Opioid crisis...

[ggmike1992]

Just moved to WV so I see it in the news fairly regularly. I default to the notion of personal responsibility. It’s no secret about the possibility of an overdose yet people still chose to fo it. Well if one still choses to do it then they also chose the possibility of OD-ing and dying. Can’t say that garners much sympathy from me.

 

[Imtotallynottribe]

Just moved to WV so I see it in the news fairly regularly. I default to the notion of personal responsibility. It’s no secret about the possibility of an overdose yet people still chose to fo it. Well if one still choses to do it then they also chose the possibility of OD-ing and dying. Can’t say that garners much sympathy from me.

And that’s why Mericuh and Mericuhns suck. Too much celebration of psychopathology and a lack of common human compassion.

 

[ggmike1992]

So I, as a law-biding, responsible citizen am to blame?

 

[ggmike1992]

http://www.herald-dispatch.com/_rec...cle_54460216-942e-11e8-b3c6-5be33b8889a3.html

This happened a few weeks ago one block from my house and across the street from the President of Marshall’s house. Just imagine had they hit some kids instead of a lightpole. These scumbags need to be off the street.

 

[MIKE_G]

This is why I don't keep up with people from high school.

 

[GwinnettNole]

My dad is addicted to pain-killlers....

 

[Fijimn]

So I, as a law-biding, responsible citizen am to blame?

I have no idea how you could possible infer this from his post. He is suggesting that the continued "war on drugs" policy has contributed to this epidemic. If you compare that to other countries that follow legalization and treating addiction as a medical condition and not "you made a bad choice, you go to jail."

 

[Imtotallynottribe]

Since you are in the field, what would you do if you were in charge(in 500 words or less, if possible)?

There’s a lot that can be done to limit (albeit never solve) the problem.

1) Institute a nationwide prescription database and require that all doctors and pharmacists see what the patients have already been prescribed. There are state databases in most states now, but they don’t interface so you can hop state lines to dr shop as well as use online pharmacies and physicians.

2) Remove the ability for untrained physicians and nurse practitioners to write scripts for more than 3 days worth opiates, benzos and other drugs of concern. It’s the primary care doctors handing them out like candy that is the main problem on the supply side.

3) Encourage the use of microsurgery, a hernia operation using a Davinci robot requires one day or recovery and one day of opioids as opposed to being sliced open and needing a week or more of recovery and opiates which can lead to addiction.

4) Require Proof of failure of NSAIDS and other alternative treatments before opioid therapy can be used for chronic pain management.

5) Require coprescribing of naloxone to all chronic pain and cancer patients. Not only will it save their life but the abundance and knowledge of use about naloxone will save others as well.

6) Put in real (meaning not just a token mil here or there to pretend they are addressing the problem, but at least three stealth bombers worth of) GOVERNMENT dollars towards creating other new opioids and combinations with built in antiagents to remove the ”high” while leaving the pain relief. Suboxone is already used for that but the Buprenorphine in it is not great for some patients.

7) Put in requirements for insurance companies to adequately fund addiction treatment. Some are doing as low as four days of residential treatment even though study after study says that 30 days is much better and 60 and 90 days is even better. The insurance companies are relying on actuarial inputs saying small stays fix the strong while the weak die and thus stop heavily using the plan. The incentive to allow patients to die must be removed.

I’ll stop there as it looks like about 500 words but there is a LOT more that can be done, that’s just the biggest changes that need to happen off the top of my head.

 

[Imtotallynottribe]

I have no idea how you could possible infer this from his post. He is suggesting that the continued "war on drugs" policy has contributed to this epidemic. If you compare that to other countries that follow legalization and treating addiction as a medical condition and not "you made a bad choice, you go to jail."

Absolutely.

 

[runkpanole]

There’s a lot that can be done to limit (albeit never solve) the problem.

