tag:blogger.com,1999:blog-7772182113499451603.post3490221731489745306..comments2024-03-27T10:50:53.692-05:00Comments on Real Psychiatry: Drug Overdoses As A Proxy For Drug EpidemicsGeorge Dawson, MD, DFAPAhttp://www.blogger.com/profile/03474899831557543486noreply@blogger.comBlogger2125tag:blogger.com,1999:blog-7772182113499451603.post-11733229066473966402018-10-09T21:56:21.404-05:002018-10-09T21:56:21.404-05:00Thanks for your comment.
Opioids are highly polit...Thanks for your comment.<br /><br />Opioids are highly politicized in the USA and that now extends to physicians. On Twitter for example there is a aggressive group of people who promote the use of opioids for chronic pain to the point that they suggest that people with concerns about addiction are responsible for ruining the lives of people who need opioids or who suicide because of pain. They have become more outspoken with the point I comment on in the graphic suggesting that this is not a problem with prescription opioids because of the problem with heroin and fentanyl. <br /><br />I don't believe any physician who has talked with heroin or fentanyl users has heard that they started using those compounds initially. The progression is usually an opioid prescription for a minor athletic injury, dental extraction, headache, back pain, etc or a diversion from an old prescription sitting unused in someone's medicine cabinet. That is my concern about interpreting the spread of these drugs. The other issue is geographic spread and that includes rural areas where even 20 years ago heroin overdoses were unheard of. <br /><br />I agree that physicians share some of the blame, but the regulatory initiatives by the Veteran's Administration, pain societies, and even the Joint Commission made "pain as the 5th vital sign" as standard. Managed care companies that hire physicians also made physicians satisfaction ratings a standard practice. One dimension of those ratings is basically whether the physician gives the patient what they want. Another bad idea. All of those influences made many physicians much more likely to prescribe opioids and opioid prescribers to prescribe more.<br /><br />I do believe that there are some chronic pain patients who do reasonably well with opioids but the paradox is that they have to be appropriately selected and those selection criteria are subjective and far from foolproof.<br /><br />Regarding the issue of overprescribing - I address it many times on the blog.<br /><br />Here is a link to overprescribing for ADHD and how it compares to overprescribing of antibiotics (the antibiotics win). Stimulant medication for ADHD is overprescribed and it is probably driven by the fact that every college freshman thinks it is a performance enhancing drug: <br />https://real-psychiatry.blogspot.com/2013/04/the-spike-in-adhd-diagnoses.html <br /><br />Benzodiazepines are overprescribed just based on their long term toxic effects, addiction potential, and tolerance limiting therapeutic effects.<br /><br />There are some conditions and indications that just need to be ignored. Here is a post on prescribing stimulants for binge eating disorder that ignores that fact that stimulants are proven to be worthless for weight loss and in the process caused significant addiction:<br />https://real-psychiatry.blogspot.com/2015/02/did-fda-forget-about-americas-first.html<br /><br />The antidepressant question is a little more complex since these drugs are prescribed for a lot of different conditions (depression, bipolar disorder, anxiety disorders, chronic pain, headaches, menopause, etc). Given the conditions covered and the fact that many if not most people either do not fill the prescription or stop taking it after the first month or two - it is probably not a high figure.<br /><br />I have a bubble diagram on what I think contributes to overprescribing. An implicit dimension in the diagram is that the physician has enough time to address all of the elements. There has to be a mutual expectation that a magical prescription will address all of the patient's problems. That tends to happen in a 5 minute appointment.<br /> https://real-psychiatry.blogspot.com/2014/04/overprescribing-bubble-diagram-explained.htmlGeorge Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-1614339299868639592018-10-09T20:24:13.782-05:002018-10-09T20:24:13.782-05:00As an American citizen living abroad, I've bee...As an American citizen living abroad, I've been horrified by the opioid epidemic. Japan has always been and continues to be hesitant to prescribe painkillers: a bout of intense acute back pain here ("Just a pulled muscle" I was told) resulted in a (non-refillable*) prescription for an NSAID at 1/3 the dose used in the US (and physical therapy (covered by insurance)). So it's no surprise to me that Japan doesn't have an addiction problem.<br /><br />Which brings me to my point: I'm very impressed with the care with which you express the point that "it could account for the mortality curve in Figure 1 as a single rather than multiple epidemics." I'd just jump to the conclusion that doctors in the US caused this problem and ought to be seen as having moral, if not criminal, liability. Stating it the way you did will get more people to listen. It's interesting that the science is that opioids are no better than OTC painkillers for chronic pain but that the pushback at attempts to restrict opioid prescriptions comes from people who would be better off with the OTC painkiller side effects. (I realize that the vast majority of folks prescribed opioids don't become addicted, but the side effects are worse than NSAIDs.)<br /><br />Anyway, relevant to the main topic of this blog, I understand that 1 in 10 Americans is on antidepressants, and that seems similarly excessive to the overprescription of opioids. Do you agree that 1 in 10 is too high?<br /><br />*: Japan doesn't have refillable prescriptions for any prescription medication. You have to go back to your doc.<br /><br />Anonymoushttps://www.blogger.com/profile/16317248278298169528noreply@blogger.com