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The DEA's Prescription Drug Problem:

The Drug Enforcement Administration is concerned about the abuse of prescription drugs, but its solution may do more harm than good. Writing in today's WSJ, former FDA official Scott Gottleib explains that the DEA is threatening to interfere with medical practice decisions, to the detriment of many Americans who benefit from prescription drugs.

The Drug Enforcement Administration is, sensibly enough, targeting the small number of physicians who inappropriately prescribe drugs in violation of current laws, the "patients" who doctor shop for painkillers and hoard drugs to abuse or sell them, and the criminal diversion of these medications from pharmacies and distribution centers. But the DEA is also trying to influence clinical decisions about when these drugs are prescribed.

This is a mistake. Clinical issues are not the expertise of the DEA. Placing more restrictions on the legitimate prescribers can harm real patients and ethical physicians.

Tom952 (mail):
Before we get the DEA very involved, we should assess the magnitude of the problem. If the problem is caused by relatively few irresponsible physicians, it can be solved without bringing it under the umbrella of the war on drugs.
2.27.2008 10:55am
Thoughtful (mail):
"This is a mistake. Clinical issues are not the expertise of the DEA."

Yes, absolutely. If clinical issues WERE the expertise of the DEA, THEN it would make perfect sense for them to interfere with the private decisions of competent adults as to how to best live their private lives. Because obviously what one chooses to ingest or inject oneself with is only a medical issue, having nothing to do with personal autonomy or abstract issues of freedom.
2.27.2008 11:03am
Grover Gardner (mail):
"If clinical issues WERE the expertise of the DEA, THEN it would make perfect sense for them to interfere with the private decisions of competent adults as to how to best live their private lives."

Not that I necessarily agree with the DEA, but if the problem is doctors who overprescribe, the patient may not be making a competent "personal" decision. He or she may be pain-wracked, depressed or in an otherwise unstable state. Could we say with certainty that Heath Ledger made a "private" decision to over-medicate himself?
2.27.2008 11:12am
ejo:
the Government interferes in the private decisions of adults seeking medical treatment all the time. useful medications get taken off the market or less than useful ones put on the market due to lobbying. Doctors have a tendency to prescribe first and ask questions later-why should they, of all professions, be free from government oversight?
2.27.2008 11:22am
Mark Buehner (mail):
Doctors have a tendency to prescribe first and ask questions later



Not when it comes to pain killers, I can assure you of that. Doctor shopping is no easy thing these days, there are all kinds of protocols that make it tough if not impossible.

All the DEA is going to accomplish in all likelihood is to continue the practice of denying pain relief in hospice care. We cant have red blooded Americans dying of cancer while all hopped up, now can we?

This whole thing is a freaking joke. Doctors have the biggest incentive in the world not to overprescribe- their bank accounts and their livelihoods. Risk of malpractice lawsuits is a fine market solution that doesnt require the feds using their muscles to enforce this weird temperance movement that continues to exist in America for some reason.
2.27.2008 11:30am
WR:
How is it that it took a Constitutional amendment for the federal government to have the power to regulate alcohol, but it now regulates (other) drugs by simply passing a law (or worse yet, by issuing a regulation)?
2.27.2008 11:36am
therut:
Well this will be a mess. I already refuse any new patients that comes to the office with primarily a chronic pain problem(usually back) because of the risk and hassle(for 27.50 payment) of the governemtnt or some nasty lawyer getting involved if the patient is lying and abusing the drugs or selling them. After all my insurance has the deep pocket. Patients who truly need chronic narcotics are going to get left buying on the black market. I also get tired of beig cussed out and begged for pain meds, finding out the patient is seeing other physicians and dentists and getting meds, going to multiple ER's for meds. The problem is we have no way of telling (as does .gov disability assessors or the patients disability lawyer who does not care whether the patient is hurting or not). Just hope you never need chronic pain meds cause the time is coming you may not get them.
2.27.2008 11:38am
ejo:
doctor shopping no easy thing-I completely disagree on that. I see plaintiff's prescribed multiple pain meds from multiple physicians all the time, all without a clue as to what the other is providing. my favorite is an opiate addict who actually underwent treatment for addiction who continues to receive prescriptions for opiates from the uninformed doctor.
2.27.2008 12:00pm
Fub:
Jonathan Adler wrote: February 27, 2008 at 10:09am:
The Drug Enforcement Administration is concerned about the abuse of prescription drugs, but its solution may do more harm than good.
That characterization of DEA's motives and the consequences of DEA's actions is Pollyannish at least. But it is understandable. An accurate characterization might raise immediate outcries of "Godwin!"

