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Narcotics

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Letter to Patients Regarding Pain Medications

It is one of the biggest struggles and least favorite areas of being a doctor, yet it is something I see far too much: patients taking short-acting narcotic pain medications for chronic pain.  There is a degree to which it a good thing, allowing people to get regular prescriptions of smaller amounts of pain medication to use for increases from their background pain; but far too many of them call for their prescriptions on the month, often asking for a little bit more this month because of increased pain. Many doctors see these people as "drug-seekers" - a description with a very bad connotation, implying that the medication is central, not the pain.  While I know there are drug-seekers out there, many of whom feign pain so they can get prescriptions and then make money selling it, there are also a lot of people with bad pain who want to escape.  In fact, I try to make that number 100%, as I want nobody lying to me to get medications they don't need or use.  Those phone calls every month for narcotics, often trying to get it a little early, get a stronger dose, or get more in each prescription, I think are people who really hurt and really think they need the medication.

But short-acting medications are a deal with the devil when used regularly for chronic pain.  They create more problems and much, much bigger problems than they treat.  So in response to this, I am starting to send the following letter to my patients who are using medications like this on a regular basis:

Dear <Patient>

I am sending this letter to patients who are using narcotic pain medications on a regular basis for chronic pain.  I am doing so, not as an accusation or a sermon, but to educate you as to the reasons use of medications in this setting is not only risky, it almost always will cause problems down the road when used for a chronic problem.  This also does not imply that I will not give prescriptions for these medications when you need them.  I will give pain medication for appropriate pain, but I will also do everything possible to minimize the use of short-acting pain medications.  What follows is an explanation as to why I think this is so important.

Chronic pain is pain that lasts for a long time - more than a month.  While it is OK to use short-acting pain medications (like hydrocodone or oxycodone) for short-lived pain (like that from an injury), it is not good use them regularly in long-term pain. •    It may work for a short while, but the body develops a tolerance, requiring the dose to go up to get the same effect. •    Going up on the dose will only work for a while, and then an even higher dose is required. •    Eventually the person with chronic pain will require very high doses of narcotic to get even a modest effect. •    Being at high doses like this comes at a cost: withdrawal.  A person on high-dose narcotics (especially short-acting ones) will always cause withdrawal when the medication is stopped.  Withdrawal from narcotics is far worse than the pain for which the medications were given. •    To avoid withdrawal, the person on short-acting narcotics must continue taking the medication, creating a dependency on the drug that is hard to escape, while at the same time offering little pain relief.  It’s a horrible trap. •    Additionally, patients who take large amounts of narcotics are often labelled as a “drug seeker” by any new doctor they see or hospital they visit.  If this happens, it is much less likely the person will be taken seriously by the medical professionals. •    Finally, the doctor prescribing pain medications in large quantities puts his/her career at risk by doing so.  Careless prescription writing invites abuse by patients - something that can cause a doctor’s license to practice medicine to be taken away, and may even result in criminal charges. It is good to be concerned about a person’s pain, prescribing short-acting pain medication for chronic pain only promises to add a new problem to the picture: dependency and addiction.  The life of a person with chronic pain is bad enough without the dependency on narcotics, so the use of these medications except on an “as needed” basis for break-through pain is to be avoided.

Can anything be done for the person with chronic pain?  Yes, but the expectation should not be that the pain will be eliminated; it will only be reduced.  Here are ways to deal with chronic pain without the regular use of short-acting narcotics: •    Some antidepressants and seizure medications can reduce the overall need for pain medication. •    Treating the underlying problem (back surgery, for example) can reduce pain. •    Injections of cortisone or local anesthetics, as well as procedures done to block pain by pain specialists can help in certain circumstances. •    Long-acting narcotics (like Oxycontin, MS-Contin, or Duragesic/Fentanyl patches) can be used to lower the overall pain level, allowing short-acting medications to be only used as needed for breakthrough pain.  This is much less likely to cause dependency, relieves pain better than short-acting medications alone, and uses less medication in the process.  These do, however, put the person at risk for withdrawal symptoms if stopped suddenly.

If none of these work?  The sad answer to that is that the person will have to live with the pain.  Adding short-acting medication may offer short-term relief from the pain, but the long-term problems it inflicts are far worse than any benefit they have.

I hope this helps you.  I always want to have my patients feel the least amount of pain possible, but there are some things that may seem like they help in the short-term, but really cause problems much larger than the original pain.  I will work with you to find ways to minimize the need for these medications.  You should do everything you can to use them sparingly.

Again, I am happy to take care of you, and this letter is an attempt to give you the best care I can.

Sincerely:

Robert Lamberts, MD

I don't want my patients to hurt, but I also don't want to be party to hurting them more - even with the best of intent.  I hope this letter helps them see.  I hate to tell some people that they just have to feel pain, but unfortunately that is usually a better option than these medications.

