapering off starting that day and the plan was to get me completely off and I totally freaked out. That was while I was still in pain from cancer issues and it made no sense! My actual doctor came in afterwards looking confused and asked if I had asked to taper. When I told him what happened he was like “that makes more sense, if you’re still in pain you’re not ready to taper.” Thank goodness for doctors with an actual head on their shoulders.
I get the magnesium link. I actually never considered that. But a lot of people are magnesium deficient and our food supply is as well. Interesting.
I hadn't heard this... Low iron and RLS have a connection?
It *can* be connected. But they don’t really understand all of the potential causes so everyone has different responses to treatment like that. For some people an iron supplement or magnesium supplement “cures” them. Then some others just massage their legs and take hot baths or exercise. Some take Gabapentin or dopamine agonist (I may be saying that wrong) and it works. Then people like me on opioids, (but not just any opioid, oxycodone seems most well established in studies) 🤷♀️ a big mystery overall since those are all so different.
So important! What can be done to make all of us MDs less sheepish?
I believe that Joint Commission played a big part in over prescribing. They were relentless in their insistence that we were letting patients suffer from pain, and went way overboard in monitoring notes and charts to push for more treatment.
Thanks for this interesting and thoughtful post. I agree that, while overprescription and fraud has been a problem, it is probably not the primary driver of the opioid crisis in the US. The medical profession has allowed politicians to demagogue and scapegoat physicians and Pharma over this problem. And despite major prescription reform, the public health problem of opioid overdose keeps getting worse.
The primary driver of the opioid crisis was the patent for OxyContin. Without the patent and the money that goes along with the patent…nobody in the pharmaceutical ecosystem has motive to push the opioid. Opioids have been around for thousands of years and everyone knew they were very addictive prior to the OxyContin patent. Btw, everyone knew cigarettes were addictive and the cigarette produced such huge profits that a new great American university could be established in Duke. And keep in mind Duke is the newest great American university and so if Silicon Valley has been making profits like cigarette companies then why haven’t Big Tech oligarchs endowed a new university with a $20 billion endowment along with a bucolic campus that would cost several billion dollars to develop??
So once the reason for the crisis has been established—$$$$—then cracking down on prescriptions ends up looking counterproductive because opioids didn’t cause the problem….greed caused the problem. And greed caused people to lie about cigarettes for decades.
Speaking as a recent patient, I feel there needs to be more nuance around this topic rather than blanket policies. I was recently hospitalized for blood clots including one that caused the majority of my spleen to be infarcted. It felt like I was being stabbed under the ribs. They gave me morphine in the ED and then oxy after I was admitted which was ultimately switched to Percocet because the oxy gave me a headache. The doctor explained that the pain could last a week or so. When it came time to discharge home, in addition to Eliquis, a 7 day supply of Percocet was ordered. When I arrived at the pharmacy they had readily filled the Eliquis but not the Percocet. I was told I would have to reach out to my doctor if I wanted it filled. I was tired, in pain, and just wanted to go home. I tried to manage with extra strength Tylenol but that wasn’t cutting it at all. I couldn’t sleep. I was finally able to get it filled and only ended up needing to take it twice. It was a week’s supply for an acute problem. I would have greatly preferred not to have had to jump through hoops and not to have been unnecessarily miserable for an extra day.
Here is a solution that is sure to inspire a lot of emotional response. Eliminate prescription drugs. Any adult can purchase any drug they choose. They may choose to consult a physician or not. This is not a random thought that just popped into my head. I have held this opinion through 40 years of medical practice and stand by it today. We had a "noble experiment" with legal prohibition of alcohol a hundred years ago and that worked out so badly that it had to be repealed. We have had a war on drugs for at least the last fifty years. How has that worked out for us?
Love starting over from scrap instead of trying to fix unfixable things.
Here one problem is that prescription also serves to manage the cost to patients of very expensive drugs.
Something which states could not afford if anyone could buy them at low prices. Though this could be easily fixed by transforming the prescription into such discount, approved by a physician.
The main problem is the externalities though.
We could subsidize addiction (in Switzerland they tried it, if I'm not wrong), but it doesn't look like a great project, neither ethically, nor economically in the long term.
Sorry to say that I don't understand what you are proposing here. Surely it is obvious that requiring a prescription raises the cost of drugs to consumers. Allowing people to obtain drugs without a prescription at market prices doesn't subsidize anything. The chief externality of drug legalization would be a very marked reduction in the crime rate---a positive in my opinion. Opting for individual liberty is always a good idea; both ethically and economically.
1) Simplifying rules is good. Eliminating bad rules is best.
2) Prescription allows necessary drugs to be covered by insurance which is important for poor people to afford necessary medications.
3) You could eliminate the barrier to access and still keep the discounted price option via a repurposed prescription.
