Waiting List Mortality? - An Example of Nocturnal Panic Attacks

Any PubMed search on waiting list mortality will produce a long list of articles on mortality that occurs on transplantation waiting lists and all of the associated ethical and logistic problems.  I could not locate any work done on waiting lists to get in to see psychiatrists, primary care physicians, or specialists.  To an extent, waiting list mortality is expected and some of the risk factors (increasing age, significant chronic medical illnesses, high  risk medications) is undoubtedly predictive.  But what about the person who calls in and describes a clear cut problem that is misclassified and the error is potentially life threatening.  I have picked up a few of these problems in psychiatric clinics where the ultimate emergency diagnosis was unrelated to the reason for the appointment.  Seeing a patient who is white as a ghost, complaining of coffee ground emesis, and determining the hemoglobin to be 7 is one of many examples.  Anxiety was the reason for that appointment.  I have found a number of acutely anemic patients due to blood loss with complaints about anxiety, shortness of breath, and panic attacks  who really needed blood transfusions.

I have a more concrete recent example that is much more common in psychiatric practice, especially if a significant number of patients with alcohol and benzodiazepine problems are being seen.  That is the problem of nocturnal anxiety with panic attacks.  To make it a little more interesting, let's say our hypothetical patient is 55 years old, has a history of paroxysmal atrial fibrillation (2 brief episodes), does not take an anticoagulant, and takes flecainide to prevent atrial fibrillation and metroprolol to prevent palpitations.  He has obstructive sleep apnea and is on APAP.  His AHI is 3.5 or less on any given night.  He has never has an electrophysiological study. Stress test and echocardiogram were both negative.  He has had to taper the metoprolol over a period of about 5 years from 25 mg BID to 3.125 mg daily due to lower and lower BP.  Suddenly the patient is noticing palpitations at night.  They seem to occur at the end of REM type dreams and do not seem to correlate with the emotional content of the dream.  The awakenings with palpitations typically occur at 4AM.  He has not had a panic attacks in 35 years.  He does not drink or use benzodiazepines.  To terminate the palpitations he gets up and drinks a large glass of water or walks around and they resolve in about 10 - 20 seconds.  He gets a small single lead ECG device that reads one aberrant beat as "occasional PVC".

He gets in to see his primary care MD in a couple of days.  His exam is normal and he is in sinus rhythm.  No aberrant heart beats are noted by his internist.  Electrolytes and magnesium level are normal.  He goes home that night and the palpitations continue.  He calls his sleep medicine physicians who tells him to start with his Cardiologist.  He calls the Cardiologist who concludes that "these are beats that originate in the lower chambers of the heart and there is nothing to be concerned about." Despite the acute change in symptoms that is waking him up on a nightly basis - no further testing, examination. or diagnosis is offered.  Frustrated - he calls a referral center and schedules a sleep study in about 2 1/2 months.

Is there something else that could have happened in this case? If you happen to be this man's psychiatrist - like I am in many of these cases of sleep related symptoms what is the differential diagnosis and what else can be done.  A reasonable differential diagnosis of these palpitations might consider the following list of conditions.

 

Night time palpitations – differential diagnosis:
1.	Sleep  terrors
2.	Nightmares
3.	Nocturnal panic attacks
4.	Alcohol or sedative hypnotic withdrawal
5.	Stimulant or hallucinogen intoxication
6.	Cardiac arrhythmia Tachyarrhythmias Ventricular arrhythmias Supraventricular arrhythmias Conduction delay arrhythmias

In considering the list. there are some useful clinical features.  Sleep terrors are rare in adults.  They typically occur in the first half of the night.  The patient suddenly arouses from sleep.  They may  scream.  They have intense sympathetic output including diaphoresis, flushing, tachycardia, tachypnea,and mydriasis.  They may appear to be disoriented.  Nightmares are typically dreams with negative emotional content that occur with awakening from non-REM sleep.  Sympathetic arousal is not as prominent.  Nocturnal panic attacks (NP) can occur in people with daytime panic attacks (DP) or as a separate entity.  People with combined DP/NP had more symptom severity. Palpitations are a feature of panic attacks.  In a recent study (2) the authors also rule out associated disorders  like substance use problems and obstructive sleep apnea by exclusion and testing.  The pure NP group were predominately male, had a childhood history of sleep terrors, and were more likely to have respiratory symptoms (choking sensations) despite a lower overall symptom severity score than the DP/NP group suggesting a more common mechanism with night terrors.  Because of the similarity between nocturnal panic attacks, sleep terrors, dream anxiety attacks and nocturnal seizures some authors encourage "extreme caution" in making the diagnosis (3).