Jonathan Adler quotes Scott Gottleib:
This is a mistake.
It is not a mistake. It is a methodically calculated strategy.

Maybe Scott Gottleib treads so lightly because he has more to lose if the DEA uses the power and influence of government office to publish lies about him like DEA administrator Karen Tandy lied about Radley Balko a few years ago.
2.27.2008 12:10pm
NI:
I think the policy question is which is worse: overmedicated drug addicts (some of whom, like Heath Ledger, actually will kill themselves); or people screaming in agony who can't get treatment because doctors are scared of losing their licenses. I myself come down on the side of freedom. There always will be irresponsible people, and their existence should not deprive people who really need something of being able to get it. I'd be just as happy to abolish the DEA altogether. The current temperence movement, as someone aptly called it, is like saying that there should only be G-rated movies because it's possible children might see something they shouldn't. Sorry, but responsible adults have rights too.
2.27.2008 12:22pm
Soronel Haetir (mail):

As someone who has been on such medications for years now to treat cronic pain caused by nerve degeneration movements like these are of great concern to me. I have seen multiple reports of enforcement agencies with little understanding of actual patients.

My case is made harder by the complete lack of any scanable cause for my pain, yet without meds I would not get out of bed and may well have committed suicide years ago.

I do have a suggestion for the problem of doctor shopping and multiple prescriptions if such a problem actually exists. Require electronic filing of the prescription and track recipients. This would have the additional benefit of reducing errors from scribbling. I have received the wrong medications more than once in non hospital settings from this cause.
2.27.2008 12:27pm
Ak:
Implying this is a "mistake" erroneously assumes that the DEA doesn't want a decrease in all narcotic use, both legal and illegal. Precisely why this is the case is unclear to me. Maybe they're just Puritanical zealots? Or power hungry? I don't know, but they sure do hate painkiller use.
2.27.2008 12:32pm
Mark Buehner (mail):
I see plaintiff's prescribed multiple pain meds from multiple physicians all the time, all without a clue as to what the other is providing


That doesnt mean it was easy to do. A lot of doctors and hospitals wont prescribe painkillers to new patients. Sure if you have a doctor of longstanding and are willing to jump through the hoops to get multiple scripts, its entirely possible. But that doesnt make it easy. It CERTAINLY doesnt make it easy for the geniune victims of a chronic condition if they need a new doctor.

Thats really the question- are we so damned worried about some pill-head getting a few dozen extra oxycodine in his pocket that we are willing to let people in genuine distress languish? And pain is a medical condition mind you- we are killing people by denying them pain treatment just as sure as letting somebody O.D.

Also, im pretty sure the guy doctor shopping isnt the guy selling a thousand pills a week out of his trunk, which theoretically is who the DEA is supposed to be concerned with. Stop the guys coming up in a van from Mexico, and quit bothering doctors.
2.27.2008 12:35pm
ejo:
wish all you like but the trend is going to be towards greater, not lesser, control of physicians by the government. if you think that greater socialization of care is going to lead to more medical freedom, you have been dipping into the free samples. I would agree as a general matter that we should have greater freedom to take the medications we think should help us, particularly after having been informed of the risks. That's not the world we live in today, however, based on both government regulation and lawsuits.
2.27.2008 12:51pm
Bill Poser (mail) (www):
The irony of this is that it is well established that pain is undertreated in the United States. This is partly because of the restrictions already imposed and the fear of physicians that they will be prosecuted for legitimate prescriptions, and partly because of the residual tradition that people deserve their pain or that pain is not real and patients are just malingering. When anaesthetics first became available for surgery, many physicians opposed their use.
2.27.2008 1:20pm
ReaderY:
Why should the federal government completely regulate all aspects of medicine simply because it involves commodities that happen to have traveled through interstate commerce?

