A Sad Irony

Allow me to preface this article by saying I’m not against the appropriate use of opioid analgesia when indicated in any age group. While there has been legitimate concern regarding the over prescribing of these drugs especially to pediatric and adolescent patients, it also does not create a generalized scenario where we as health care providers can or should stop using these agents altogether. I completely agree that while using opioids for simple sprains and other similar minor injuries is indeed overkill, that does not mean they should be withheld in all cases. The child whimpering due to a supracondylar fracture, a child with terminal painful cancer, and burn injuries are just some of the cases where these agents should be utilized. Not only should they be used in these instances, I would argue if you are not using them, you need to take a long look in the mirror and ask yourself why you are still in medicine. Part of our job is to ease suffering and if you are willing to withhold proper pain management for significant illness or injury over what may happen in the future, I question why your are still practicing medicine.

That obligatory disclaimer aside, we cannot ignore that over-prescribing of opioid pain medications has become an issue if not an outright epidemic. How many of us know or know of a health care provider who have had their license suspended or revoked for improper prescribing of narcotics? At the same time, we have seen well respected physicians change their views on the dangers of marijuana. We have seen marijuana’s listing as a schedule I controlled substance and it’s label as the gateway drug questioned. I would pose that there is a changing of the guard in respect to what is truly the gateway drug.

It’s not even up for debate that opioid analgesia has proliferated and is ubiquitous. The U.S. uses almost 98% of the world’s hydrocodone [1]. Oxycontin prescriptions rose from 76 million to almost 207 million annually from 1991 to 2013 [2]. What prompted this to occur?  In 1999 claims were made that chronic pain was under treated. In response to that, the Veterans Administration came up with the “Pain as the 5th Vital Sign” campaign. Two years later, the Joint Commission spread this notion throughout the rest of the health care system by instituting pain management standards based of the VA’s campaign [3]. What soon followed was pharmaceutical companies convincing health care providers, patients, and regulators that opioid were safe for chronic non-cancer related pain. Some of the misinformation was so egregious that the makers of Oxycontin plead guilty to federal criminal charges [4]. And what has been the end result? Prescription opioids are the most commonly abused drugs in many states, such as in Connecticut [5]. Patient’s who are addicted to prescription opioids are 40 times more likely to become addicted to heroin [6]. The end result is that prescription opioids have become the gateway drug to heroin as patients look for a stronger high or when then can’t get their opioid prescription.

In the other corner, we have marijuana. The cause of the laughable “reefer madness” and historically known as the gateway to other drugs. There is much I could get into regarding non-scientic reasons for its banning (hemp industry) and possible medical uses but they go beyond the scope of what I’m writing about. Dr. Sanjay Gupta has probably been the most famous physician to verbally reverse his views of marijuana being dangerous. Dr. Gupta points out that Marijuana was place on the Schedule I list in 1970 due to “a void in our knowledge of the plant” per Dr. Roger O. Egeberg then Assistant Secretary of Health. Yet there were studies as early as 1944 that showed marijuana did not lead to any significant addiction medically and did not lead to using other drugs. While reports vary, marijuana leads to addiction in 9% to 10% of users. Compare that to cocaine (a schedule II drug which is supposed to have less abuse potential than schedule I drugs) leads to addiction in 20% of users. Tobacco, which is legal leads to addiction in 30% of users, many of whom die from health issues related to smoking [7]. Look at the other schedule I drugs along with marijuana; Heroin, LSD, peyote, and Ecstasy[8]. Let’s use some common sense here. Yes, I know, it’s not very scientific and we humans have a brain and common sense that allow us to assess situations. I’m sure many of you reading this know others who smoke marijuana. Certainly, there are some who do nothing but, however that is the exception, not the rule. Nearly all the people I know who smoke marijuana can take it or leave it, forgetting they even have it half the time. No one smokes marijuana alone, gets behind the wheel of a car, and commits vehicular homicide unlike with our legalized friend alcohol. If anything, they get hungry, eat, and go to bed. No one overdoses and dies from marijuana alone or needs a reversal agent. Many of those who smoke marijuana have a good education and live a responsible, productive life. If not legalized, marijuana should be at least moved to a lower schedule and have well designed studies done with it if indeed we have had a “void of knowledge” all this time. It certainly has nothing in common with its companions on the Schedule I list and even Schedule II. As our medical culture prides itself so much in “evidence based medicine” it amazes me they have let this void exist for so long.

