I’m Surprised More People Don’t Die!

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combined_RX_surgkfe_gun_knifeIn a twisted turn of events over the last few weeks, an astute Student Pharmacist turned to me and said, “I’m surprised more people don’t die”.  The sad truth is; I am too.  In my previous blog entitled Collective Bludgeoning, I compared gun control to opioid control.  Perhaps I should have compared knives to opioids.  After all, once a bullet pierces the flesh, it can never be good.  But a knife is different.  It can be skillfully employed to surgically remove or repair; opioids in much the same way can be employed to improve quality of life if they enter the body slowly, skillfully, and with exceptional care.  If either becomes sloppy, the result could be harm or death.

Here to tell us why he is surprised more people don’t die is Student Pharmacist Mazen Saeed…


I have always envisaged interacting with patients and providing information that may impact and improve their daily lives and overall health.  I have read several online blogs and stories of prescribing errors with the wrong medication, misdiagnosis, surgeons removing the wrong knee, or pharmacists dispensing the wrong medication. As a fourth year student pharmacist, I was extremely excited to experience different settings of the pharmacy profession.  In particular, my long anticipated rotation with Dr. Fudin has been an eye-opening experience to say the least. Daily activities have included pain assessments and evaluations with concentration on pharmacotherapy combination.  This comes with incredibly intense relationships that we establish with our patients and their families to improve their daily activities and lifestyles.

But, I am surprised that more people don’t die!

No, it’s not because of the opioids.

It’s because of the patients themselves.

It’s because of poor decisions and flippant attitudes I have seen by some patients.  These include Dr. Google, the neighborhood pain expert, or “my sister”.  Recently, I read an article by the CDC entitled Understanding the Epidemic: When the Prescription Becomes the Problem. The article was well written, but the title should have been “Understanding Opioid Death: When the Patient Becomes the Problem”.

This is sort of reminiscent of NRA’s slogan, “Guns don’t kill people, people kill people” as Dr. Coleman eloquently pointed out in a previous paindr.com blog, Collective BludgeoningBut in my mind it is nothing more than a catchy campaign phrase to minimize the 30,000 plus deaths per year that are seen from accidental or purposeful massacres, yet gun enthusiasts and sportsmen in favor of lenient gun laws continue to blindly chant “Guns don’t kill people, people kill people”.  All this, to preserve Second Amendment gun rights as outlined in the United States Constitution preserving the right of the people to keep and bear arms, adopted in 1791.

How can people be so blind?  As Dr. Fudin points out above, perhaps a comparison of guns to opioids was a bit overreaching and knives are more akin to what’s happening here. It doesn’t really matter if guns, knives, or opioids kill people or if people kill people – THEY ARE ALL STILL DEAD!

What about the right to bear opioids for patients who require them for adequate pain control and improved function?  Perhaps we need to establish another NRA (Narcotic Reality Awareness) group.  That slogan can be “Opioids don’t kill people, people kill people”. Or maybe, “Don’t panic, carry naloxone”.  But seriously all of these slogans are idiotic.

In Understanding the Epidemic: When the Prescription Becomes the Problem mentioned above, statistics regarding opioid deaths from opioids are suggestive of overprescribing. Although admittedly opioid deaths have surged congruently to the number of opioids prescribed over the last 10 years, does that really mean that the prescribers are responsible?

Maybe colleges are responsible for giving inadequate attention to pain management for practicing clinicians.

Maybe regulatory agencies should require comprehensive mandatory continuing education (and not 2-4 hours that we sometimes see).

Maybe prescribers and pharmacists should be responsible for underestimating the dangers of opioids, seeking educational opportunities, and taking the proper precautions to assess for risks and reassess for those risks consistently.

Or, just maybe people kill people, and opioids don’t.

Maybe it’s not just that DEAD is DEAD!

It is true that opioids can cause opioid-induced respiratory depression (OIRD) and overdose death. On the other hand, patient conduct towards taking opioids must be considered and must be taken very seriously!

