Addiction and Pain

Pain rots the soul.  Opioids can effectively treat pain – and then rot the soul and body.  The treatment of pain remains a difficult dilemna for the whole country.

A new study in the New England Journal of Medicine highlights the opiod mess in a a new way, demonstrating how one prescription in the ER may lead to chronic opioid addiction.

In the study, only about two percent of people given opioids ended up becoming chronic users – using pain pills more than 180 days a year.  But some ER doctors were more frequent prescribers.  For these “high intensity prescribers”  the rate of chronic use was about 30% higher.

But they were often acting well within present guidelines.

Do ER Docs Give Lots Of Opiates?

The study in the New England Journal was special in a group of ways.  It studied those who had not had an opioid prescription for at least six months in 375,000 Medicare beneficiaries, most of them over the age of sixty five.  The elderly take up much of the cost of health care, but are a particularly difficult group when treating pain.  Many have compromised kidney function, or are hypertensive.  Using standard pain reducing NSAIDs, like ibuprofen or naproxen, thus produces added risks.  And lots of people don’t respond to tylenol. When someone in front of you is writhing in pain, especially someone older who may not have a lot of social support, what do you do?

ER doctors are well aware of what the opioid epidemic does to people.  In many cases, they are the first line of treatment and often the sole providers to opioid addicts.  In one study out of Brigham and Women’s, ER doctors provided more than 30 opioid pills merely 1.5% of the time.  If they do give out the pills, it’s usually in doses for  an expected 3-5 days.

This fits the ethos of ER medicine – solve the problem, in and out.  ER docs are supposed to take care of emergencies.  “Regular” physicians can handle the rest.  ER docs, like those doing in-hospital medicine, like having rest periods away from work where they are not “on call.”  Control of leisure time is a major selling point for a career in emergency medicine.  Emergency physicians shouldn’t  have to provide indefinite follow-up – they sometimes they do.

And regular, outpatient physicians may continue the opioid prescription given out in the ER.  ER docs are often harried – particularly when nearly half their time is spent doing paperwork.  Elderly patients are not regarded as likely to become addicted to opioids as much as younger folk.  And where is the time to explain to people how to do stretching?  To prescribe physical therapy, which may not get paid for? When much of the treatment of pain is now being relegated to regimes like cognitive-behavioral therapy, whose got time for that in the ER?

Yet now we know single visits to the ER may result in lifelong addiction.  Will ER docs have the time and opportunity to talk to people about non-drug treatment of pain?  Will they even possess the inclination, when the ethos of their work is solve the problem and move on?

This brings us to another “one shot” problem.

The Strange Case of Xanax

Many Americans experience panic attacks.  About two-thirds of them think that first panic attack may be a  heart attack.

Many go to the ER.  The ER staff, relieved to have “ruled out” a heart attack, often gives them xanax,  whose generic named alprazolam.

It works quickly.  Problem solved.

Except about half of people who go on xanax have a helluva time getting off.

Psychiatrists and sleep doctors often dislike xanax. The only time I’ve seen a NIH research officer booed on stage was when he said xanax created no major  problem of addiction.  In the 1980s, numerous studies came out pointing out the many difficulties of getting off xanax; I was one of those people conducting such studies.

Xanax is part of a large group of drugs called benzodiazepines.  Benzos or BZs,  as they are sometimes  called, attach to benzodiazepine receptors in the body, of which there are several. Many sleeping pills, like ambient and lunesta, hit one of these receptors.

Xanax is unusual.  It attaches to BZ receptors quickly, and comes off them quickly.  The end result for many – rebound anxiety and insomnia.

Thus the problem of addiction.

So how is it that 30 years later, xanax remains such a popular drug?

Because it’s a simple answer.  It works fast.  It’s part of the “standard of care.”

And physicians like myself spend years getting people off of it.  We do that because of the increased death rates, the inability to work or function, the hip fractures and falls, the failing memories, the “dementia” that disappears when xanax is stopped.

Lots of folks get their first dose of xanax in the ER.

Bottom Line

American medical care is increasingly fragmented.  Much of what goes on in ER or through in patient “hospitalists” can exacerbate this fragmentation.   The electronic medical record, whose giant cost was sold as helping coordinate care, often does the opposite.  Physicians treat the chart rather than the patient (some estimates put 44% of ER physician time as spent on charting), and many electronic records are walled off from each other, even in the same institution.  Add to this the neglect of a public health perspective, and medical care’s profit motive which often requires emphasizing volume and speed. The result – ERs become great places to start people on chronic addictions.  The ironies are many, including that many ER docs often hate the horrible medical results of addiction.  Until structural changes are effected, and ER services are paid for that include counseling patients about pain and how to treat it, we can expect our “inadvertant” addiction problem to continue a very long time.