Part of the problem is that many health care providers fall into one of two camps. They either never prescribe narcotics across the board or use them when appropriate AND with chronic abusers enabling their addiction. The age old habit of viewing an issue with a narrow, binary mindset. There are no absolutes and the answers do not lie in the extremes. Opioid pain medications still have a vital and important role in the treatment of acute short term pain due to certain injuries, post-operative patients, and palliative care for terminal, painful conditions. These patient’s should not be made to suffer for what may happen in the future. However, it’s role in chronic, long term pain management has justifiably come under scrutiny and it certainly should not be used for minor injuries. The sad irony is that while marijuana has been the pariah all these years, prescription opioids have actually become the gateway to heroin and other illicit drug abuse. As such, there have been and are health care providers which have enabled this to happen.

  1. https://www.incb.org/documents/Publications/AnnualReports/AR2008/AR_08_English.pdf
  2. http://www.samhsa.gov/data/sites/default/files/DAWN127/DAWN127/sr127-DAWN-highlights.pdf
  3. Mularski RA, White-Chu F, Overbay D, et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Itern Med. 2006;21(6):607-612.
  4. http://www.newyorker.com/business/currency/who-is-responsible-for-the-pain-pill-epidemc
  5. http://www.nhregister.com/article/NH/20150331/NEWS/150339887
  6. http://www.cdc.gov/vitalsigns/heroin/
  7. http://www.cnn.com/2013/08/08/health/gupta-changed-mind-marijuana/
  8. https://www.dea.gov/druginfo/ds.shtml

Being Set Up to Fail

I was actually using the Pill ID function of the pharmacopeia on my smart phone the other day when I came across something that was both interesting and disturbing. The pictures of two very different medications that were very difficult to tell apart.

While there are subtle differences between the two, the overall similarities are unmistakable. They are both tablets (as opposed to capsules), both white, both round, both single scored, and both have an imprint on the side opposite the scoring. Now I do realized there are only so many sizes, shapes, colors, etc to work with but even if we forgive that, I am astounded at the imprint. One with “54” over “425” and the other with “54” over “452“. The same number, printed in similar fashion, with just the transposition of the last two numbers being the difference. I cannot believe that we are so limited characteristics that drug manufacturers can produce two tablets with five of the same characteristics and the same imprinted numbers with just order of the last two switched.

Honestly, people could not be set up to fail anymore unless the manufacturers intentionally switched the containers in which these drugs came in. (Writers Note: I’m not actually suggesting they do this). Medications can be tough enough to identify when they are the same shape and color, even by well trained medical professionals working in fast paced environments. Seeing this, it’s almost like the drug manufacturers are, either by ignorance or apathy, working against all the procedural safeguards hospitals institute to minimize medication errors.

But what about the patients, the ones who may not pay attention to such minute details? It is actually the patients that are higher at risk for confusing these medications. It is quite feasible that this scenario might occur with these medications, not to mention any other medications that we don’t know of which may share multiple common identifying characteristics. Consider the following…

  • In this day and age of better living through chemistry, it’s not unusual to see patients on both lithium and hydromorphone. And even though we are supposed to be addressing the opioid epidemic, I’ve seen hydromorphone, one of the stronger opioid analgesics, prescribed and I’ve taken care of many patients who were on it.
  • Many patients take their medications out of the labeled bottle and either keep them together or place them in daily dispensing containers.
  • Patient’s on these medications may be less alert and therefore less able to distinguish between such similar pills.

It’s quite the perfect storm for patients to unintentionally put themselves into lithium toxicity or have an opioid overdose. It begs the questions have patient’s in the past experienced overdoses of either drug because of their similarities and how many opioid overdoses where intentional versus accidental.

In the meantime, I can only say that we as healthcare professionals need to keep our already hyper-vigilance up, we need to make sure our patient’s are informed and aware that similar looking drugs exist to this degree, and pharmaceutical companies need to get their act together and start instituting better safeguards in the manufacturing process.