Semen and eggs are valuable commodities worth money in interstate commerce. Choosing to use them for personal sex or reproduction rather than having them commercially harvested for the market would appear, under Raich v. Ashcroft would appear to be a commercial decision with privacy implications whatsoever.

he Supreme Court has said many times that privacy is the end point of a spectrum whose other end is interstate commerce. Privacy involves non-commercial matters.

However, under Raich, activities which tend hold commodities which could be used in commerce from the market(even if it is illegal to do so) are commercial activities. It is difficult to conceive of non-commercial ones.
2.27.2008 1:56pm
BruceM (mail) (www):
"physicians who inappropriately prescribe drugs in violation of current laws..."

That sounds straightforward and logical enough, but the only law in question is the one that says controlled substances may only be prescribed for "a legitimate medical purpose in the normal course of medical practice." That's a very broad, ill-defined, definition to use to support criminal prosecutions, let alone to give potential defendant-physicians adequate notice of what is prohibited.

Additionally, it's important to note that while a lot of people think it is against the law to prescribe controlled substances off-label, in fact it is not. Drugs like Oxycontin (oxycodone) are "indicated" (FDA-approved) for the treatment of "moderate to severe pain" but as long as it's a legitimate medical purpose, it can be prescribed off-label for something else, like diarreah, cough, or certain psychiatric problems. This is just an example, there are many alternative drugs for those indications and few doctors are going to be willing to write an Oxycontin Rx for diarreah. But like all opioids, it causes constipation and thus treats diarreah.

The other issue is that the DEA likes to decide for itself what a "legitimate" dose is, usually focusing on the number of pills rather than the quantity of medicine per pill. Doctors are safer writing a Rx for 100 50mg pills than for 200 25mg pills, 100 sounds better than 200 in front of a jury being told you're worse than Pablo Escobar. The DEA has no business or expertise in deciding what dosage of medicine a given patient should take, and many pain specialists treat people who have had chronic pain for a long time, and thus have been taking opioid medications for a long time so as to have a very high tolerance. Opioids have a linear dose to response curve, there is no upper limit to how much a human being can take, LD50 is based entirely on individual tolerance.

The bottom line is the DEA has no business regulating the practice of medicine. There is going to be a certain amount of diversion of controlled substances, and there's simply nothing that can be done about it. You can't stop people from giving each other pills. And unless the doctors are actually selling prescriptions to people who ask for them, with no examinations, and with the patient deciding what drug and how much of it they will pay for, the DEA needs to get out and stay out. If a patient has been on opioids for chronic pain for 20 years and needs 1400mg of oxycodone per day, then that's none of the DEA's business.

All this creates a massive chilling effect on the willingness of physicians to write prescriptions. Unfortunately the DEA has their own doctors who will write all the oxycodone and fentanyl prescriptions necessary when one of its agents needs painkillers (Agent Bob got hurt by bumping his foot on a file cabinet while on the job fighting doctors who prescribe more opioids than Agent Bob, who never went to medical school, felt was legitimate... but Agent Bob knows he's a "good guy" so he should be allowed to get all the painkillers he wants.).
2.27.2008 2:04pm
ejo:
sorry, not buying the unavailability of prescription painkillers. I have yet to see a case where someone is suffering and no doctor is writing the scrips for pain. The more common one I see is someone with phantom pain or causation issues getting multiple pain meds from multiple doctors. The DEA isn't going to go away nor is government oversight of prescription drugs.

