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Humans will be human.

March 17, 2016

This week the governor of the great state of Massachusetts, my home state, signed into law a bill that puts strict limits on new opioid prescriptions, specifically a limit of a dosage sufficient for 72 hours, among other things.  This of course, is in response to the opioid addiction problem afflicting the country.  Many other states are taking similar measures.

I am of two minds on this.

Such laws are a good idea

First of all, why are these laws targeting doctors?  Well, we’re the source, at least in part, at least at the beginning.  It has become a habit with surgeons to send patients home with 30 percocet after a hysteroscopy, for instance, or a knee scope.  I can’t speak to the habits of other kinds of doctors, but according the the New York Times, primary care doctors prescribe the bulk of opiates in this country, so there’s habits there too for, say, back pain or a sprained ankle. (http://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addiction-doctors.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region&region=top-news&WT.nav=top-news&_r=0).

Why so many pills?  For the same reason I sometimes (well, a lot of times) put pre-packaged snack bags of Goldfish in my kids lunch instead of cutting up fruit or putting baby carrots in sandwich bags.  It is the habit of human nature to go with what is easier.  Escalators vs. stairs, jarred marinara instead of homemade, roller bags vs. the kind you have to carry.  Dishwashers.  Those things guys put on their heads so they can drink beer out of a straw while watching football.  Quicker and easier.  The patient will not call you on the weekend for a refill.  The patient will not ask for more at their next office visit.  It takes a lot longer to tell a patient why they can’t have a drug than just give it to them.  It’s a hassle to explain to the people who do patient satisfactions surveys why Mr. Jones sent in a bad review because his doctor wouldn’t give him what he wanted.

On the other hand, it is generally taught in medical school that pain that doesn’t go away in a timely manner should prompt an investigation into why it hasn’t gone a way.  This is definitely true for acute pain.  If you’ve had your appendix out, 3-5 days of a mild narcotic should get you through the post-op phase.  If you’re still having pain requiring opiates after a week, the doctor will, or should, look for other causes of pain like infection or perforated bowel.  So in the case of acute pain in which the source is clear, Governor Baker’s (Charlie, of Massachusetts) new law makes sense.

Plus, the doctor can tell Mr. Jones it is not her fault – blame the government.

Such laws solve nothing

Studies suggest that giving patients a short course of opioids for acute pain does not lead to addiction.  Here’s Scott Strassels, a pharmacologist writing in the journal Advanced Studies in Pharmaceuticals in 2008.

…several studies have demonstrated very low rates of addiction among patients receiving opioids for acute pain. One chart review of nearly 12,000 hospitalized patients who received opioid medications identified only 4 patients with evidence of iatrogenic [treatment-caused] addiction.” (http://www.utasip.com/files/articlefiles/pdf/2nd%20article.pdf)

Secondly, anyone who has ever met an addict knows that restricting one source of his or her fix only sends the addict to a different source, i.e, the practitioner of the unregulated open drug market also known as your local heroin dealer. If my kid wants chocolate and my answer is no, they’ll go to their dad, the babysitter, the mailman, anyone else, hoping for a different answer.  This is because it is human nature to want chocolate and kids want what they want NOW.  Addicts are no different.  Doctors are not responsible for what people put in their mouths or how they choose to use the pills they are given.

Lastly, drug prescribing restrictions are, or can be, a trifle condescending.  Here’s Dr. Sarah Wakeman, a Massachusetts General Hospital physician who served on Baker’s Opioid Working Group, according to the Boston Globe:

“We prevent diabetes by limiting exposure to foods and beverages. We prevent lung cancer by limiting exposure to tobacco smoke,” she said at the news conference. So the proposed opioid prescription limit will help to minimize excessive exposure to opioids.”

Well, no actually.  We (meaning doctors I assume) don’t limit exposure to foods, we don’t limit exposure to tobacco.  We can recommend that people do these things, but people do what they want.  Opioid addiction is a problem because of behavior, not just opioids.

 

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From → Healthcare

3 Comments
  1. thetinfoilhatsociety permalink

    Well there go the satisfaction scores for the hospitals. And the nursing homes. And the rehab facilities. And any clinics that participate.

    I am in the process of taking a palliative care course for a certification. There’s simply no other option for many of the people I see. Rural area, 30miles to the nearest town, no transportation other than a medical taxi, having to wait HOURS for a return ride home, limited income, the list goes on and on.

  2. Just discovered your blog, really enjoying your POV! I’m an internist over at MGH, maybe we’ll run into each other someday. On the opioid issue, I agree, the one-time short-term Rx isn’t usually the problem, it’s the ongoing, chronic, huge numbers of pills that are more likely to be associated with addiction and diversion. But, you are correct, short courses are short for a reason, and even major abdominal surgery should not require more than a few days of a mild narcotic.

  3. Thanks for reading! I’m glad you like my work. Yes, the habit that doctors have of prescribing 30 percocet no matter what is not helpful and is actually going away, I think. The philosophical fight comes in the chronic pain realm, where the issue is much more complicated.

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