Opioid overprescribing is a big deal right now. I am a psychiatrist who often has to treat complicated cases that other types of docs think are rare, but which are actually very common.
This is a short version of my standard talk to physicians regarding opioid prescribing:
PAIN CONTROL MEASURES:
The Number Needed to Treat (NNT) to accomplish a 50% reduction in acute pain (considered a "response”) using oxycodone 15mg is 4.6. NNT for a combination of Ibuprofen 200mg and Tylenol 500mg is 1.6. In other words, you are about 3 times as likely to be helped by IBU+APAP as you are by OXY. Confirmation studies keep coming out: the same trends apply to dental pain, post op pain, acute injuries and acute LBP. Chronic pain studies are lacking, but chronic pain is often complicated by "Opioid Induced Hyperalgesia."
Translation: Opioids cause worsened pain.
See ( http://www.nsc.org/RxPainkillers )
And no one ever believes me when I tell them that, until they're off of the pills.
WHY IS THIS SUCH A BIG PROBLEM?
We've been conditioned in medicine to think of pain as vital sign. It's not. We've been conditioned by administrations, insurance companies, and patients to think that the only outcome that matters is patient satisfaction. It isn't.
As an inpatient psychiatrist, I tend to treat difficult/refractory cases, and my patient population consists LARGELY (More than 1/2) of patients who have abused prescription meds. How did they abuse them? Their doctors let them. The docs are beholden to their hospital’s and clinic's patient advocates/satisfaction personnel, insurance companies, lawyers, and administrators. Those people, including extraordinarily well-meaning other providers such as nurses, techs, and outside caregivers, all put pressure on physicians to deliver an certain product. When the doc doesn't do it, he is fired, flamed on the internet, cursed at, threatened, sued, etc. I've had to respond to the most ridiculous complaints made by addicts because I diagnosed them with addiction and offered treatment for both pain and addiction. All providers have been through this. The reason?
The customer is NOT always right.
Satisfied patients die more often than dissatisfied patients. (Several JAMA and NEJM articles confirm this.) The direct cost of inappropriate opioid prescriptions and diversion is in the tens of billions. The indirect costs may exceed that. This problem has arisen because in the 90s we were sold a bill of goods by makers of MS Contin, Opana, Duragesic, Oxycontin, etc., and in the 2000s we were marketed to by the Suboxone makers and clinics and chronic pain clinics. All of those people wanted us to believe that all pain ends, just like all bleeding stops. Well, that's true, and for the same reason. That doesn't mean we never use opioids any more than it means we never do surgery. But we've been irresponsible. Almost all of us have. The data are clear.
For what it's worth:
It usually takes me 4 days to get someone off of opioids entirely. They ALWAYS feel better. They have pain, but they note that the severity is either the same as or better than it was when they were on opioids. (It's surprising how often it is better, not just the same.) Well over 1/2 of patients in my practice have developed opioid-induced hyperalgesia. My practice is obviously selecting for the worst actors. Easy cases do not make it as far as me, but most practices weed out their problem cases and without realizing how much they are contributing to the problem.
If you don't work in psych, addictionology, or chronic pain clinics, it is possible (probable?) that you have a patient population selected for responsible use. The reason for this is because once you set a limit, the addicted patient finds another provider, then another, then another. They don't come back to you. You never have the chance to realize that you were their first drug dealer. You got them hooked, but you don't know it. I mean, you only saw them a couple of times! However, today they won't be able to shop around as easily. The new regs and recs mean they'll be cut off at their PCPs far more often. I'll see a boom in business from patients referred because they "just need something for the pain" when, in fact, the drugs themselves are causing it.
Thanks for the business, (sarcasm!) but anybody can treat this. It's not even dangerous to try at home, if opioids are the only problem. Here's how:
*For tremors, anxiety, sweating, goosebumps:
Clonidine 0.1mg up to tid if blood pressure is sufficient. (Hold if Systolic BP is less than 100 or if pulse is less than 60 bpm)
*For muscle spasms:
Cyclobenzaprine, Tizanidine, metaxolone, methocarbamol (NOT soma/carisoprodol) given two to four times daily per the PI.
*For diarrhea:
Loperamide 2mg per loose stool. Doesn't usually require a loading 4mg dose. Max 8mg per 24 hrs.
*Nausea:
Ondansetron 4mg per 4 hours is preferred over phenergan. Ginger helps.
*Insomnia:
Trazodone 50 to 200mg QHS. If not effective, Seroquel 50 to 200mg qhs.
*Pain:
IBU 200mg + APAP 500mg Q.I.D. (unless the patient was using percocet or Vicodin or another combination drug. In that case, nothing really helps because they get rebound headaches from stopping the NSAID, but it is usually gone entirely within 96 hours)
*Anxiety:
Hydroxyzine 25-50mg TID as needed for anxiety if the patient is under 55 y/o. Seroquel 25-50mg TID as needed for anxiety for over 55 y/o if clonidine isn't sufficient. Monitor BP with seroquel + clonidine; the orthostasis risk is high.
*Each of the above is "as needed," and patients taper themselves without prompting because the above agents are not reenforcing.
CAVEAT !!! ---
One must always consider whether the patient is self-treating a mood or anxiety disorder by using opioids. That is incredibly common. If you fail to treat the primary condition, the opioid use will recur in greater than 85% of cases. However, using benzodiazepines causes a similar phenomenon with anxiety disorders. The anxiety symptoms will pass, and the patient won't die from a bit of anxiety. So don't shoot yourself and the patient in the foot by using benzos. If you have a bipolar patient or PTSD patient or MDD patient, talk to your friendly neighborhood psychiatrist for some suggestions, or send those folks to a dual diagnosis program.