The alcohol and substance intoxication and withdrawal states may be less obvious outside of treatment setting specializing in these disorders.  Patients with these problems may not disclose the full extent of use.  In the proper context, discontinuation of both cannabis and hallucinogens like LSD occurs due to increasing anxiety and panic attacks.  Alcohol and sedative hypnotic withdrawal can cause prominent sympathetic symptoms including night sweats, tachycardia, and panic attacks.  Those symptoms typically resolve with treatment of the underlying withdrawal syndrome.  In some cases the anxiety and panic attacks persist and require additional treatment.

Pure cardiac symptoms associated with sleep can be confusing.  The patient is aroused and may notice the arrhythmia.  The question becomes is the arrhythmia secondary to anxiety and sympathetic arousal or is the anxiety secondary to the chest sensation?  In the case of a patient with known sleep apnea and atrial fibrillation here are several possible causes including breakthrough atrial fibrillation at the time of the awakening.  In this case there was a crude monopolar tracing that showed a ventricular premature beat (VPB).  VPBs are commonly associated with anxiety, but is it enough to count on the patient capturing the event by getting up out of bed and holding an inexpensive device to his chest?  Patient with sleep disordered breathing are at increased risk from nocturnal death (midnight to 6AM) and one of the mechanisms may be arrhythmia from the cardiac effects of sleep disordered breathing. 

The patient in this case is very much alive and functioning at a high level.  He still has the nocturnal palpitations but is less anxious about them because they are now intermittent and always seem to resolve in a short period of time. If he thinks about it for nay length of time the question that comes up is: "Why now?"  He hopes that the referral center will have the answer to that question.

  I don't have any outcome or ready solutions to this problem. In many ways it highlights a potential quality problem in the high tech American healthcare system.  Here we have a patient who is fairly compulsive about his own health care.  He has a primary care physician who he saw and contacted both his specialists.  When there was no answer, he contacted a referral center and set up an appointment 2 1/2 months out into the future.  What will happen while he is on that waiting list is a probability statement with a series of unknown probabilities.  What is disappointing from my perspective as a physician trained in the 1980s is that at some point - the rigorous intellectual approach to patients problems has fallen by the wayside in favor of rationing.  We are no longer in pursuit of a diagnosis that might make a difference.  We are satisfied with saying "I checked off all of the boxes and I didn't see anything".  It's a 21st century variation of the old joke: "The operation was a success but unfortunately the patient died."

I am very interested in what the cost of this approach is in terms of human life and additional comorbidity.  I think that what happens to people on these waiting lists (compared to controls) is where the emphasis should be place and not on how fast patients should be discharged and not readmitted to hospitals.  Despite all of the press about unnecessary tests and the risks associated with those tests, the commonest errors I see that result in patient injury is missing the obvious diagnosis and not doing the appropriate tests.     

There is something wrong with a health care system when a psychiatrist cares more about these problems than the physicians running the system.               


George Dawson, MD, DFAPA


References:

1:  Selim BJ, Koo BB, Qin L, et al. The Association between Nocturnal Cardiac Arrhythmias and Sleep-Disordered Breathing: The DREAM Study. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2016;12(6):829-837. doi:10.5664/jcsm.5880.

2: Nakamura M, Sugiura T, Nishida S, Komada Y, Inoue Y. Is nocturnal panic adistinct disease category? Comparison of clinical characteristics among patients with primary nocturnal panic, daytime panic, and coexistence of nocturnal and daytime panic. J Clin Sleep Med. 2013 May 15;9(5):461-7. doi: 10.5664/jcsm.2666. PubMed PMID: 23674937.

3: Shouse M, Mahowald MW.  Epilepsy, sleep, and sleep disorders.  in: Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine. 5th ed. St. Louis, Missouri. Elsevier Sanders, 2011: 1048-1063.










