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So Which One Is It?

March 3, 2015

The New York Times is driving me batty today.  No fewer than three articles on over-medicating, and all of them confusing.

Article number 1:  Psychiatric drug overuse.  http://nyti.ms/1wHaQJn.

Federal investigators say they have found evidence of widespread overuse of psychiatric drugs by older Americans with Alzheimer’s disease, and are recommending that Medicare officials take immediate action to reduce unnecessary prescriptions.  Toby S. Edelman, who represents patients as a lawyer at the Center for Medicare Advocacy, said, “We could save money and provide better care if nursing homes reduced the inappropriate use of antipsychotic drugs.”

This one is the least confusing, actually.  Nursing homes, and sometimes caregivers in the home, use antipsychotics to control patients with dementia.  The reason they do this is that staffing at a lot of these places is abysmal.  The ratio of staff to patient that would be needed to adequately keep these patients safe would likely cause Mr. Edelman to protest that we are spending too much money on nurses’ aides.

Article number 2: SSRIs.  http://nyti.ms/189klLa.

At least one in four women in America now takes a psychiatric medication, compared with one in seven men. Women are nearly twice as likely to receive a diagnosis of depression or anxiety disorder than men are. For many women, these drugs greatly improve their lives. But for others they aren’t necessary. The increase in prescriptions for psychiatric medications, often by doctors in other specialties, is creating a new normal, encouraging more women to seek chemical assistance. Whether a woman needs these drugs should be a medical decision, not a response to peer pressure and consumerism.  Obviously, there are situations where psychiatric medications are called for. The problem is too many genuinely ill people remain untreated, mostly because of socioeconomic factors.

Julie Holland, who has been getting a lot of journalistic mileage from her assertion that women are over-medicated, has me wondering what the problem really is?  Over-treatment or the “problem that too many genuinely ill people remain untreated”?  Which is it?

Article number 3: Painkillers.  http://nyti.ms/18fEsr2.

Using a strong painkiller is appropriate if clearly needed but a review of the relevant scientific data, published on Feb. 17 in Annals of Internal Medicine, casts doubt on how much opioid treatment is really necessary. The review was conducted by recognized experts in evaluating medical evidence and treating chronic pain at the Oregon Health and Science University, in Portland, Ore., and the University of Washington, in Seattle, Wash.  The researchers found little or no evidence that long-term opioid therapy (therapy lasting more than three months) relieves chronic pain, in part because almost all the studies are of short duration. It is extremely reckless to allow opioid usage and deaths to soar in the absence of proof that the treatment is effective. By contrast, there is considerable evidence of opioid therapy’s dangers, including overdoses, opioid abuse, fractures, heart attacks and sexual dysfunction. Doctors and patients must approach long-term opioid therapy with great care. Many patients with chronic pain do not get enough painkillers at high enough doses, meaning that their pain is undertreated. Many others are overtreated and harmed by doses they probably don’t need.

Wait.  I thought the authors (the editorial board of the New York Times) said that research has shown that long-term opioid therapy doesn’t help.  Then they say that “many patients with chronic pain do not get enough painkillers at high enough doses”.  I’m not sure what the medical expertise is of this editorial board, but I have to ask: Which is it?

I agree that there’s a lot of overprescribing going on.  While demographic trends are all well and good, at the end of the day health care is personal.  A woman on an SSRI performs much better at work, where crying is frowned upon.  A nurse’s aide with 15 patients can’t watch them all adequately.  Treating chronic pain is a very complex process involving narcotics, nerve blocks and stimulators, and psychological support, among other things, and no treatment plan is a smooth ride.  These articles, which constitute blanket statements about what doctors should and shouldn’t be doing, are not helpful in the exam room.  There it’s just two people trying to figure out what to do.

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