If doctors want a different oversight regime set up, I would suggest that put as much effort into setting it up as they do trying to put legislative roadblocks against malpractice claims.
2.27.2008 3:25pm
BruceM (mail) (www):
ejo: it's more the undertreatment of pain rather than the absolute unavailability of painkillers. Most people are lucky to get 5mg of vicodin. That's barely anything.
2.27.2008 3:33pm
Thomas_Holsinger:
I have personal experience both ways. Doctors seem to be very free with minor prescription painkillers. My wife and I accumulated a whole bag of the things over 10-20 years of athletic accidents, root canals, car accidents, etc. We didn't like using any when we didn't have to because they clouded our minds too much.

So at one point when I developed a gum infection, I jammed all our left-over pain medication into a bag and took it with me to Urgent Care to invite the doctor to choose what she thought would work best for me rather than issuing another prescription that I'd use only a little of.

She took one look at the vials I dumped on her desk and cried, "Do you know the street value of that?" Then she started looking at the dates and said, "But it's almost all time-expired." So I invited her to throw out the ones she thought we should dump, and she told me to use some not-too-old Vicodain until the antibiotics reduced the pain and swelling of my gum infection.

On the other hand, my mother starved herself to death in a hospice when her esophogheal cancer recurred, and the staff there had enornmous fights getting her the pain medication she needed. Even though her prognosis was terminal and she was refusing all nutrients.
2.27.2008 4:12pm
cathyf:
...people who have had chronic pain for a long time, and thus have been taking opioid medications for a long time so as to have a very high tolerance.
You know, I've never heard anyone comment on the very curious adoption of the word "tolerance" when describing the body's acquired resistance to narcotics. Why use this weird nice-sounding euphemism to hide the underlying process? Because, of course, resistance is bad; it's a problem. People with "insulin resistance" have the early stages of the devastating disease diabetes. Bacteria which develop "antibiotic resistance" are a public-health nightmare. When enemies in battle offer up stiff resistance, that is bad for our side. But "tolerance" is a good thing, right? When someone needs a drug that can have debilitating side effects, and it turns out that the particular individual doesn't suffer from them, we sigh with relief that he "tolerates" the medication. People who let their neighbors live differently without molesting them are "tolerant". Indeed, "tolerance" is one of the core values of a functioning civil society.

No, let's call it as it is: people who take painkillers over time develop physical resistance to the pain-killing effects of the drugs. There's plenty of the kafke-esque in the "War on Drugs" -- allowing the neo-Temperance movement the unquestioned Orwellian abuse of language doesn't help.
2.27.2008 4:13pm
cathyf:
"a legitimate medical purpose in the normal course of medical practice."
While we're on the subject of literary metaphors, the are the multiple Faustian bargains in "the normal course of medical practice." Take the "pain clinic." This is a specialized medical facility where a patient is allowed 5 days worth of painkillers per month. In exchange, the patient must agree not to go looking for more painkillers on the black market, not to go trying to find another doctor or another pain clinic, not to request any pain meds for the other 25 days in the month, indeed not to react to the 25 days of untreated pain each month with the slightest sign of dismay or any negative emotion at all, because that is, by definition, "drug-seeking".

Oh, yeah, and if you die from the liver damage caused by taking too much tylenol, or bleed to death from the advil-caused gastric ulcer, that's just because you were too stupid to "read and follow label directions."
2.27.2008 4:30pm
Earnest Iconoclast (mail) (www):
It's is tolerance in the sense that someone who is in extreme pain and/or has had a lot of exposure can tolerate doses that would kill someone who was not in pain and who had not had any of the drug before.
2.27.2008 4:31pm
NI:
I agree completely with BruceM. And how is it not practicing medicine without a license (which in most jurisdictions is a criminal offense) for a non-MD DEA agent to decide what is a legitimate dosage?

(For that matter, how is it not practicing medicine without a license for an HMO to decide what procedures a patient needs, but that's another topic.)
2.27.2008 4:47pm
cathyf:
It's is tolerance in the sense that someone who is in extreme pain and/or has had a lot of exposure can tolerate doses that would kill someone who was not in pain and who had not had any of the drug before.
It is also "tolerance" in exactly the same sense as a bacteria which has acquired antibiotic resistance (from overuse of antibiotics) can "tolerate" antibiotic doses that would kill bacteria that is not antibiotic-resistant because it had not been exposed to the antibiotic before.