1) Institute a nationwide prescription database and require that all doctors and pharmacists see what the patients have already been prescribed. There are state databases in most states now, but they don’t interface so you can hop state lines to dr shop as well as use online pharmacies and physicians.
We are getting closer to that. Florida has finally started allowing the share of information in its system to other states and 45 states (give or take a couple) are all using the same software and are sharing better information. One thing though is the new requirement in Florida to do a mandatory check of the system has some prescribers and dispensers upset and already wanting to change the law. A large problem is the practitioners themselves that complain about the "extra work" even though this data can be integrated into the patients EHR.

2) Remove the ability for untrained physicians and nurse practitioners to write scripts for more than 3 days worth opiates, benzos and other drugs of concern. It’s the primary care doctors handing them out like candy that is the main problem on the supply side.
Florida now requires mandatory CE on the dangers of opioid prescribing.

3) Encourage the use of microsurgery, a hernia operation using a Davinci robot requires one day or recovery and one day of opioids as opposed to being sliced open and needing a week or more of recovery and opiates which can lead to addiction.

4) Require Proof of failure of NSAIDS and other alternative treatments before opioid therapy can be used for chronic pain management.

5) Require coprescribing of naloxone to all chronic pain and cancer patients. Not only will it save their life but the abundance and knowledge of use about naloxone will save others as well.
Florida's new law also does this for the dispensing of Schedule II drugs for patients with traumatic injuries. Further funding was added in the bill to supply first responders with naloxone.

6) Put in GOVERNMENT dollars towards creating other new opioids and combinations with built in antiagents to remove the ”high” while leaving the pain relief. Suboxone is already used for that but the Buprenorphine in it is not great for some patients.

7) Put in requirements for insurance companies to adequately fund addiction treatment. Some are doing as low as four days of residential treatment even though study after study says that 30 days is much better and 60 and 90 days is even better. The insurance companies are relying on actuarial inputs saying small stays fix the strong while the weak die and thus stop heavily using the plan. The incentive to allow patients to die must be removed.

I’ll stop there as it looks like about 500 words but there is a LOT more that can be done, that’s just the biggest changes that need to happen off the top of my head.

I added some comments based on my knowledge of the issue.

 

[fsu1jreed]

That’s not entirely accurate. The way I understand it is the limit on opioids is for acute pain ie a broken arm. If you have chronic pain you will still get prescribed what you need. My friend has a major back issue and he is being prescribed 60 ten milligram Percocet every 30 days.

Nope.......the CDC wrote a paper a couple of years ago that no person should be on anything more than 100mg equivalence of morphine per day and I was WELL over that, so my PM doctor starting cutting me back (he said that in no certain terms they were "ordered" to cut everyone back) and I started going into DT's one day at work.

That was last July so I went into my PM doctor and told him to send me somewhere to get off it completely so I spent 13 days in a detox while they quickly weened me off. It took about 4-6 weeks for all the DT symptoms (random mild chills, etc.) to stop and about 4-5 months for my spasms to start calming down (though not 100% yet and may never be).

 

[Imtotallynottribe]

Nope.......the CDC wrote a paper a couple of years ago that no person should be on anything more than 100mg equivalence of morphine and I was WELL over that, so my PM doctor starting cutting me back (he said that in no certain terms they were "ordered" to cut everyone back) and I started going into DT's one day at work.

That was last July so I went into my PM doctor and told him to send me somewhere to get off it completely so I spent 13 days in a detox while they quickly weened me off. It took about 4-6 weeks for all the DT symptoms (random mild chills, etc.) to stop and about 4-5 months for my spasms to start calming down (though not 100% yet and may never be).

I’m shocked your insurance let you have that much detox. We just had a woman that my medical director said (and he’s got 25 plus years in the field, is triple Board certified in addiction, psychiatry and the combo addiction psychiatry and is the FADAA professional of the year for 2018) he has never seen a patient with as much and as many different drugs still alive. And her insurance only covered five days of detox so we’re having to treat her for detox issues while she’s in residential.