Reality Check

Here are some quotes from real patients over the last few weeks…

“I take 2 or 3 tablets of methadone; it depends on my pain frequency.”

“My sister gave me methadone, so I only take 1 or 2 tablets a day on the days that I feel the pain.” (This patient wasn’t prescribed methadone)

“I was in agony so I put on a second fentanyl patch.”

“I took a blue pill besides the pills you gave me.  I’m not sure what it was – my friend gave it to me.” (FYI, we believe it was morphine extended release 15mg)

“My fentanyl patch doesn’t work anymore, so I took some pills my friend gave me. He said they were oxycodone”.

To truly understand the opioid epidemic, we need also to consider that just maybe the patient factor is frequently left out of the equation.  In the meantime, compliant well-intentioned folks needing these medications are left in agony because of overarching fears from regulatory agencies, law suits, and their livelihood.

So for some pain sufferers, if you are not a part of the solution to advocate for opioids among your constituents, perhaps without realizing it, you are a part of the problem.

And for prescribing clinicians, the solution is a shared activity in which patients and medical providers need to be partners, to trust but also confide in one another.

The first step is establishing with your patient that you are the expert, and if you’re not, please find one for the patient – this might even be a behavior health expert working in tandem with a physician.

But the patient cannot be the expert; Google cannot be the expert; siblings cannot be the expert; neighbors and best friends cannot be the expert.  And to all you pain sufferers, please feel free to bring in your documents and/or advisees so that we can have a frank discussion while you’re still alive.

Remember, chronic opioids don’t generally kill people who use them correctly and as prescribed, unless there are no new unpredicted risks such as a new medical problem, drug, or food interactions.

So to all the gun-carrying zealots, anti-gun activists, opioid advocates, and anti-opioid activists, next time you “shoot” off your mouth, remember the new NRA (Narcotic Reality Awareness) slogan…

Opioids don’t kill people;
People kill people!

As always, comments are welcome!

MazenSaeedMazen Saeed obtained his bachelor degree in medicinal chemistry from the University at Buffalo and subsequently pursued a Pharm D. degree. He is currently in his last year of the dual degree program at Albany College of Pharmacy and Health Sciences for his Pharm.D./MBA.   Mazen plans to start a Medication Therapy Management (MTM) in a community setting with a pain management focus. He is currently under the mentorship of Dr. Jeffrey Fudin.  This post was prepared on Mazen’s own time and reviewed by Dr. Fudin and not part of any government duties.

References:

  1. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.
    http://books.nap.edu/openbook.php?record_id=13172&page=1.
  2. Fine PG, Portenoy RK (2004). “Chapter 2: The Endogenous Opioid System”(PDF). A Clinical Guide to Opioid Analgesia. McGraw Hill.
  3. Corbett AD, Henderson G, McKnight AT, Paterson SJ (2006). “75 years of opioid research: the exciting but vain quest for the Holy Grail”. Br. J. Pharmacol. 147 Suppl 1 (Suppl 1): S153–62.doi:1038/sj.bjp.0706435. PMC1760732. PMID 16402099
  4. Stein C, Schäfer M, Machelska H (August 2003). “Attacking pain at its source: new perspectives on opioids”. Nat. Med. 9 (8): 1003–8.doi:1038/nm908. PMID12894165.

 

 

 

 

 

21 thoughts on “I’m Surprised More People Don’t Die!

  1. Another analogy would be automobiles and opioids; both are essential (unlike guns), but potentially deadly when mixed with alcohol, used recklessly, etc. In contrast to the current hysterics emanating from the CDC et al, prescribing rates of oxycodone and hydrocodone (the top 2 prescribed opioids) has declined every year since 2012. And from 1997-2010, opioid prescribing quintupled while opioid-associated deaths quadrupled, meaning that toxicity deaths did not increase proportionately with prescribing rates. Misinformation abounds, opioid toxicity deaths often involve benzos and/or alcohol, and it pays to take a closer, skeptical look.

