Wednesday, August 14, 2013

Prescription painkillers (I)

Gina was one of my most challenging patients. She had overwhelming anxiety, and with just a phone call, she could make our clinic spin like a top. I knew pretty early on that she had a tendency to overtake medicines-- and not just the addictive ones. She even overtook non-prescription medicines like acetaminophen (aka Tylenol), diphenhydramine (generic for Benadryl, an anti-itch and allergy medication) and omeprazole (generic for Prilosec, an acid reflux medication).

She was a beautiful woman, and though her mental health issues were intense, she was really quite endearing. Each time I saw her, she gave me a big hug; she also often brought me thoughtful little gifts. At one visit, she brought a beautiful silk flower clip for my hair. (I sometimes wear it on tough days in clinic). A few months later, she gifted me a picture of her swimming with the dolphins in Hawaii. That picture hangs above my desk; she is smiling broadly in it, and I love to think of her without pain and without anxiety.

I last saw Gina one Wednesday morning more than a year ago. She had just had a successful hysterectomy and was particularly anxious. She had a history of chronic back and hip pain and was on small doses of methadone for this pain. Two days later she was found dead in her own bed.

I was not surprised to learn that, on autopsy, unsafe levels of methadone were found in her blood. She clearly overdosed on her prescription painkillers and never woke up. I will never know the whole story, but I doubt she did so intentionally.

Prescription pain medication overdoses are on the rise-- over 14,800 deaths in the US in 2008 (that's more than cocaine and heroin combined, and more than motor vehicle accidents too). When you see the term "prescription painkillers",  this usually refers to the opiate or narcotic pain medicines: vicodin, (hydrocodone), oxycontin (oxycodone), morphine, and methadone. Unfortunately, these are medications often prescribed for surgical procedures like wisdom teeth extractions or appendectomy, or even during simple ER visits for minor trauma. These drugs aren't inherently evil-- they work quite nicely for people with acute pain that is self-limited. I personally prescribe them for every one of my post-cesarean section patients and often for patients with fractures (e.g. broken legs).

Check out this image from the Center for Disease Control (CDC):

In 2008, there were 14,800 prescription painkiller deaths.4 For every one death there are: 10 treatment admissions for abuse.9 32 emergency department visits for misuse or abuse.6 130 people who abyse or are dependent.7 825 nonmedical users.7

According to the CDC, most prescription pain medications are prescribed by primary care doctors (yup, that's me). And, perhaps even more alarming as someone who prides herself on her care of women, recent data released shows that prescription painkiller overdoses in women have increased 400% since 1999 (they have also increased dramatically in men by 265%). More than 5 times as many women died as a result of pain medication overdose in 2010 than in 1999. And opiates are involved in 1 out of 10 suicides. Ay!

We need to do better.

Clinicians (ahem. . .myself included) need to be more careful about how we approach pain, what medications we offer our patients, what are our expectations. We need to use the statewide databases and really encourage our patients to get rid of leftover medications (rather than share them with family members). We also need to screen women (and men) for risk of abuse/misuse and be clear about our plan from the get-go with ourselves and our patients.

Patients (that's all of us) need to be aware that these painkillers are a group of potentially addictive medications. There is an appropriate time and place for their use, but pain meds should be used wisely for limited periods of time. They may or may not actually help people feel better but definitely can kill (or make you impotent, depressed, constipated, and dysfunctional).

Do me a favor, go to your medicine cabinet right now and throw out that leftover Vicodin you have sitting there from your last encounter with the healthcare system. I know you've been keeping it around 'just in case', but it just ain't worth it. Don't share it with your neighbor or your partner or your kid. Pitch it. Or, even better, throw it down your toilet (though please don't do that with the rest of your prescription meds- click here for more info,).

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  1. Thanks for this one, Vero. You know it is an important subject for us, especially right now. It is certainly hard to sort things out when someone you love is in such pain everyday.

  2. Yes, this is such a tough topic for so many families. And very complicated. I labeled this (part 1) because I know with certainty I will have more thoughts and opinions (parts 2-?) on this topic.

  3. as someone who suffered great back pain, painkillers were a god send but i also worked with a therapist to reframe what i was feeling, some days my back just had more "energy" ie "pain" and others it did not, was a great solution. I also worked closely with my dr.

    1. Yes, Ty, you are totally right. Painkillers can be a totally useful tool. But they are only one tool in the toolbox. . .glad to hear about the reframing. So important and so often overlooked. I heard at a meeting today "Pain might be inevitable, but suffering is optional." I like the notion that pain can be reframed to exclude the suffering.

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