But nobody calls that "tolerance" -- because they don't want you to make the mistake of thinking that "antibiotic tolerance" is a good thing.
2.27.2008 5:40pm
BruceM (mail) (www):
I never said tolerance/resistance (whatever you want to call it) was a "good" thing. It's just a reality of taking opioid medications long-term. Usually people do reach a plateau. It's also important to note that when one's regular dose of pain medicine no longer works as well, it could be tolerance or it could be an increase in the severity of the underlying pathology, as any pain management doctor will tell you. Pain that's controlled by 100mg may get more severe and require a higher dose to control.

Tolerance is merely the accepted word. Resistance, I think, implies an opposing force. Tolerance is merely less efficacy of a given dose over time.

CathyF: Never in my life have I heard of a pain clinic where people only get 5 days worth of medicine per month. Please show me a link that indicates such a place exists. If a patient has chronic, intractible pain, it would be per se malpractice for a doctor to prescribe 5 days worth of medication, requiring the patient to suffer the other 25 days. Remember, not prescribing necessary medicine is not only a violation of the hippocratic oath, it's malpractice.
2.27.2008 5:44pm
Phelps (mail) (www):

Before we get the DEA very involved, we should assess the magnitude of the problem.


Actually, before we start calling it a problem, let's determine if a problem exists.


Not that I necessarily agree with the DEA, but if the problem is doctors who overprescribe, the patient may not be making a competent "personal" decision. He or she may be pain-wracked, depressed or in an otherwise unstable state.


Uhh... if the patient is too pain wracked to make an informed decision, I think that this the best argument possible to prescribe more painkillers. That's a perfect catch-22 -- "I can't prescribe you painkillers because you are in too much pain. Do something about your pain and I'll prescribe you some painkillers."
2.27.2008 6:32pm
cathyf:
From people I know with adhesion disease, the standard regime at pain clinics is once-per-month appointments, with 30 pills dispensed at each appointment. If one pill lasts 4 hours, 4 hours/pill * 30 pills = 120 hours, and 120 hours = 5 days.

(The further irony, of course, is that while 30 pills per month is pathetically inadequate for pain control, it's probably often a perfectly adequate supply for the addict who is faking pain and using the drugs recreationally.)

Yeah, you would think it was malpractice, wouldn't you. My friends tell me that lawyers that they have consulted tell them not to bother with a lawsuit. Maybe you lawyers here can explain that better than I can. My non-lawyer guess is that 1/3 of the amount of money which is the expected return of such a lawsuit wouldn't cover the lawyer's expenses. There was a successful suit some years back where a cancer patient died in agony because the puritan nurse in the nursing home took it upon herself to "save" him from drug addiction by flushing his morphine down the drain. The family sued and the award was, I believe, $3 million. But that was a special case where the patient in pain was terminal (and proveably so, since he was already dead at the time of the lawsuit.) The neo-puritans will grudgingly allow pain meds to end-stage terminal patients, but the ingrates who insist of staying alive are another matter entirely -- the fact that they are still breathing is some sort of proof that they must be faking the pain.
2.27.2008 6:39pm
BruceM (mail) (www):
cathyf where are you getting these numbers from? Where have you heard of 30 pills per month for pain management? Methadone and buprenorphine last about 24 hours, are you thinking of clinics that treat opioid addiction with either methadone or buprenorphine? That's a once-a-day (30 pills a month) regime. But it's not for pain. It's to wean people off of pain medication dependence/addiction.

Unless you can show me differently, I assure you that there are no pain management clinics ("clinic" is really just a couple of doctors sharing the same practice) that have a policy of giving 5 days worth of medication for pain with the condition that the patients go untreated and suffer for the remaining 25 days each month. No such thing exists, it would be per se malpractice for the doctors involved (and it would be a worthwhile lawsuit to any semi-intelligent lawyer), and such a place would be a derisive joke to even the most suffering chronic pain patient - nobody would go there except recreational drug users who would get a kick out of having a handful of pills per month to use for recreational pleasure, as you point out).
2.27.2008 8:51pm
Kathryn in California:
Entire counties in California are empty of doctors who feel safe prescribing effective painkillers to people who need them. I know this because I know someone dealing with this on a daily basis.