 

[runkpanole]

Nope.......the CDC wrote a paper a couple of years ago that no person should be on anything more than 100mg equivalence of morphine and I was WELL over that, so my PM doctor starting cutting me back (he said that in no certain terms they were "ordered" to cut everyone back) and I started going into DT's one day at work.

That was last July so I went into my PM doctor and told him to send me somewhere to get off it completely so I spent 13 days in a detox while they quickly weened me off. It took about 4-6 weeks for all the DT symptoms (random mild chills, etc.) to stop and about 4-5 months for my spasms to start calming down (though not 100% yet and may never be).

The new law in Florida is specific to acute pain. Chronic pain is defined in Florida statute as pain that persists for more than 90 days. Some believe it should be limited for other types of pain as well, but the law was specific to acute pain.

 

[Fijimn]

Nope.......the CDC wrote a paper a couple of years ago that no person should be on anything more than 100mg equivalence of morphine and I was WELL over that, so my PM doctor starting cutting me back (he said that in no certain terms they were "ordered" to cut everyone back) and I started going into DT's one day at work.

That was last July so I went into my PM doctor and told him to send me somewhere to get off it completely so I spent 13 days in a detox while they quickly weened me off. It took about 4-6 weeks for all the DT symptoms (random mild chills, etc.) to stop and about 4-5 months for my spasms to start calming down (though not 100% yet and may never be).

My mom had home hospice before she died. After she died, we bagged up all her meds to be incinerated There were the highest dosages of Oxy, morphine syringes and fentanyl. We had like a gallon bag of pills and stuff. Fijimn from the past chuckled about how much money we were about to burn up.

 

[fsu1jreed]

I’m shocked your insurance let you have that much detox. We just had a woman that my medical director said (and he’s got 25 plus years in the field, is triple Board certified in addiction, psychiatry and the combo addiction psychiatry and is the FADAA professional of the year for 2018) he has never seen a patient with as much and as many different drugs still alive. And her insurance only covered five days of detox so we’re having to treat her for detox issues while she’s in residential.

My insurance would have paid for 30 days, but I was just there to get past the worse of the withdrawals so didn't need them all.........once I was done with bute and after a few days of observation they discharged me.

The new law in Florida is specific to acute pain. Chronic pain is defined in Florida statute as pain that persists for more than 90 days. Some believe it should be limited for other types of pain as well, but the law was specific to acute pain.

My post was in reply to the "If you have chronic pain you will still get prescribed what you need" comment. But in looking, 20mg/day of percoset is only 30mg/day of morphine equivalence, which is WELL below CDC "recommendations"......with my conversations with MANY people on PM, most are WELL above that.

 

[Imtotallynottribe]

My insurance would have paid for 30 days, but I was just there to get past the worse of the withdrawls so didn't need them.........once I was done with bute and after a few days of observation they discharged me.



My post was in reply to the "If you have chronic pain you will still get prescribed what you need" comment. But in looking, 20mg/day of percoset is only 30mg/day of morphine equivalence, which is WELL below CDC "recommendations"......with my conversations with MANY people on PM, most or WELL above that.

Apparently I need to start tracking potential patients with your insurance. That’s shockingly good.

 

[fsu1jreed]

Apparently I need to start tracking potential patients with your insurance. That’s shockingly good.

Group policy of UHC.

 

[Imtotallynottribe]

Group policy of UHC.

Note to self, stalk all holders of Humans policies. Got it!

 

[Formerly Rockymtnole]

There’s a lot that can be done to limit (albeit never solve) the problem.

1) Institute a nationwide prescription database and require that all doctors and pharmacists see what the patients have already been prescribed. There are state databases in most states now, but they don’t interface so you can hop state lines to dr shop as well as use online pharmacies and physicians.

2) Remove the ability for untrained physicians and nurse practitioners to write scripts for more than 3 days worth opiates, benzos and other drugs of concern. It’s the primary care doctors handing them out like candy that is the main problem on the supply side.

