Sunday, October 15, 2017

Opiates - A Public Health Crisis

Opiate abuse is on the rise and we are not just talking about heroin.  Prescription opiate abuse has grown over a 50% rate increase since even two months ago in some parts of the country, 50%!  Doctors, nurses, and other health care professionals are trained to give pain medicine when it is appropriate for the patient.  Many of such cases are post surgery or post injury.  Sadly, even taking these medications for as little as one week can leave a person "hooked".

Hospitals get rated and with ratings, which is mainly patient satisfaction, comes either fines or money to put into their operating budget.  When a patient is at the hospital, the biggest score to watch is the patients "pain scale".  So, if a patient says my pain is at an 8, the staff is REQUIRED to do something, which means either an oral pain pill or even an IV injection of say, Fentanyl.  The patient can do this as many times as they want and within the time limits of each medication, the hospital is required to respond and give the medication.  This means the patient can lie and yet, medication must be given and therefore, the patient can be discharged and hooked on pain medicine.

Checks and balances have been put into place.  Many states have a pain medication monitoring system, that allows doctors and nurses to see a patients prescription history and therefore, can refuse to give a patient pain medication knowing they had a fill from another doctor and pharmacy just last week.  However, if that same patient comes into the hospital ER and talks about pain, medicine will have to be given and cannot be refused.  Therefore, some patients are able to get their fix with oral pills and skip around pharmacies knowing the loop holes and others skip around hospitals getting an IV fixation of medicine. 

The sad thing is that many, in fact, almost all of these patients never wanted to get "hooked".  In fact, most had an actual injury or surgery that lead them to becoming introduced to the medicine and with say a surgical complication or really bad injury, the patient was on pain medication for several months, maybe even having multiple hospitals stays and surgeries and thus, they were on the medicine for long periods of time.  When it came time to get off, they were not able to do so and experienced horrible withdraw which only lead the patients to get back onto the medicine. 

Withdraw is a horrible experience for anyone.  Sweating, nausea, diarrhea, insomnia, increased pain, lack of energy, depression, and much more will take the patients full focus leaving him or her to not be able to work or even function around family.  It can last a few days to several weeks and destroy home relationships and friendships.  It can also cause patients to loose time at work and even get fired.  Therefore, in order for the patients body to function naturally, they must get back on the medicine.  Many patients are not getting the medication to get "high", but to at least not have chronic pain and to be able to function normally.  It is like someone who has diabetes and has to have insulin injections.  Those injections allow the patient to live normal, control their diabetes and thus, focus on other things and not just their diabetic problem.  Same goes for the patient who is hooked on pain pills.  They must be able to get back to a normal "level" of function within their nervous system, thus taking at least one or two pills does this.  However, it leaves the patient hooked and not knowing what to do other than to continue to take the pills.  The sad thing is that over time, the patient has to take more and more to get to that same "level" of normal functioning, which is called building a tolerance to the medicine and can lead to more and more issues such as taking stronger and stronger medicine. 

This particular post, which is the 1st of a 4 part series, isn't focused on the many issues and questions just coming from the above overview of this complex topic.  Rather, it is about the lack of help for these patients once they do become hooked, which is a huge part of driving this public health issue deeper and deeper into the dark and leaving many to wonder if they will ever get off of these pain medications. 

Doctors and other health care providers do not have the time to deal with patients above after they have become a "problem" patient.  In fact, when a doctor feels the patient may be more or less addicted, many doctors send a letter to the patient advising them they will no longer see them as a patient, in fact this is the doctors way of "breaking up" with the patient.  That same patient will end up then finding a new doctor who will help them, but then could end up in the same boat.  For some patients, when they feel they have reached the end of the line with doctors, some will turn to illegal ways of getting the medication or perhaps, go to a more dangerous and stronger type of opiate, such as heroin.  This is what leads to the sharp increase of patients from a low dose of pain medication to the more dangerous opiate and causing more health problems and also death by accidental overdose. 

While our society has put pressure on hospitals to ensure patients are "happy" and that pain is bad and must be "blocked" by the brain, we came up with a simple answer.  Give them a pill and that is all they need.  What we need to do is to look at other ways to treat pain, including massage therapy, therapy itself of the mind, other medication that isn't an opiate, and many other such types of pain management.  However, this isn't ever really talked about, as many of us have been patients and have had surgery, think about what you were told and given options as when you had pain.  Think about the simple visit to your doctor when you got pain medication given to you, if you have been down that road.  Much of this goes back to the education at medical school and how medical students are not taught about pain, all the issues surrounding pain, and how many different types of therapy exists for pain treatment.  Doctors are busy, taking time to discuss issues such as this could cause them to lag behind in their daily schedule and get a penalty.  All of this comes back to the ratings that hospitals and doctors get when dong their job.

The sad thing is that much of this is totally preventable, even by having a short simple, but frank discussion, when patients are given or will be given a pain medication.  Even giving them other options should be verbalized to them.  However, many times it is not.  More needs to be done in this area, which will be the focus of our next blog.  Finally, when a patient is "cut-off" instead of throwing them into the cold ocean, as many doctors offices do (they break up and turn their backs knowing the patient may have an addiction problem), they forget about that patient and say; "It isn't my problem".  Sure, say that to the family that just had their loved one overdose with a problem that was small at best, yet grew into a huge problem and therefore, they died because they were ignored.  This is the FAILURE of our system.  Would a doctors office or ER ignore a patient who came in with half their finger cut off?  No way.  So why do they do just this?  Is it because we still see a "mental illness" as not a real illness, when it really is no different than someone who has heart disease?  Addiction is a disease of the mind, but don't be scared of it, rather refer that patient out to get help just like you would if they had a heart problem.  Failing to help these patients by cutting them off and turning your back is cold, wrong, and honestly goes against the Hippocratic oath that EVERY doctor takes when graduating from medical school; "I shall do NO harm".  Yet, they do when they send that letter as their last correspondence to the patient saying they won't see them anymore and that is it.  What needs to be done is learning how to really approach these patients, softly describing to them that addiction may be of concern and thus, WE CAN HELP.  Many patients would welcome the help as many of them are scared not knowing how to get off of the pills, because many of these patients WANT to get off of the medication.  But when they are looking into the deep blue ocean, it is easier to go and get that life boat or life jacket then to jump in on their own for fear of drowning. 

As a public health expert, I must say that we are FAILING to give any patient help when they see that deep blue ocean.  It is causing patients to move to illegal ways of obtaining the medication and then leading to getting onto stronger forms of an opiate all the way to death.  Patients who had shoulder surgery didn't plan to get addicted, they wanted their pain in the shoulder to stop and thus had surgery done.  They didn't ask for another COMPLICATION of the surgery, opiate addiction.  But when that did occur, they need help.  Would we ignore a patient with a bleeding complication from surgery?  No we wouldn't, so why are we ignoring this complication?  Because the attitudes of many health care professionals is it is not their problem or they didn't create this problem or the patient needs to find help on their own as psychiatry isn't part of my job as a surgeon.  If we do not start to retrain medical education on this subject, how pain management includes MANY options other than opiates all the way down to doctors knowing how to recognize a patient who "might" be addicted and knowing what path to take for that particular patient, it could change the lives of many patients ONE PATIENT AT A TIME.  And if we do that, then our stats get better and thus, public health gets better.  Therefore, we need to implement PUBLIC HEALTH POLICIES that change the way we not only think about this, but the way we ACT about this....because at the end of the day, one life taken back by getting off the pain medication successfully without relapse, means one life saved which means the world is a better place.

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