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Narcotics

drug_addictIf you do much reading of medical blogs, you will come across the word narcotics a lot.  Much of the lives of physicians (including myself) deal with medications, and a good portion of these drugs are controlled substances. It occurred to me that many readers might not know what narcotics and controlled substances are.  The term narcotic for many people brings to mind the image of a junkie on the street or someone who is addicted to prescription drugs.  So I thought it would be helpful to many for me to give an overview of narcotic drugs, as well as other controlled substances - discussing their appropriate and inappropriate use.  I will also touch on the concepts of addiction and chemical dependency - as they are obviously closely related to these drugs. Narcotics

Wikipedia defines narcotic as follows:

The term narcotic is believed to have been coined by the Greek physician Galen to refer to agents that benumb or deaden, causing loss of feeling or paralysis. It is based on the Greek word narcosis, the term used by Hippocrates for the process of benumbing or the benumbed state. Galen listed mandrake root, altercus (eclata) seeds, and poppy juice (opium) as the chief examples.

In U.S. legal context, narcotic refers to opium, opium derivatives, and their semi-synthetic or fully synthetic substitutes "as well as cocaine and coca leaves," which although classified as "narcotics" in the U.S. Controlled Substances Act (CSA), are chemically not narcotics. Contrary to popular belief, marijuana is not a narcotic, nor are LSD and other psychedelic drugs.

So basically a narcotic is a medication which alters the consciousness of the person taking it.  The term is used by many medical professionals synonymously with the term controlled substance.  When I use the word narcotic, I generally include the following classes of medications:

  • Opioids - Potent pain medications, drugs in this class include Morphine, Dilaudid, Fentanyl (Duragesic), Oxycodone (Percocet, Oxycontin), Meperidine (Demerol), Hydrocodone (Lortab, Vicodin), Codeine, and Propoxyphene (Darvocet).
  • Benzodiazapenes - "Tranquilizer" medications, generally used to treat anxiety.  Common drugs in this group include Diazepam (Valium), Lorazepam (Ativan), Clonazepam (Klonapin), Alprazolam (Xanax).
  • Barbiturates - These are prescribed infrequently - used to treat epilepsy and are also somewhat sedating.  The main drug still used in this class is Phenobarbital
  • Amphetamines - These are stimulant drugs, generally used for attention deficit disorder, although they have been used to help weight loss in the past.  Drugs in this class include Methylphenidate (Ritalin, Concerta, Focalin), Dexamphetamine (Dexadrin), and Amphetamine Salts (Adderal, Vyvanse).

This list is not meant to be exhaustive; I just put what I encounter most commonly.

Controlled Substances

So what about controlled substances?  The term comes from the Controlled Substances Act (a US law passed in 1969) in which potentially abused drugs were controlled to varying degrees.  These levels are called schedules, and each schedule carries its own set of rules as to how these medications can be prescribed.  The schedules are as follows:

  • Schedule 1 - These drugs are illegal to prescribe (except with DEA permission) because, in large part, of their high addiction potential and low medicinal benefit.  Drugs such as Heroin, LSD, and (to some people's consternation) Marijuana.
  • Schedule 2 - These drugs can be prescribed by professionals approved by the FDA to do so.  They carry significant abuse potential, and so have significant restrictions on how they can be prescribed.  For instance, they cannot be called in or sent electronically and cannot have refills.  Recently they have required the use of special (expensive) paper with these prescriptions, and many states require the use of a "triplicate" form for prescriptions.  The main Schedule 2 drugs I prescribe are ADD meds (Ritalin, Aderall, etc.), and pain medications (Duragesic, Oxycodone).
  • Schedule 3  - These drugs are "weaker" and overall have a somewhat lower abuse potential (although I am not sure how they made that decision).  We can call in and fax these drugs (but for some reason e-prescribing isn't allowed), and they can be given with refills up to 6 months.  Drugs on this list include anabolic steroids (testosterone preparations), as well as pain medications (Lortab).
  • Schedule 4 - Supposedly lower abuse potential than schedule 3, but the medications of this class are some of the more commonly abused prescription drugs (such as Xanax, Valium, Ativan).  Sleep medications (Ambien) and weaker pain medications (Darvocet) are also in this class.  The rules for prescription are the same as schedule 3 (generally).
  • Schedule 5 - Lowest abuse potential - includes cough medications with codeine, and (for some reason), Lyrica - the seizure medication used for fibromyalgia.

The significance of this drug schedule lies in the legal repercussions if they are distributed in an illegal manner.   Prescribing them in a way that does not adhere to the Controlled Substances Act or giving them in an irresponsible manner can result in significant negative repercussions.  If a patient begs me for an antibiotic when not indicated (they do sometimes) or for Viagra (ditto) and I give in to their begging, I am simply practicing bad medicine.  However, if a patient begs me for a narcotic when they don't actually need it and I give in, I am committing a crime.  Physicians with "suspicious prescribing behaviors" can come under review by the DEA.  If guilty, they may get their DEA license revoked or even possibly be prosecuted for a felony.