       

More on Benzodiazepines (Like Xanax).

The topic of benzodiazepines will just not go away.  At the top and bottom of this post - I include a number of book covers from my library on the topic from the last 30 years.  The publication dates are 1983, 1985, and 1990.  I wrote a brief review for the Psychiatric Times and included my unedited version  on this blog from earlier this year.  My overall message was that benzodiazepines as a group are great for very specific indications.  In fact for some indication like detoxification from alcohol or sedative hypnotic drugs and catatonia they are life saving.  The majority of benzodiazepines are not prescribed for those indications.  They are prescribed primarily as add on medications for anxiety and insomnia.  Their use is limited by tolerance and addictive properties that are expected from a medication that reinforces its own use.  It is also problematic to prescribe them to any population of patients where alcohol use is prevalent and not expect significant drug interactions or abuse.

I really wanted to include a graphic from the paper listed below (1) from JAMA Psychiatry on the prescribing rates of benzodiazepines in patients being treated for depression.  I will post it if I get permission.  That graph illustrates the growth in benzodiazepine prescribing from 2001 to 2104.  During that time the fraction of patients taking a benzodiazepine in addition  to an antidepressant rose from 6% to 12.5% of the depression treated patients.  Subgroups were analyzed and psychiatry came across as a the top prescriber of benzodiazepines across all years.  Other practitioners and specialists came in under the curve prescribed by psychiatrists. 

 A recent anxiety disorder diagnosis was a strong predictor of concurrent use of benzodiazepine use with 24.1% of patients with a recent unspecified anxiety disorder diagnosis and 39.1% or patients with a panic disorder diagnosis taking both the benzodiazepine and antidepressant.  At 6 months 45.6% of the antidepressant + benzodiazepine and 48.1% of the antidepressant monotherapy were still taking an antidepressant.  After initial adjustments 12.3% of the simultaneous benzodiazepine and antidepressant users received long term benzodiazepines with 5.7% taking them for one year.  The prescribed benzodiazepines were almost all high potency including alprazolam (43.9%), lorazepam (26.3%), and clonazepam (21.8%).  About a tenth (13.5%) of the patients got a limited supply of for only 1-7 days).

The authors generally conclude that benzodiazepine prescribing seems to be consistent with current guidelines.  These suggest that a Cochrane report that concomitant benzodiazepine use with antidepressants increased the short term antidepressant response and decreased the drop out rate attributable to antidepressant side effects.  I would think that would be offset at least as much by guidelines suggesting limited use.

The overall strength of this report is that it is a study of a very large insurance database population of 684,100 new antidepressant users and 81,020 simultaneous antidepressant and benzodiazepine users. They give a breakdown of antidepressant classes (overwhelmingly SSRIs).  Only 12.7% and 16.5% (respectively) of the patients in each class were treated by psychiatrists.  Interestingly 77.4% and 80% of each class had not received any form of psychotherapy, although it is conceivable that at least some patients were being seen by therapists outside of the database.  As noted psychiatrists were more likely to prescribe combination therapy.  The authors speculate that may be due to referral patterns and psychiatrists seeing patients with more severe anxiety and depression, training patterns in psychiatry, or more familiarity with benzodiazepine pharmacology.  I think a more likely factor is chronicity and the fact that psychiatrists tend to see more patients with chronic anxiety and temperamental forms of anxiety that are not taken into account in DSM-5 nosology.

Despite the large N, there are many drawbacks to database studies like this one.  I think it is useful in terms of the basic pharmacoepidemiology of prescriptions but it doesn't say anything about symptoms severity and many of the practical issues involved with benzodiazepine prescribing (like substance used disorders) are eliminated by the study protocol.  The authors do a good job of describing the downsides (use disorders, falls/fractures, motor vehicle accidents) of benzodiazepines in their discussion.  I would have included cognitive problems and tolerance. It also does not address the optimal way to address combined anxiety and depressive disorders. My biggest concern is the current "evidence based" fad of diagnosing anxiety and depressive disorders using symptom rating scales like the PHQ-9 (Patient Health Questionnaire-9) and the GAD-7 (Generalized Anxiety Disorder 7-item).  In a primary care setting they pass for a diagnosis.  In a psychiatric setting they short circuit any analysis of the etiological factors of anxiety or depression.  Instead these disorders are conceptualized as disorders that that require a basic medical treatment and they resolve.  That is a gross oversimplification.     