This isn't for short-term visitors doctor-shopping in the county— this is for patients who'd be willing and able to get their pastor to count the pills each week, or otherwise find ways to show they're taking every pill they're prescribed as prescribed.

My friend's father "B" spent the last 25 years of his career running a Bay Area non-profit providing help to the homeless. B's work included heavy lifting in their food bank, and by the time he retired a few years ago his back was shot.

30 years ago B and his wife bought property up near Red Bluff- a rural area in far Northern California (6 hours north of the Bay Area). They'd planned to retire up there.

Except B cannot get pain medication in Red Bluff or anywhere nearby --every doctor is afraid of the DEA. The nearest doctor who can prescribe pain medications is several hours south—several very painful hours away, if you've ever had to be in a car while in severe pain.

The damage to B's body from stress and lack of sleep is going to kill him far earlier than any hypothetical "addiction" to opioid drugs could do. I write "addiction" because if one person requires a much higher dose than another for a painkiller to work, but can tolerate that dose for years, that isn't addiction in my book.

B's constant pain means his wife is also always stressed, B's children are always worried that then next phonecall will be a message of B's early death. B's grandchildren rarely see him, because B cannot travel to them, and when the grandkids visit B is usually in bed, in pain.

If you think you don't know anyone affected by the DEA's policy, ask around.
2.27.2008 9:28pm
LM (mail):
ejo,

sorry, not buying the unavailability of prescription painkillers. I have yet to see a case where someone is suffering and no doctor is writing the scrips for pain.

And that means what? That it doesn't happen? That you haven't witnessed it directly? Well here's another one you can claim never happened.

My cousin and lifelong friend slipped on the ice playing football one Saturday in Boston about thirty years ago, and was carried by friends into the emergency room. He was X-ray'd (negative), told he had severe spasms, maybe more, and encouraged to see an orthopedist as soon as he could. Then he was told he could leave.

Pain killers? Phthhth....

Muscle relaxants? Right....

He was obviously in agony and nobody accused him of a rouse to score drugs. They just said it was hospital policy to refuse any medication for pain to walk in patients who aren't admitted. (Whether not admitting him was correct is another question, but one he had no interest in pursuing when it was brought up later.) His friends carried him back to the car.

After laying on his living room floor for a sleepless day and a half with some food, water, empty bottles and a bedpan, he saw an orthopedist who eventually fused the vertebrae surrounding his ruptured disc. But the upshot was that this nerdy kid who'd never smoked a cigarette, much less a joint, and who had been drunk once on his 18th birthday, promised himself he'd never be vulnerable again to what happened at the hospital. So he proceeded to hoard and eventually abuse pain killers for the next nine years. By the time he was a first year resident (he's a surgeon) the pills were jeopardizing his career. He managed to give them up and has been in AA for 20 years.

This is somebody who knows and preaches the dangers of drug abuse. But he's also told me numerous accounts of doctors who are intimidated by the DEA into under-medicating for pain, and others like therut who methodically screen out potential patients with chronic pain needs. But what I find most appalling are the stories he hears just like his own; people whose initiation into drug abuse was somebody's traumatizing, callous refusal to administer minimally necessary pain relief.

He doesn't blame anyone for his addiction. He's of the "addiction is a disease" school, and he says it only hinders his treatment to dwell on anybody's responsibility except his own. But he doesn't deny knowing that an unintended consequence of all the the scrutiny and suspicion of painkiller prescriptions is triggering some unknown number of active addictions. Part of his therapeutic philosophy is that they were all inevitable anyway. To me, that's highly speculative.
2.27.2008 9:46pm
LM (mail):
Yes, that should be "ruse," not "rouse." Spell-checks lend such a false sense of security.
2.27.2008 10:00pm
BruceM (mail) (www):
I have a friend who lives in Austin who has to come to Houston once a month to see his pain specialist - he cannot find anyone in austin willing to treat his pain. And he has a verifiable, congenital condition, not like "back pain" or something else hard to verify the existence and degree of.