  2. Not sure what to make of this, but all I can add is that I at 41 have had 4 back surgeries, and 12 epidural injections, these procedures led to a condition called arachnoiditis, I also have epidural fibroids in my thoracic encasing a nerve root. I needed the operations otherwise I would have been in a wheelchair. I am now left with severe chronic pain….. And a host of other strange sensations. I have a great pain management doctor who takes care of me, and I trust her implicitly…I know there are drug seekers out there,but the chronic pain person should not be penalized because of the fools that don’t treat the opiods with care. The doctors are not dumb, they know who they need to treat with what and who is just seeking a high. Leave it to the doctors not the government to treat their patients or you will see suicide on the rise from pain patients not getting adequate relief.

  3. Everyday somewhere the news media makes sure that the public hear’s the horror stories of “another innocent youth” being taken from this earth because of the horrible drugs circulating in our country. Recently, they have placed the blame on physicians treating pain & have totally left heroin out of the mix (even though most addicts will abuse both) There is no mention of the Pandemic of Chronic Pain or how it affects 100 million people in the US! Yet, you turn on Cspan and hear a physician (Kolodny) say that pain medication is heroin in pill form & suggested to an elderly caller to “suspect” her physician if he tries to prescribe them to her. I heard this again out of the drug Czar in the 60 minutes piece this last weekend. How is the public perception of medical practice supposed to support treatment advances, when voices such as those we hear in the media on a daily basis, constantly attack compassionate providers? I know it’s a little off topic, but we must be aware of what the public is being lead to believe if we are to bring common sense to the discussion

  4. Very interesting article. I am currently trying to use humor, distraction, meditation, and crying in dealing with severe pain from a condition that my doctors are trying to diagnose. I have been given tramadol to deal with pain along with take only when absolutely necessary (how do you decide?), especially when given a small number of pills? I can understand people trading meds, comparing medications, trying to find some relief when they are in pain. It’s 2:07 am, I can’t sleep, pain. Is it bad enough for a pill? Or do I try other methods?

  5. Well done Saeed! My favorite from this week is “I got jumped by six men in the Taco Bell drive-thru and they took my meds!” In all seriousness, with so much attention on decreasing abuse and high dose opioid therapy, more and more providers now feel comfortable telling all their patients that they will not prescribe opioids for anyone. In my opinion that leads to just as much harm as indiscriminate prescribing. It’s so easy to deal in absolutes but much much harder to balance the risks and benefits for each patient. If we can’t learn that then more patients will suffer than are saved.