But the main limitation should be evident - we do not have a specific enough diagnostic system with reliable objective markers.  In that context a large N doesn't mean as much unless we know how many subtypes there are and the associated treatment parameters.

George Dawson, MD, DFAPA

References:

1:  Bushnell GA, Stürmer T, Gaynes BN, Pate V, Miller M. Simultaneous Antidepressant and Benzodiazepine New Use and Subsequent Long-term Benzodiazepine Use in Adults With Depression, United States, 2001-2014. JAMA Psychiatry. 2017;74(7):747–755. doi:10.1001/jamapsychiatry.2017.1273

Minnesota's Abandonment Of Severely Mentally Ill - Nearly Complete

For years I have been documenting the systematic dismantling of the public mental health system in the state of Minnesota.  A chronic unanswered question is how the midwest's most liberal state has come up with such a horrible system.  The most obvious answer is that the system is being run by people who do not have a clue about the treatment of mental illnesses.  A Governor's Task Force, convened a year ago has not put a dent into the further systematic deterioration.  This 30 year race to the bottom in terms of deterioration is why I was not surprised at all by the latest piece of bad news.

The Minneapolis Star Tribune published a story three days ago that St. Joseph’s Medical Center in Brainerd Minnesota stopped accepting patients who were being treated on an involuntary basis under civil commitment.  They cite an increased length of stay and safety issues. Both of these are valid concerns with people committed for treatment of a mental illness.  The system of hospital reimbursement put in place in the 1980s encourages rationing and absurdly short length of stays in inpatient psychiatric units.  People who have undergone civil commitment generally have more difficult to stabilize mental illnesses compounded by a lack of recognition that they have a problem.  Some of them are also violent and aggressive and those behaviors are directly attributable to the mental illness.  The article refers to an incident where one of these patients threw a wooden chair at a nurse and the next day six voluntary patients requested discharge.  This is a relatively mild incident compared to what is possible in acute inpatient settings trying to care for people with the most severe forms of mental illness.  The most important aspect of treating violent and aggressive patients is having an environment of highly trained people to work with them.

The reality of the situation is reflected by the balance of both acute care and public psychiatric hospital beds.  There are 145 hospitals in the state of Minnesota and 125 have 24 hour emergency departments. Thirty two of these hospitals have psychiatric units.  These community hospitals have a total of  1,124 inpatient mental health beds statewide. Nine hundred sixty of these beds are for adults, and 164 for children and adolescents.  On the public side, there are 194 public beds for patients with severe mental illnesses who are committed.  Only committed patients can be admitted to these beds.  According to the Treatment Advocacy Center states need about 50 beds for 100,000 people.  Minnesota has 3.5 per 100,000 public beds and 22.8 per 100,000 beds in community hospitals.  Notice that in a comparison to psychiatric beds in OECD nations, the national average in the US is 22 beds per 100,000.  The United States ranks 29 out of 34 countries ranked in terms of fewest psychiatric beds.  Beds in public hospitals are not equivalent to beds in community hospitals and the newspaper report highlights the differences.  Like most states Minnesota continues to lose beds largely because of mismanagement at the level of state government and what has been an implicit initiative to shut down the state hospitals system.

The bed situation is compounded by a number of factors besides the lack of beds.  There is inadequate housing for people disabled by severe mental illness and inadequate resources to help them live independently.  The average person is expected to come in and see a psychiatrist for a discussion of medication and whether or not their acute symptoms are in remission.  Treatment for combined severe mental illness and substance use disorders is practically non-existent.  The inpatient crisis got worse when legislators passed a very poorly thought out law allowing incarcerated mentally ill patients to be transferred to remaining state hospital beds as a priority over committed patients waiting for transfer in community hospitals. This was an initiative to correct the statistic that Minnesota incarcerates 1.2 people with severe mental illness for every 1 person that it hospitalizes. 