I should also note that except for the acetaminophen intentionally added into some opioids in order to make them toxic in large doses ("less abusable" is the way they phrase it, but the intent is to cause liver damage), and except for propoxyphene which has a toxic metabolite and is so weak an opioid that studies show it works no better than ibuprofen, opioids are the safest drugs known to man. They have no side effects other than constipation, and in high doses respiratory depression - which is how people overdose on them. But any medication, drug, or substance - even water - can be toxic in large doses. The poison is in the dose. Insofar as drugs go, opioids are the safest ones in existence.

I'd also like to add that you can abuse kittens, puppies, little children, and yourself, but you cannot abuse a chemical. It has no feelings.
2.28.2008 12:59am
Fub:
ejo wrote:
sorry, not buying the unavailability of prescription painkillers. I have yet to see a case where someone is suffering and no doctor is writing the scrips for pain. The more common one I see is someone with phantom pain or causation issues getting multiple pain meds from multiple doctors. The DEA isn't going to go away nor is government oversight of prescription drugs.
Perhaps you never saw the case of Richard Paey.
2.28.2008 1:35am
Mary Katherine Day-Petrano (mail):
Next thing you know, DEA is going to ride into town, ban, and prosecute doctors who prescribe and autism patients to utilize horeseback riding therapy, for releasing too many opiod endorphins in the brain.
2.28.2008 3:08am
ejo:
all I see are anecdotes about how rough it is to get painkillers while, in my practice, I routinely see folks with multiple scripts from multiple doctors who are completely clueless about what is being taken. I guess I am supposed to credit anecdotes over my lying eyes. I would further guess, despite these anecdotes, that you would see absolutely soaring usage of prescription pain killers over the last 20 years, not the absolute lack of them as is the theory being presented here. Can someone direct me to a source which shows some precipitous drop in the amount of painkillers being offered to american patients? I would guess that would show up somewhere on the bottom line of companies who manufacture the items.
2.28.2008 10:33am
cathyf:
There is also the whole counting statistics problem...

Imagine a town which has 100 doctors, and 1000 people in severe, intractable, chronic pain.

50 of the doctors are so afraid of the DEA that they screen out all new patients in pain. A few of those doctors have 1 or 2 long-time pain patients that they trust -- 20 patients total.

980 patients left.

45 of the remaining doctors will take new pain patients, but they are very cautious to limit their numbers so as to not attract DEA attention. They average 5 pain patients apiece -- 225 total.

755 patients left.

5 doctors left.

Suppose each of those 5 doctors took on 150, 125, 100, 75 and 50 pain patients respectively, then:

1/4 of the patients in severe pain (255 of 1000) would be left with their pain untreated;

The DEA would be on those doctors like white on rice;

First the DEA would jail the doctor with the 150 pain patients -- the typical doc in this town has 5 patients on narcotics, and this guy has 150 -- it would be trivial to convince the jury that they only explanation is that he's a drug dealer.

The 150 patients "out in the cold" when Dr. One-Fifty goes to jail try to redistribute themselves to the other doctors. But those doctors have all been terrorized by the prosecution of Dr. One-Fifty. Most likely, no more than 5 or so will find new doctors, so the untreated will increase from 255 out of 1000 to 400 out of 1000. Less likely, Dr. One-Twenty-Five will be ethical enough (i.e. soft-headed enough) to take some fraction of them in -- leaving him the next doctor going to jail because "his numbers are too high".

The added terroristic effect of the second prosecution most likely makes the 95 doctors who altogether only had 245 pain patients start "firing" their more worrisome ones. This simultaneously increases the fraction of untreated patients desperately looking for a doctor who will treat them (aka "doctor shopping"), and makes the "numbers" for the 3 remaining doctors who are willing to treat people for pain, look, in comparison, even worse, and put them at even more risk for DEA prosecution.

