The Prescription Drug Crisis: It’s A Cultural Problem

Monday, February 27th, 2012

Jason D. Fodeman, M.D. internal medicine resident, writes an interesting post about the prescription drug crisis. He says:

The tragic death of Whitney Houston has once again shined the spotlight on the abuse of prescription drugs and the doctors who prescribe them. Legislators, experts and pundits are blaming physicians for liberally prescribing narcotics, but an honest debate must also examine how government policy has helped foster this crisis.

The abuse of prescription medications is not limited to Rodeo Drive and the Upper East Side. It is a national problem. From Crenshaw to Harlem, and practically everywhere in between, it plagues the practice of good medicine in both the inpatient and outpatient settings.

Inevitably, doctors with the power to prescribe these medications have found themselves at the center of the storm. Are physicians avaricious enablers looking to profit off the addiction of others or are they merely pawns desperately trying to stay afloat navigating the system legislators and regulators have established?

His answer is no, that’s it’s more complicated than that. I’m afraid physicians are being let of the hook. Please go read his whole post.

Chiropractors (and I am one) work with many pre and post-surgical patients suffering with back pain, joint problems, head aches, etc. The vast majority of patients use at least one medication. Most, many more. A scary number have used meds for non-medical reasons. They are not alone.

In the last couple years, easily over 50% of the patients are on some form of anti-depressant. Nearly 100% of patients who went to their MD’s first for some ache or pain are prescribed narcotics or muscle relaxants. No, that is not an exaggeration.

There is nothing quite so appalling as seeing a patient “not there” due to some psychotropic med or who is suffering drug withdrawals from trying to get off a narcotic for a relatively innocuous discomfort.

My feeling is that the medical profession, while harried and pressured by patients, just don’t see the harm in the medication. Most view it as an objective good and a benefit in the modern medical world. And while medications, and even narcotics, are indeed amazing advances, they are dangerous because they are so powerful and effective.

Very few docs watch their post-surgical or quasi-surgical (trying to not have patient go to surgery) patients closely. Many give huge prescriptions for narcotics instead of being circumspect and forcing the patient to come back for more meds if there’s trouble or prescribing something less pain-masking but easier to wean from.

A patient has to be very medication-wary themselves and press the doctor for alternatives.

Pain medication of the narcotic variety are psychologically as well as physically addictive. They remove the feeling of pain everywhere — body and mind. People don’t realize what pain they’re living with until it’s not there. Dangerous.

The solution to the problem of over-prescribing: doctors need to get into the mentality of least interventionist policy necessary. They also need to better monitor patients on psychotherapeutic and pain meds.

Most importantly, patients need to educate themselves. There’s this notion that narcotics or psychotropic meds are no big deal. Many friends and patients are shocked when I tell them something like this:

Caffeine –> Speed –> Ritalin, Adderall, and Dexedrine (ADD medication) –> Crystal meth

Those are stimulants, just as an example. There’s a reason why kids are smashing Adderall and snorting it. It’s a rush and it is more powerful than regular old speed.

Here are the order for narcotics:

Codeine (e.g. Tylenol #3) –> Hydrocodone (e.g. Vicodin) –> Oxycodone (e.g. Percocet, Oxycontin)

Percocet and Oxycontin, well all of these drugs, but especially these last ones are highly sought after as street drugs for a reason. I watched a post-surgical friend go through withdrawals, have trouble sleeping, get the shakes, etc. As his friend, I knew that he wasn’t feeling pain from the surgery anymore. He had a great surgeon, who was paying attention, but was still a wee bit lax. So his wife and he talked and he agreed that he was wanting the medication because it felt good but that he wasn’t feeling pain so much. He was scared by this and so were we and so, his wife helped wean him. It was a tough week. And this was a guy who had needed the medication very badly. He recovered fine, but he had to gut it up for a few days.

Here are the order for muscle relaxants which are also addictive (did you know that? most don’t). Good site about meds generally:

Carisoprodol (Soma). This drug’s dosage is 350mg every eight hours as needed for muscle spasm. Soma is typically prescribed on a short-term basis and may be habit-forming, especially if used in conjunction with alcohol or other drugs that have a sedative effect.
Cyclobenzaprine (Flexeril). This medication can be used on a longer-term basis and actually has a chemical structure related to some antidepressant medications, although it is not an antidepressant. Usually it is prescribed as 10mg every six hours as needed to relieve low back pain associated with muscle spasm, or it can also be prescribed as 10mg at night as needed to help with difficulty sleeping. Flexeril can impair mental and physical function, and may lead to urinary retention in males with large prostates.
Diazepam (Valium). Valium is usually limited to one to two weeks of use, and the typical dosage is 5-10mg every six hours as needed to relieve low back pain associated with muscle spasm. Because of its habit-forming potential, and because it changes sleep cycles and makes it very difficult to sleep after stopping the drug, Valium should not be used long term. Patients should also note that Valium is a depressant and can worsen depression associated with chronic pain.

Mind you, most patients with back pain alone are on multiple medications. After two meds, no doctor can predict the interaction.

Both patients and physicians are far too casual about their medication use. I haven’t even included anti-inflammatories or anti-depressants or anti-psychotics (over used now for depression and/or ADD off-label), or NSAIDs.

Did you know that the NUMBER TWO cause of death in the United States is prescribed medication poisoning?

“Deaths and hospitalizations associated with prescription drug misuse have reached epidemic proportions,” said the study’s lead author, Jeffrey H. Coben, MD, of the West Virginia University School of Medicine. “It is essential that health care providers, pharmacists, insurance providers, state and federal agencies, and the general public all work together to address this crisis. Prescription medications are just as powerful and dangerous as other notorious street drugs, and we need to ensure people are aware of these dangers and that treatment services are available for those with substance abuse problems.”

While Dr. Foderman is right to bring attention to this very important issue, I think he lets doctors and patients both off the hook.

Americans are far too pain-avoident these days. Unwilling to suffer even a tiny amount, patients are asking for and getting, or just being given, very powerful medications that have far worse consequences than the discomfort would itself.

This is a cultural problem as much as it is a medical one. Escaping from pain creates more pain.

Bonus: All the celebrities who have died from prescription med overdose. Add Whitney Houston who had Xanax, Valium, and alcohol in her system.