All of the usual commentators are appear in the article - the Commissioner of Human Services and an advocate.  The reader is told that everyone is troubled by this development and wringing their hands.      

Well I'm not.  The entire sequence of events has been observable and is totally predictable.

This is a system that has been severely rationed nearly to the point of near extinction by Minnesota lawmakers and bureaucrats.  It has been interfered with by advocates and in some cases by very bad hiring decisions of people who were supposed to correct the problem.  The only thing we have to show for 30 years of hand-wringing is a a non-existent system of care that does not start to pull resources together until after a person has gone through a civil commitment hearing.  Psychiatrists have been marginalized in the process in favor of administrators who come up with one bad idea after the next.  Managed care systems seem to only recognize dangerousness as an admission criteria to inpatient psychiatric units.  The impact of that bias on commitment frequency, damage to the physician-patient alliance, and damage to the inpatient milieu is probably significant but nobody is interested in studying it.

From the article, the problem is clearly solvable.  There are an estimated 4,000 patients a year who need these services and only 194 beds available to them.  They cannot be humanely treated in community hospital acute care units.  They can also not be humanely treated in group homes designed to be surrogate state hospital beds.  They receive the least humane treatment in jail. The solution is not to blame community hospitals who cannot treat the problem.  One of the issues not mentioned in the article is that the state hospitals have been so decimated - they also cannot treat the problem.  There are probably three community hospitals in Minnesota who have adequate staffing and professional resources to address this problem.  It is conceivable that many more of the remaining 28 community hospitals with psychiatric units will adopt similar policies if they can.  The administrative measure of saying that they can't do this is really not a solution because they really can't provide the necessary care.  The state should know this from their failed initiative to provide smaller local units for committed patients.  That initiative failed for the same reason that St. Joseph's Medical Center no longer accepts committed patients.  They cannot provide adequate care for severe mental illnesses especially when aggression and violence is involved. 

I have posted the solutions in the past and they are obvious. Today I just have three:

1.  Build facilities necessary for the humane treatment of people with severe mental illnesses. Staff these facilities adequately and develop continuity of care with local facilities  when patients are ready to be discharged.  Build these facilities as state-of-the-art facilities in metropolitan areas and not rural areas.  The time is past when people were sent away to the country with mental illness.  Modern mental hospitals need easy access to advanced diagnostic and treatment equipment as well as expertise that is only concentrated in large cities.

2.  Immediately stop arbitrary transfers from county jails to state hospitals, unless the incarcerated patients have been assessed by psychiatrists who agree that a state hospital setting is the best place for them to be. 

3.  Get out of the way of the people who were trained to work there and run them - psychiatrists, psychiatric nurses, and social workers.     


George Dawson, MD, DFAPA



References:

1:  Chris Serres. Brainerd hospital stops admitting patients with severe mental illnesses, citing state bottlenecks: Brainerd decision alarms officials, mental health advocates.  StarTribune November 1, 2017.

Supplementary 1: The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons. The original image was Photoshopped with a graphic pen filter.

Another PSA On Pain, Opioids, and Addiction

It turns out that Twitter is an inadequate forum for discussing the issue.  Twitter is an ideal format for discovering if a poster knows anything at all about the problem.  A lot of people don't and they seem to just be there to argue.  I don't have a lot of time to waste on political approaches to medicine.  Political approaches to medicine typified by managed care companies, pharmaceutical benefit managers, and government guidelines that are supposed to improve care but don't are the reasons we have an expensive, fragmented and inefficient health care system.

The apparent political factions on Twitter consist of pain specialists who take the position that pain care and access to opioids is now being rationed and their pain patients are being unjustly treated.  They claim there is a faction of addiction specialists making various claims that they take offense to.  But my experience there is the past few days is that these are all basically red herring arguments.  A few of those claims include the idea that addiction specialists would consider pain patients "drug seekers", would recommend treating pain with only acetaminophen, are calling pain specialists "quacks", and of course that addiction specialists have some interest in distorting and overplaying the dangers of opioids.  In some cases the arguments have gotten to the absurd claim that the pain advocates (or more appropriately anti-addiction contingent) claims that most heroin users start using heroin directly rather than using legitimately prescribed or diverted pain medications first.

