The Opioid Crisis, Part I

Twenty years ago, there was a push to make pain the fifth vital sign.  Whatever was perceived to be necessary to relieve pain became the driving force in pain management.  The patient became the final authority on what was satisfactory pain treatment.  Being pain free became an entitlement.  The end result has been the current opioid crisis.

Several years ago, for one twelve-hour shift in a busy emergency department, I kept track of the meds patients were already on when they presented for treatment. Eighty-five percent of all my patients that day were already on scheduled substances.

A scheduled substance is rated depending on its proclivity for abuse.  Schedule IV medications include such things as codeine-based cough syrup and some sleep aids.  Schedule I medications include Suboxone, LSD, and others.  A provider has to have a DEA (Drug Enforcement Agency) number that is assigned to him/her based on location.  Most prescribers aren’t licensed for Schedule I drugs.  Missouri requires additional licensing with the BNDD (Bureau of Narcotics and Dangerous Drugs).  That provider is susceptible to audits and may face jail time and/or loss of prescribing privileges

Prescription medications are taken to achieve an effect.  Side-effects are those that are not the primary intention for the medication, but sometimes become the most desirable.  When they are taken for reasons other than for what they are intended, this is abuse.  One problem that occurs is that on the way to recovery from an injury or illness, the reasons for the drug to be taken in the first place resolve, but in the meantime, the patient becomes dependent on side-effects.  What didn’t exist before becomes the primary reason for taking the medication.

There is a concept in pharmacology called tachyphylaxis.  This involves the range of dosage of a medication required to achieve desired effects.  With pain medication, for example, the dose required to achieve a desire effect increases with time.  Eventually, the magnitude of the dose can become incompatible with life.  This is heightened if multiple drugs are involved.

There are conditions that call for scheduled substances and if addiction occurs, it doesn’t matter.  For the cancer patient, unresolved pain is just not acceptable.  For the otherwise healthy individual, continued use of addictive drugs is also not acceptable.

Richard E. Draper, a double board-certified emergency medicine physician, blogger, and speaker, and practices in the Kaleidoscope Weekly distribution area. The Healer’s Heart is based on his perceptions and observations of his experiences in the ER over his career. Any similarities to actual patients are purely coincidental.

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