      1. According to the most recent report of the Florida Medical Examiners Commission, in 2014, “The drugs that caused the most deaths [ed.: in Florida] were benzodiazepines (1,175, including 569 alprazolam deaths and 174 diazepam deaths), cocaine (720), morphine (705), ethyl alcohol (595), oxycodone (470), heroin (408), fentanyl (397), methadone (312), and hydrocodone (250).” If we compare these figures with those from 2010, the year before the pill mill statute was enacted in FL, we can readily see the differences: In 2010, the Commission reported: “The drugs that caused the most deaths were Oxycodone (1,516), all Benzodiazepines (1,304 – includes 981 deaths caused by Alprazolam), Methadone (694), Ethyl Alcohol (572), Cocaine (561), Hydrocodone (315), Diazepam (277), and Morphine (262).” In 2010, heroin was the cause of 48 deaths in FL. So, what can we tell from this? A) Oxycodone-caused deaths decreased 69 percent; B) Benzodiazepine-caused deaths decreased 10 percent; C) Methadone –caused deaths decreased 55 percent; D) Ethyl alcohol-caused deaths INCREASED 4 percent; E) Cocaine-caused deaths INCREASED 28.4 percent; F) Hydrocodone-caused deaths decreased 20.6 percent; and G) Morphine-caused deaths INCREASED 169 percent. Heroin that was not considered a major drug of abuse in 2010 in FL when it was caused 48 deaths, rose 750 percent in 2014 to cause 408 deaths. This put heroin in-between oxycodone (with 470 deaths) and fentanyl (with 397 deaths). I think it makes more sense to look at the actual numbers rather than percentages because the latter can be misunderstood because of small sample distortions. Also, I would caution jumping to conclusions that the crackdown on pill mills in FL has driven former pill addicts to IV heroin. I’m sure this is so in some cases but not all. What is needed is a time-study of the before and after effects of the 2011 statute. In other words, how many opiate addicts began their addiction with heroin, moved on to prescription opioids when they became easier and cheaper to get at the pill mills, and then, when the pill mills were closed down, returned to their original drug of choice? I would think that the FL prescription drug monitoring program records could be most useful in such an analysis to determine, for example, how many of those 408 victims of fatal heroin overdoses last year previously showed up in the PDMP’s archives as recipients of scheduled opioids. I think that such a study would be dispositive in shedding light on an important issue involving medicine and public policy that currently seems to draw mostly emotional advocacy from one side or the other. Overall, the state of Florida had a modest increase in drug-related deaths (+3.6% or 301) over the previous year. The trend, however, from before the new statute took effect on July 1, 2011, remains downward and significantly so in the case of certain drugs (e.g., oxycodone). Yet, there are perplexing signs that addicts are adapting to the changes. We are beginning to see unusual spikes in the abuse of certain drugs that heretofore stayed under the radar. The 2014 Medical Examiners Commission report note, “Overall, while deaths related to oxycodone and methadone decreased, occurrences of tramadol (7.3 percent) and morphine (25.8 percent) increased when compared to 2013. Deaths caused by tramadol (6 more than 2013) and morphine (137 more than 2013) increased in 2014.”

  6. http://www.rightrelevance.com/search/articles/hero?article=144271c6ca2188d810b0097450f9651cb48cb765&query=primary%20care&taccount=internalmedrr
    How many persons with chronic pain needs (complex care patients with multiple comorbidities) are effectively locked out by poorly trained gatekeepers. Too many I warrant. We need to understand this piece of the puzzle and its’ impact on persons to turn to Dr,.Google and their neighbors for information.
    We also need to understand what happens to patients when poor practitioner training results in their turning to Dr. Google and their equally poorly trained peers.

  7. Mr. Saeed provides a refreshing view into this controversial subject, and I agree with his premise — guns and opioid analgesics, to name just two, are products that can do good or harm, depending on the user’s free will.

    Currently in America, pain management is under attack from those who would treat chronic pain as acute pain, and who blame addiction on the treatment of pain. Many claims are being made, but the facts about chronic opioid treatment in the person with long-standing intractable pain lie in a great gray area of the map of medical knowledge labeled unknown. Here’s a few examples:

    Given a patient with a chronic pain condition on 120mg of morphine equivalent daily dose or more…
    Q: What is the increased risk in mortality for chronic pain patients treated with COT?
    A: Unknown — yet we point to increased mortality rates without any evidence of causality, as a reason for limiting opioid therapy in people who suffer daily pain.

    Q: What is this person’s risk of addiction based on his or her chronic pain condition and daily required opioid dose?
    A: Unknown — yet we seek to limit the maximum daily dose of all persons in chronic pain on COT to reduce the risk of addiction with opioid use.

    Q: What is this patient’s risk for hyperalgesia, allodynia, colon cancer, liver disease, or other physiological harm based on his or her chronic pain and COT?
    A: Unknown — yet we seek to set standards of care to limit harm in the treatment of chronic pain with COT.

    We have been told (but not much lately) that proper training and greater understanding of methadone’s pharmacological properties would have have prevented 1/3 of those famous “opioid-related” deaths of 1999-2008, yet are we teaching medical students and residents to better use the highly effective pain medication called methadone?

    I don’t believe we are.

    Over 50% of PCPs say they are uncomfortable or very uncomfortable in treating chronic pain with higher than normal dose opioids. Are we training physicians to do so?

    A few people are doing such training, but the vast majority of PCPs are not getting the information that they need.