3) Encourage the use of microsurgery, a hernia operation using a Davinci robot requires one day or recovery and one day of opioids as opposed to being sliced open and needing a week or more of recovery and opiates which can lead to addiction.

4) Require Proof of failure of NSAIDS and other alternative treatments before opioid therapy can be used for chronic pain management.

5) Require coprescribing of naloxone to all chronic pain and cancer patients. Not only will it save their life but the abundance and knowledge of use about naloxone will save others as well.

6) Put in real (meaning not just a token mil here or there to pretend they are addressing the problem, but at least three stealth bombers worth of) GOVERNMENT dollars towards creating other new opioids and combinations with built in antiagents to remove the ”high” while leaving the pain relief. Suboxone is already used for that but the Buprenorphine in it is not great for some patients.

7) Put in requirements for insurance companies to adequately fund addiction treatment. Some are doing as low as four days of residential treatment even though study after study says that 30 days is much better and 60 and 90 days is even better. The insurance companies are relying on actuarial inputs saying small stays fix the strong while the weak die and thus stop heavily using the plan. The incentive to allow patients to die must be removed.

I’ll stop there as it looks like about 500 words but there is a LOT more that can be done, that’s just the biggest changes that need to happen off the top of my head.

Good thoughts on how to help keep people from becoming addicted.

But what do we do about the currently addicted- implementing roadblocks to legal drugs just sends people to the streets for the cheaper heroin and other drugs, no?

This is where the legalization argument loses me, unless it’s coupled with significant increases in funding and health coverage for addiction treatment. IMO legalization alone would be a mess. (For drugs other than pot)

 

[fsu1jreed]

Note to self, stalk all holders of Humans policies. Got it!

United Health Care

 

[Imtotallynottribe]

United Health Care

Siri “fixed” my response to humans, not sure how that happened from United Health unless it’s some creepy terminatoresque thing where IT wants to stalk all humans.

 

[fsu1jreed]

Siri “fixed” my response to humans, not sure how that happened from United Health unless it’s some creepy terminatoresque thing where IT wants to stalk all humans.

Main reason why I don't do ANY of those voice activated devices.

 

[Hopkins Medicine]

Doctors today are trying to please everyone instead of doing what needs to be done. In the "bad old days" docs wouldn't hand out dangerous drugs like candy.

But in today's modern society, where the customer is always right, docs have gone soft and basically give in way too easy for patient demands; not just for narcotics but also for antibiotics, anti-anxiety meds, ADD meds, etc

We need a return to the days when docs told the patient the best medical advice instead of just accepting whatever the patient demands. The patient is not always right, and we need doctors to grow a spine and tell the patients that, even if they put bad reviews online about how the doc "wouldn't listen" to them or "ignored my pain" nonsense.

 

[12Nole]

Doctors today are trying to please everyone instead of doing what needs to be done. In the "bad old days" docs wouldn't hand out dangerous drugs like candy.

But in today's modern society, where the customer is always right, docs have gone soft and basically give in way too easy for patient demands; not just for narcotics but also for antibiotics, anti-anxiety meds, ADD meds, etc

We need a return to the days when docs told the patient the best medical advice instead of just accepting whatever the patient demands. The patient is not always right, and we need doctors to grow a spine and tell the patients that, even if they put bad reviews online about how the doc "wouldn't listen" to them or "ignored my pain" nonsense.

Scary that the culture of customer is always right has found it's way into medical field.

 

[Formerly Rockymtnole]

Scary that the culture of customer is always right has found it's way into medical field.

Yes, but doctors don’t know everything and most are swamped. You have to take control of your own care.

 

[12Nole]

Yes, but doctors don’t know everything and most are swamped. You have to take control of your own care.

Fair point.

 

[DFSNOLE]

Yes, but doctors don’t know everything and most are swamped. You have to take control of your own care.

Maybe true but they're almost guaranteed to know more than the patients.

 

[Formerly Rockymtnole]

Maybe true but they're almost guaranteed to know more than the patients.