4) But the main problem is that of the externalities: in particular if I had free access to legal opiates I'd like to have a trip every now and then, but others would end up becoming addicted which IMO is an induced pathology. I don't see any individual or societal benefit as relevant as this downside.
5) I'm for drug legalization but in a very specific & regulated way. Your expectation that allowing access to drug is simply going to improve crime rates is ill-advised: in many countries and areas there is practically no enforcement for drug crimes and yet crime rates are high. To decrease crime rates related to drug addiction you have to subsidize it, which isn't ok.
6) "Individual liberty" as a general principle ("always") is naive from many points of view. The main one: laws and liberty are in conflict; when is one more important than the other?
We would have to make it illegal for big pharma to advertise. They are there to convince everyone that they need their drugs for everything real and pretend. They would use their propaganda to influence poor choices for profit.
Advertising is not mind control even though trial lawyers love to claim we-and even our physicians-are too stupid Or spineless to resist its hypnosis.
Not that I disagree with your premise pharmaceutical companies should not be advertising. It’s ridiculous we treat this like it’s rocket science and we’ve never chosen to limit who may advertise or not before.
🖤
All advertising is propaganda. There is little hope for those naive enough to take it at face value. Violating free speech starts us down the steep slope to tyranny as we have seen over the past few years.
Somehow, that suggestion doesn't seem rational to me! Our specialty is understanding medicines, how to dose, watch for interactions, etc - that is a complex proposition. To have people go on autopiolot doesn't make much sense. There is probably a whole host of medications that could be completely OTC - but certainly not all. And as people age and poly pharmacy comes into play, self prescribing makes even less sense. Trying to equate prescription drugs with alcohol or drugs of abuse also doesn't make much sense.
If anyone wants to see what happens when we "decriminalize" street drugs, see what has happened to Portland, OR. did not go well.
That is why I wrote "They may choose to consult a physician or not." I don't see a link between the happenings in Portland and the legalization of street drugs. People on street drugs cannot even organize a trip to the bathroom much less a full blown riot. What they actually do is commit crimes against innocent victims in order to get the money to afford drugs that are massively overpriced due to their illegality. Didn't the police stand back and watch one of their stationhouses get torched? I think the problems in Portland go way deeper than drug legalization.
I knew we were in trouble when in 1994 the California legislature mandated for the first time a specific topic for all physicians’ continuing education. That topic, of course, was pain management. Many or most of the instructors for these courses were shills for Purdue pharma. The lectures could have been written by their marketing department. We have paid the price for this disastrous legislation.
Nice article.
My 2 sociological cents: how can a society thrive when, whatever you do, you are under the suspicion that you're acting under a conflict of interests?
The point is that in our society this distrust is completely justified.
This is THE problem. Though not a strictly health related problem.
Pain as a vital sign is still very much alive in hospitals, so much so that nothing will get a nurse fired faster than a patient complaining their pain wasn't addressed fast enough, or eliminated. Managers chart daily patient pain scores and their 1 hour intervention reassessment, and inadequate pain control is a "black mark" on performance reviews. Even a patient you have to sternal rub to get them awake and states their pain is a 10 must have their pain addressed. Patients accustomed to the medical regime have come to expect a totally pain free existence, and the chase to achieve it. Our pediatrician's office used to have a sign that read, "you have a RIGHT to have your pain addressed". No idea if it is still there, my kids are grown now.
Once JCACHO/CMS stops mandating a perfect 0 on patient's self reported pain scores, it will go a long way toward achieving a decrease in opioid use..
Good point. Pain focus is still there, but now we've added asking everybody about depression and anxiety, with the medical "establishment" telling medical providers that people now have a right to have these issues addressed and controlled.
Great article. Brings to mind:
* What happened to the WHO ladder of pain management? Starting out with NSAIDs is best practice, but at some point those NSAIDs become adjuvants when opioids are introduced
* How are the FLACC and numeric scales for deducing pain levels of any value? Aren't we taught pain is subjective and it's whatever the patient says it is? I know I cry (somewhat exaggerated) when I get an ingrown toe nail and my daughter doesn't flinch after having total top teeth removal surgery). Don't ask me what my pain level is via numbers, you won't understand it.
* I haven't known a pain clinic yet that can manage pain any where near as well as a hospice medical director and his nurses.
* I rarely hear of anyone getting "rebooted" on their pain management. After years-long dependency on opioids due to chronic back pain, don't the medications lose some of their efficacy? Was it once or is it still a practice of medically removing all analgesics and starting again?
* Stand up for what you believe or know to be true despite who is offended. I've always done that and it has cost me dearly over the years - but I sleep well at night.
Fully agree. And I am from a generation that gave outpatients an oral narcotic only if the patient was dying of a very painful cancer. They’re lousy pain pills. But once one is eniured to them you’re choices are limited.
My long termers are model patients. Some a bit of a pain but better me than a pill mill or the street.