They Rarely ask for Pain Pills Now
Reflections on medical policy, DEA permits and the fentanyl crisis
When I was in my residency training, from 1990-1993, we were in the nascent phase of the ‘pain is a vital sign’ madness. We were told, over and over, that we should treat pain aggressively and should not be afraid to give narcotics to patients in pain. Who were we to judge someone’s pain, after all? The young man who fell onto his knees at work, with a normal blood pressure and heart rate, looking about the room, might well categorize his pain a ‘10/10,’ and we should honor that, respect it and treat it.
As the years went on, drug reps actually gave physicians samples of opioids for their patients. (Talk about a good investment in reaching your market!) We had them in our hospitals in cabinets, before the days of computerized pharmacy systems. It was apparently no big deal.
Thanks to academic insitutional policies and brilliant pharmaceutical marketing, Pain pills such as hydrocodone, oxycodone and later oxycontin were well known and much desired. Many a patient concocted elaborate tales of horrible pain, undocumented cancers, physicians out of the country, pills inexpicably eaten by dogs or spilled down the toilet. (This was before we had searchable registries for opioid prescriptions, which have been a wonderful thing.)
Much of our work as physicians was a balancing act between trying to show genuine compassion, mandated compassion and appropriate skepticism about pain scales and the lies concocted in pursuit of drugs.
‘So, just to be clear, your hangnail is a 10/10?’
‘Maybe a 12/10, honestly.’
‘Let’s go over the scale again, shall we?’
One of my very favorite patients (I really liked him despite his addiciton…or diversion, who knows), was an adult male who endlessly entertained me with stories about how his brother had beaten him and taken his Lortab. ‘Mama’s in the car, you can go ask her!’ He was about 40 when I knew him. I wasn’t going to ask Mama.
Well, we certainly made our bed and now lie in it. We are in the throes of a horrible epidemic of illicit drugs. The healthcare system at large has done a remarkable 180 degree turn and over the past few years has basically said, ‘whoa, there, we never said that! Doctors are the problem!’ So now we’re constantly subject to educational programs on how to prescribe opioids better and smarter, or not at all.
In fact, it’s almost time for me to renew my federal Drug Enforcement Agency license to prescribe controlled substances. But this cycle I have to take a new eight hour class on proper prescribing habits and pain managment.
https://deadiversion.usdoj.gov/pubs/docs/MATE_Training_Letter_Final.pdf
This, of course, in addition to the $888 fee for said three year license.
As one accustomed to mandates and tests, certifications and fees, I didn’t think about it much. ‘One more class, whatever.’
But then I had an epiphany.
Which was that nobody really argues with me about pain pills anymore. Certainly, not with the theatrical skill of the old-days. Now we’re only supposed to give a three day supply. We tell people that and they shrug. It’s a little disappointing, really. Their hearts just aren’t in it anymore.
But I think that there may be a more sinister reason that nobody argues. Which is, fentanyl. It’s just so easy to get the stuff. It’s inexpensive and it’s everywhere. It’s in drug houses and gas station parking lots. It’s in high schools and college campuses. It’s in prisons and homeless encampments. In fact, according to independent journalist Jonathon Choe, it can sometimes be found for $.50 per dose in homeless camps.
I suspect that diverted, illegal pain pills (of the hydrocodone, oxycodone variety) are still out there. All too many people die from them. But the incredible volume, availability and shocking fatality of fentanyl makes those old school pills less relevant. (Frankly, a lot of the pills are probably fake pills cut with fentanyl anyway.)
So as physicians, in the last 20 -30 years we were told to:
1) Give potentially dangerous drugs and don’t worry. People are in pain, you medical monsters!
Then we were told:
2) Stop giving dangerous drugs and stop being bad doctors. You monsters!
And the beat goes on to this day.
The problem with oxycontin was recognized. Litigations and settlements were arranged (although even that is still working its way through the system).
However the flood of illegal fentanyl precursors from China, which then become fentanyl and flow across the Southern border, continues unabated. Millions upon millions of doses of fentanyl cross into the US regularly. And considering that we dose fentanyl in microgram doses, that is one millionth of gram, it doesn’t take a lot of the stuff to put a lot of people in the ground. Or certainly addict them. (And that doesn’t even scratch the surface of the cost of drug abuse to indivduals and society…I’ll address that later.)
https://www.dea.gov/press-releases/2024/01/18/year-review-dea-innovates-fight-fentanyl-0
I’ve been trying to carefully prescribe opioids for the entire 33 years I’ve been a physician (counting residency, that is). I’ve tried to balance compassion with caution every time. And I’ll take the silly DEA class, promise to be a proper physician and continue my regularly scheduled berating as I and my colleagues are blamed for the enormous problem of opioid addiction and death.
But it’s all rearranging the deck chairs of the Titanic until someone gets a handle on the crisis from a geopolitical standpoint. And yes, that means dealing with the border as well, the border which separates us from a failed nation-state and its cartel poisoned government.
I’m not blaming one political side or another. I’m just saying that if it isn’t taken seriously, then the deaths will keep skyrocketing. And it won’t matter how much continuing education I take, or how many times I give only 12 doses of Lortab for that fracture. Because the people who really want the high? They just don’t care anymore.
Edwin
Very good description of what passes for DEA management of controlled substances. There are many patients who have been on controlled substances for 30 years and who act responsibly in their use of them. But the DEA has turned everyone into a drug seeker, often forcing physicians to stop providing what was reasonable pain relief managed well. Every patient is different. Physicians know this, but the DEA has done a good job of prevening many physicians from providing the care they know their patents need.
Right on Edwin. And then there was the expert who told us that no one becomes addicted if they really need the medicine. Turns out he worked for Purdue.