    There is one definition of addiction that goes something like this — addiction is the act of trying the same thing over and over, even though it doesn’t work. Using that definition, we appear to be addicted to the prohibition of opioids to solve a particular psycho-social problem in society.

    Prohibition, whether enforced by decree or by ignorance is an ineffective solution to the “opioid problem” in a culture where freedom of choice is held in high esteem. Yet, some are calling again for the use of this ineffective tool to manage risk in opioid therapy.

    In a former academic life as an English major, I wrote my share of essay questions asking me to “compare and contrast” this and that. The exercise that I recommend for interested readers here is to compare and contrast the social network communications of people seeking the treatment of pain, with those of recreational opioid enthusiasts. (The vast majority of chronic pain patients on COT hate their medications, but are grateful for any measure of analgesia they afford.)

    The website reddit.com offers a chance to view a younger, intelligent, computer-literate sample population with components of both people living in pain, and recreational opioid enthusiasts:

    http://www.reddit.com/r/chronicpain
    http://www.reddit.com/r/opiates

    This exercise teaches much about the opiate crisis as a function of human desire, and highlights the invisible crisis of untreated pain in America, especially among this cohort, who are believed, unfairly, have a higher risk for abuse.

    1. Kurt W.G. Matthies,

      I have been to these sites, per your urging, and was amazed at what I saw there. I am not a prude, by any means, but the comparison of people I know on COT, and the people on reddit…unbelievable!!!

      That people compare, in any serious way, chronic pain patients on COT to THESE people made me more than furious. I was seething! You have to be kidding me!

      We are MILES apart on this as one can clearly see from the reddit exchanges. PROP and their ilk are more clueless than I even thought they were.

  8. Wonderful article! I’m one of those pain patients who “painstakingly” adhere to my doctor’s orders. He has helped me alleviate the majority of pain via smaller doses of 2 pain meds every 6 hours. I also have ANS dysaustonomia, Vascular Ehlers-Danlos Syndrome (untreatable, incurable, fatal), and oddly, scleroderma. My doctor reviews any OTC pain creams before I buy them and weighs in on how to effectively keep the pain from getting to the point where some patients would self-medicate. I do NOT, and am on oxygen at night to keep my O2 sats above the 83% during a sleep study.

    When a patient like me feels there is no help out there for said diseases, having an active and conservative pain doctor has been immensely helpful. As are your blogs, Dr. Fudin.

    Keep ’em coming! I feel so privileged to be on your mailing list. God bless you!

  9. Dr Lewis, I completely agree with you. The VA is constantly bashed when it comes to, well, everything but lately the focus has been on Pain meds and I nearly lost mine. It took changing regional clinics, a congressional inquiry, my literally losing my mind, losing my ability to work(now 100% DAV), 18 months with a wonderful Civilian pain specialist and about 5 other specialists, 2 meds that nearly killed me, and a partridge in a Pain tree.
    But I am still here and now with the right meds I am feeling better everyday. I see my VA pharmacist every month, now more than my Drs, and there are 2 of them I completely trust. They have been there every step of the way for every med change and med failure. I trust them. The VA saved my life but I now have a Team of Drs, not just one.