Where is the reality in all of this distortion?  The reality centers like most things in medicine in primary care settings.  The hundreds of thousands of internists and family physicians who provide the bulk of care for almost all problems in the US.  As I have posted on this blog many times, the evidence from both the CDC and CMS is that the majority of these physicians do a good job with opioids.  Only a fraction of their number prescribes a disproportionate amount of opioids.  Many of these physicians have a bias to underprescribing if anything.  That means the bulk of physician punitive legislation about mandatory course for opioid prescribing for these physicians will be just that - punitive toward most physicians who already know about prescribing these medications.  That legislation is also untested in terms of whether it will have any impact on the physicians who are overprescribers.

The other facet of the problem is overprescribing in general.  Part of the quality problem in medicine today is that the business and governmental management systems are focused on a brief physician-patient encounter where some medication gets prescribed.  That is the focus of the encounter. Patients expect that and come in the door with a medication request.  That results in predictable overprescriptions of medications from many classes.  The classes that reinforce their own use - opioids, stimulants, and benzodiazepines are more problematic than the rest.

At the extremes of this landscape are the pain specialists on one end and addiction specialists on the other.  Both have a broad spectrum of quality settings from state of the art to nonexistent.  These specialists know this and they know there is very little that can be done about it except to mind your own business and do the best job possible.  There are pain clinics that are "pill mills" where there is an understanding that a cash exchange with a prescriber will get you a script that can be filled on site for opioids.  That prescription is then sold in the parking lot for diversion.  There are other pain clinics where no attention is paid to addiction, psychiatric comorbidity, polypharmacy or the functional capacity of the patient being treated.  There are similarly low quality addiction treatment facilities where people are warehoused with no active treatment.  Where there is no therapeutic environment because nobody in the program is willing to consider that they may have an addiction.  There are programs where there is no medical supervised detoxification.  There are programs where there is no medication assisted treatment for opioids or alcohol use.  There are programs that do not address psychiatric comorbidity.  There are programs based on some sketchy ideas that have no proven relevance in treating addictions.  The houses of both pain and addiction specialists are not perfect because of these serious flaws.  And let's face it - the regulators of every state in the union are to blame for having so many low quality pain and addiction treatment facilities open for business and accepting reimbursement for shoddy services.   

For a moment - let's return to the idealistic world of the Twitter protagonist where the position seems to be "I am all knowing and do a perfect job."  The realities will  differ based on whether you are on the addiction or pain specialist end of the spectrum.  To illustrate, I am on the addiction end and 100% of the people are see have addictions or substance use problems.  On any given day the problematic substances average out to about 30% alcohol, 30% opioids, 20% mixed, 15% stimulants, and 5% cannabis.  Of the opioid users 30-50% have chronic pain problems.  In every case, I have a detailed discussion with the patient about how their substance use problem evolved and what keeps it going.  Over the years I see thousands of people with these problems and in that process come to know a lot about the associated issues.  My opinion is not based on my personal experience or politics.  My opinion is based on understanding the problems of thousands of people that I am supposed to help.  For example, when somebody tells me that the "average" heroin user in this country starts using heroin rather than prescription painkillers - I can say that is unequivocally wrong.  I have heard all of the details about how heroin use begins and it is almost always with a prescribed or diverted pain medication.  When somebody tells me that taking a person who is addicted to opioids and who has chronic pain off of opioids is cruel - I can also say that they are wrong.  I have had those same people tell me that they have never felt better and in less pain in years.   I can also say the following based  both on research, theory and clinical experience:

 1.  A significant portion of the population is predisposed to addiction - 

My estimate would be about 40%.  When a genetically predisposed person uses an intoxicant their reaction to it is markedly different from a person who lacks that predisposition. Opioid users report an energetic hypomanic felling where they have mental clarity like they have never experience before.  In some cases they will say that they felt like they had become the person they always thought that they could be.  This is a highly reinforcing state that leads to more opioid use.