When the DEA accuses a doctor of being a drug dealer, they are actually accusing the doctor's pain patients of being drug addicts faking pain. The three circumstances which the DEA uses as "proof" of their accusations are 1) the large number of patients on painkillers in the accused doctor's practice, 2) the small number of patients on painkillers in the vast mass of doctors not accused, and 3) the success of "doctor shopping" patients in getting painkillers from the accused. But those three circumstances are precisely what you would expect to happen with a population of patients who are not faking it and not drug addicts in an environment of a DEA terroristic campaign against doctors who treat with painkillers. This is nothing more ominous than the laws of arithmetic.
2.28.2008 12:02pm
Kathryn in California:
Ejo:I would further guess, despite these anecdotes, that you would see absolutely soaring usage of prescription pain killers over the last 20 years, not the absolute lack of them as is the theory being presented here.

Ejo, your question assumes that painkillers were being prescribed at the right level 20 years ago, and that there hasn't been an undertreatment of pain in the US. There is little evidence for, and published evidence against, that assumption.

And that you see patients doctor-shopping is not incompatible with the existence of other patients who cannot get sufficient pain medication from local doctors.

Sure, because of the double-layer of anonymity here "B" has to appear as an anecdote and not a case study, but that doesn't make the pain of his life right now less real, just more easily dismissable.

Articles such as the following are non-anecdotal evidence about pain undertreatment. At the minimum, they counter an assumption that 20 years ago pain was being adequately treated, such that increased treatment since then must represent doctor-shopping addicts getting fixes.

Kapp, M. 1997. Treating Medical Charts Near the End of Life: How Legal Anxieties Inhibit Good Patient Deaths. University of Toledo Law Review 28 (3):521-46.

Schechter NL, 1989.The undertreatment of pain in children: an overview.

Weinstein et al. 2000. Physicians' attitudes toward pain and the use of opioid analgesics: results of a survey from the Texas Cancer Pain Initiative
"BACKGROUND: Despite extensive progress in the scientific understanding of pain in humans, serious mismanagement and undermedication in treating acute and chronic pain is a continuing problem."

authors unknown, 1998. Pain in nursing-home cancer patients often goes untreated.

Scholtz, 1993. Ensuring adequate pain relief for seriously ill patients.
2.28.2008 1:37pm
LM (mail):
ejo,

all I see are anecdotes about how rough it is to get painkillers while, in my practice, I routinely see folks with multiple scripts from multiple doctors who are completely clueless about what is being taken. I guess I am supposed to credit anecdotes over my lying eyes.

False dichotomies won't reveal the truth behind either the anecdotes or your lying eyes. Why your direct observation of one type of abuse should lead you to be cynically skeptical of the other I won't speculate, but it's an attitude neither informed by nor consistent with logic.

What percentage of doctors committing either sort of prescription abuse do you think it would take to generate the incidents of under and over-prescribing reported here? Pretty low I'd guess. Which means the range of percentages of doctors who deviate from proper practice either way might be anywhere from very low to a significant minority without conflicting whatsoever with a like range deviating the other way. What the actual percentages are, I have no idea. But I find the reports, anecdotal or not, of both types very credible. In any event, there's no logical reason either is inconsistent with the other. Indeed, as I pointed out in my cousin's case, from the patient's side in some instances one may be a pre-cursor to the other.
2.28.2008 3:33pm
Mary Katherine Day-Petrano (mail):
"I agree completely with BruceM. And how is it not practicing medicine without a license (which in most jurisdictions is a criminal offense) for a non-MD DEA agent to decide what is a legitimate dosage?

(For that matter, how is it not practicing medicine without a license for an HMO to decide what procedures a patient needs, but that's another topic.)"

I agree. And similarly, when a person's doctors prescribe certain pain medication and machines and/or other devices and services for alleviation of a condition, how is it not practicing medicine without a license for a Court's "ADA Coordinator" or a Judge or a Judge's law clerk to not follow the doctor's prescription and/or prescribe something else that is not appropriate or effective or is even harmful?
2.29.2008 1:28pm