  10. I don’t think we need to fret over which analogy — guns or knives — is appropriate to express the Janus-like nature of opioids, that is, the ability of people to use opioids safely to relieve pain as well as the ability of people to misuse them for recreational or euphoric purposes. The latter, as we know, carries with it potentially dire consequences. The mayhem attributed to the misuse of guns and knives, unless we’re talking about suicide, overwhelmingly involves the use of those weapons against others, not ourselves. To be sure, there are some similarities in the regulation of guns, knives, and drugs, with access to each being restricted in some way to those seeking to acquire and use them. Incidentally, the author’s statement, “Maybe regulatory agencies should require comprehensive mandatory continuing education (and not 2-4 hours that we sometimes see),” has some merit, in my opinion, even though it has never been established to my knowledge that a lack of CE among healthcare workers is causal in the epidemic of prescription drug abuse. CE wouldn’t hurt and some state medical boards already require the 2-4 hours the author mentions. If it already hasn’t been done, perhaps someone should do a paper on the before and after effects of even this small amount of CE to see if it has any positive effect on reducing improper and/or excessive prescribing. Several years ago, at an FDA advisory committee meeting to discuss risk management programs, panelists suggested that a training protocol be developed and applicants for DEA registration (new) or renewals be tested before being granted DEA registration. The idea caught on among all the other panelists immediately and even the FDA folks chairing the meeting agreed that it sounded like a viable adjunct to the agency’s RiskMAP and REMS programs. Since DEA is the only federal agency that by law maintains a registry of prescribers of controlled substances, it was stated that DEA, rather than FDA, would be the appropriate agency to oversee this. The DEA was not in attendance at the meeting and as far as I know was never asked its opinion of such a proposal. Moreover, because a requirement such as this is beyond the current statutory language of the CSA, it likely would require congressional legislation, rather than administrative rulemaking by the agency. Although it sounds like a good idea and might have modest usefulness, a lack of training in prescribing controlled substances has never to my knowledge been shown to be a significant cause of the problem. Given the author’s attempt to draw an analogy to knives rather than guns, it begs the question, would additional training of gun and/or knife dealers reduce the misuse of these weapons by the small number of purchasers who go on to misuse them? Probably not and that’s my point, my only point.

    1. John, you point “it begs the question, would additional training of gun and/or knife dealers reduce the misuse of these weapons by the small number of purchasers who go on to misuse them? Probably not and that’s my point, my only point” is well taken. Although I haven’t looked in awhile, your query about before/after analysis with opioid/pain training has been done many times before. And, it has not changed outcomes just as you suspected.

      1. Thanks, Jeff, for bringing me up to date on those CE studies. At the meeting of the FDA panel several years ago, someone mentioned that the CE training should be voluntary but someone else noted that voluntary training generally attracts those who least need it and unless it was made mandatory as a condition of registration, for example, the ones who might really benefit from it would never get it.

  11. Just today I had a patient who told me that I should consider “going back to school in England to study herbology.” He mentioned that he was going to try to self-treat his pain with a potion of honey, apple cider vinegar, and warm water because he’s read a lot about the power of apple cider vinegar.

    Thanks, Dr. Oz.

    He also agreed to increase his tapentadol dose. So the conundrum will continue. At follow-up will he attribute his pain relief to the tapentadol increase or to the cure-all apple cider vinegar recipe? Will he have unbearable stomach upset from drinking vinegar and blame the tapentadol dose increase? Will the honey in his recipe worsen his diabetes and potentiate his diabetic neuropathy?

    Patient education is key, obviously, but sometimes it’s really hard to change stubborn patients’ minds when they are already made up.

    1. So here’s the question Dr. Carroll…
      Since tapentadol is a weak base, how would something like vinegar (acetic acid) potentially affect tapentadol excretion? I just want to make sure you get your money’s worth for working on a resident;s salary. 🙂

    2. I had a sweet little elderly lady at church bring me a book that had a secret cure for my paralysis. I researched the doctor who wrote it and he was a veterinarian educated in some foreign country that I was not familiar with. She was dead serious. Our elderly population is so vulnerable and trusting.

  12. He’s right. And there’s a reason for this. Chronically ill Patients need a working partnership with a practice TEAM. That means open communication and training. UTS and pill counts are not a substitute for patient education and support. Especially since so many have the comorbidities of generalized anxiety disorder, depression and PTSD to be managed at the same time. Chronic pain care cannot continue to be treated in a vacuum, separated from the totality of the individual who needs help. People who rely on their neighbors and doctor google are indicative of a system that is insufficient in conceptualizing pain care, the impact on people’s lives, and their capacity to support themselves in the face of phone calls that aren’t answered and appointments that are rescheduled. Maybe if we were to figure out exactly who these injured folks are and can get our act together to deliver on that thing called biopsychosocial model of care we might make some inroads,

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