2.  If the population predisposed to addiction is significant - the only limiting factor is access or availability -

This is the basic reality of the current opioid epidemic and of course very drug epidemic (methamphetamine, cocaine) that the US has seen over the past 200 years.  It is quite easy to look down from the high perch of a low availability area with low addiction rates to a high availability area with high addiction rates and conclude that "there is something wrong with those people".  The usual conclusion has been that they are morally defective.  This is how addiction services have been rationed, poorly researched, and fragmented over the years.  Even if you subscribe to a top health plan in the country - it is likely that you will have poor access to quality addiction care because of these attitudes.

3.  The burden of prescribing medications that reinforce their own use falls squarely on the prescriber - 

It is above all else an informed consent issue.  The patient needs to know that the medication they are taking is not a panacea and that there are significant risks up to and including addiction and death.  They also need to know that these medications can have cognitive side effects and affect their day-to-day functioning.  They should not be prescribed solely out of the notion that the physician feels like they need to do something for the patient.  There needs to be a pain diagnosis and treatment plan.  In the case of chronic pain the patient needs to know that there is no known medication that completely alleviates chronic pain and therefore continued dose escalation of opioids is not a solution.  The treatment plan needs to contain more elements than taking the opioid prescription.

An associated prescriber issue is polypharmacy.  Chronic pain is frequently associated with anxiety, depression, and insomnia.  That can lead to a contraindicated polypharmacy environment that includes a benzodiazepine, a z-drug, or a sedating antidepressant used with the opioid.  It can also lead to the patient taking alcohol or diverted sedatives on their own initiative with the opioid.

4.  Chronic pain patients taking opioids need thorough evaluations if possible -  

Some people in the Twitter debate seemed shocked by the idea that opioids are taken for reasons other than pain relief.  I suppose they would be even more shocked if they heard that there are people that take them who get no pain relief at all from them.  They taken them strictly because of the positive euphorigenic effects.  There are also people who take them despite the side effects for the same reason.  The first thing a physician needs to do is step back from the indication - prescription mode that most American physicians have been trained in to take a look at the entire prescribing landscape.

That means that is a person has come to idealize a medication or abusable substance they will start to use it for anything - insomnia, anxiety, depression, or "just to feel right to get through the day."  As many people tell me: "Look doc - if you can't get rid of this depression I know what I can take to feel OK for a couple of hours."  On Twitter and some other blogs readers are incensed that these behaviors exist and yet they are documented in the literature (see paragraph 6).

When I say if possible I am more aware of the fact that patients lie to physicians than non-addiction specialists.  I have had an endless number of patients tell me that they can get whatever addictive medication they want out of one physician or another.  The Mayo clinic had an addiction medicine conference three years ago and one of the presenters was a patient in recovery who basically talked about how he systematically lied to physicians to get opioids for years.  He talked about how he could identify a physician who would give him the script that he wanted and who would not.  In the case of the latter he would just move on to another clinic.

Many non-addiction specialists consider it to be poor form to suggest that patients lie.  That denies the basic reality that everybody lies.  It also denies the reality of addiction, that you are transformed into a person who is dishonest and a person that you never thought that you would become.  In the addiction field it is critical to acknowledge this to help people deal with guilt and shame so that they can recover.  The worst thing that can happen is to collude with dishonesty when the final result is the prescription of an addictive drug.  I do not consider it to be an issue that I can get this history when the physicians being approached for the medication cannot. It is all part of the illness of addiction.  On the other hand, if you are the opioid prescribing physician - the amount of information that you can get asking the direct questions about problematic use is not known until you try it.   

All things considered it is possible to treat people with chronic non-cancer pain with opioids.  I have been involved in that treatment before I switched to seeing only patients with addictions.  I consulted with some of the top pain experts in the state.  All the limits in this post need to be acknowledged and cautiously addressed.  The treatment of chronic pain is not perfect, I know that because I see a lot of the failures.  Addiction treatment is not perfect either.  The treatment needs to be highly individualized.

I wish that I could provide more clear guidance to the patients involved.  As an individual I cannot just start pointing fingers at the places (pain clinics and addiction treatment) that I think should be shut down.  I think that you need to depend a lot on your primary care physician referring you to places that he or she knows will do good work.  On either the addiction or pain end of the spectrum - there has to be more going on than the prescription of medications.

Even the most basic psychological models suggest that other cognitive, emotional, affiliative, spiritual and reconditioning changes need to occur.


George Dawson, MD, DFAPA