This is why patients with legitimate need for these medications end up feeling like they are "getting the third degree" from their doctor's office when requesting them.  No physician wants to come near "suspicious prescribing behaviors" and risk an investigation by the DEA.  Even being investigated and acquitted can end up on your record.

The Good and Bad

Narcotic medications are often the best drug for the job.  Morphine and its derivatives are some of the most effective pain medications, and so people with painful conditions may be best treated with these medications.  Similarly, Valium and other benzodiazepines are very good at helping with anxiety.  A person having a panic attack is often best treated with something like Xanax.

These medications work - and therein lies the problem.  Repeated use of these medications can result in two serious problems: chemical dependency and addiction.

Chemical dependency is a physical phenomenon described by two criteria:

  1. Withdrawal - the presence of physical symptoms and clinical signs with the abrupt cessation of the substance.
  2. Tolerance (also called Tachyphylaxis) - decreasing effectiveness of the drug over time, requiring higher doses for the same benefit.

628Most of the scheduled drugs can create chemical dependency (the biggest exception being amphetamines), but other substances can also do this.  Alcohol and caffeine are two of the best examples of things that are not (generally) prescription drugs but can create chemical dependence.  I personally get a bad headache if I don't have my coffee in the morning.

Addiction is different (although the term is sometimes used in place of chemical dependency); it is the development of compulsive behaviors associated with the substance or action.  I think of addiction as being mainly a psychological phenomenon, as a person can become addicted to things they aren't chemically dependent on (such as gambling, shopping, and checking the traffic meter for your blog - heh).  A person can become addicted to anything that offers significant intense pleasure.  In general, the quicker the onset of the pleasure, the more the addiction.

So how does this relate to narcotics?  In a huge way.

The Right Way and the Wrong Way

There are two factors to consider when approaching someone in pain:

  1. How much it hurts.
  2. How long it has gone on.

Patients with acute severe pain are unlikely to abuse pain medications, while those with chronic lower-level pain are at very high risk.  So if someone comes in with a fractured arm, pain medication is fairly safe to use.  Some physicians are still reluctant to prescribe narcotics even in this situation (being jaded by people who exaggerate or lie to get pain medications), leaving many patients to suffer needlessly.  Having broken many bones (as a consequence of distractibility), I can say that pain medications make life much better when your pain is severe.  So, for acute severe pain, short-acting medications are appropriate and low-risk.

Chronic pain is different.  Some people have longstanding pain that is fairly severe - compression fractures in the back, chronic severe degenerative arthritis, and cancer pain can be relentless.  It is very difficult for these patients to gauge the severity of the pain, as it becomes hard to remember what being pain-free feels like.  It is very hard for the physician to determine the severity as well, as there is no pain-o-meter to stick on someone and measure how much they hurt.  You have to take the patient's word for it - which can be hard if the stated pain is inconsistent with physical findings.  The result is that some patients suffer silently, while those who report severe pain are held in suspicion by the physician.

The best approach to treating someone who is in significant chronic pain is to use long-acting medications as much as possible and short-acting ones as little as possible.  The reasons for this are:

  • It is easier to keep pain away than it is to intermittently get rid of it.  Patients on long-acting pain medications end up using less medication than those who use only short-acting medications.
  • The nature of short-acting medications is to relieve the pain quickly, but for a short period of time.  This creates a repeated decision the patient has to make: "do I hurt enough to take a pain medication?"  Since these medications  have a euphoric effect along with the pain-relief (longer-acting medications with a slower onset don't have as much of a euphoric effect), the decision becomes even harder.  This is what drives many people to addiction - they start taking the medication as much for emotional reasons as for pain relief.  It is a very hard situation for the patient with true chronic pain.  Long-acting pain medications on a schedule take away this decision and make the risk of addiction much lower while doing a better job on the pain.

Long-term use of any narcotic will result in chemical dependency, but that is not nearly as big of a problem as addiction.

This approach actually works for anxiety as well - with antidepressant/anti-anxiety medications like Zoloft or Paxil being used to minimize the need for benzodiazepines.

Bad Actors

sammy_davisThere are some people, however, who are simply addicted to the euphoric effect (translation: buzz) they get from these medications.  Since we still haven't invented the Pain-O-Meter, they can claim they have significant pain and take advantage of compassionate (or just careless) physicians.  Emergency physicians see a disproportionate amount of these "drug-seekers" and so tend to be very jaded toward anyone using narcotics.  As a primary care physician, I am constantly measuring the likelihood that a patient is a drug-seeker.  It is often very difficult.

This makes many people with legitimate pain get labeled as drug-seekers and/or not get adequate treatment for their pain.

There are also some physicians who play the role of "candy-man," handing out short-acting narcotics recklessly.  This feeds the hunger the drug-seekers have for their substance of choice and make life much harder for the rest of physicians.  In every town I have worked in, I have known who these physicians are - and cringe when one of their patients comes through my door.

Narcotics are a victim of their own success.  They should simply be highly effective drugs for people with significant problems; instead, they are under-used in people with real need and abused by those who shouldn't get them.

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