Maybe before the Interweb.

 

[DFSNOLE]

Maybe before the Interweb.

The interweb has just made patients more dangerous because they think they're medical doctors.

 

[Formerly Rockymtnole]

The interweb has just made patients more dangerous because they think they're medical doctors.

I know, was just kidding. I know some docs who complain about that. But it can also help you ask better questions.

 

[runkpanole]

The interweb has just made patients more dangerous because they think they're medical doctors.

Hey, WebMD diagnosed me. It was on the interweb, it must be true.

 

[DFSNOLE]

I know, was just kidding. I know some docs who complain about that. But it can also help you ask better questions.

True. I can tell you that as a general contractor, I've had many clients who thought they knew more about building than I do even though if I tossed them a hammer, they wouldn't know which end to hold. Most of those were doctor/lawyer types.

 

[fsu1jreed]

Doctors today are trying to please everyone instead of doing what needs to be done. In the "bad old days" docs wouldn't hand out dangerous drugs like candy.

But in today's modern society, where the customer is always right, docs have gone soft and basically give in way too easy for patient demands; not just for narcotics but also for antibiotics, anti-anxiety meds, ADD meds, etc

We need a return to the days when docs told the patient the best medical advice instead of just accepting whatever the patient demands. The patient is not always right, and we need doctors to grow a spine and tell the patients that, even if they put bad reviews online about how the doc "wouldn't listen" to them or "ignored my pain" nonsense.

You must know different doctors than I do..........none of my current doctors do that and I've only had 1 maybe 2 since I've been in a wheelchair that would come close to doing that. Now, maybe it's because I know I don't know more about medicine than they do so I can't remember EVER going in and asking for something..........maybe Adderall when I first started teaching, but even then he sent me to a Psychologist/Psychiatrist for testing first before even thinking about prescribing. Usually if something new is going on (which is rare), I always let them do the diagnosing and determine any possible treatment path.

 

[Bill From Tampa]

That’s not entirely accurate. The way I understand it is the limit on opioids is for acute pain ie a broken arm. If you have chronic pain you will still get prescribed what you need. My friend has a major back issue and he is being prescribed 60 ten milligram Percocet every 30 days.

I am betting she first had to take a urine test and then her doctor apply to get her on the exempt list from having to do that every time. That is my understanding of what the process is these days in talking with a pain mgmt Dr.

 

[Hopkins Medicine]

The internet in terms of medicine is a good thing, but it does have unintended consequences.

I can tell you that I have many patient visits now that I wouldn't have had before except that they read something on the internet that they wanted further clarification on. In the pre-internet era, they would have just stayed at home.

That's why most doctors I know laugh at the thought that WebMD or the internet in general is going to take their jobs away. Internet increases the number of doctors' visits.

 

[Hopkins Medicine]

Maybe true but they're almost guaranteed to know more than the patients.

I have no problem admitting to certain patients that they might know more about a specific condition than I do.

For example as a general pediatrician I have a 5 year old patient who has AML (leukemia). His parents have been to 10 different oncologists and spent years researching everything they can find out about it. They spend at least 2 hours a night on nothing but that particular type of cancer. They know more about the clinical care of that particular type of leukemia than I do and I have no problem admitting that. They know more of the latest research than I do in that particular field.

However they also know that just because they know more about that particular condition than I do, doesn't mean they know more about the other organ systems or diseases. My knowledge base about general medicine is far larger and more in-depth than theirs will ever be.

 

[Imtotallynottribe]

The internet in terms of medicine is a good thing, but it does have unintended consequences.

I can tell you that I have many patient visits now that I wouldn't have had before except that they read something on the internet that they wanted further clarification on. In the pre-internet era, they would have just stayed at home.

That's why most doctors I know laugh at the thought that WebMD or the internet in general is going to take their jobs away. Internet increases the number of doctors' visits.

That’s because if your toe aches and you look it up, WebMD probably has cancer listed at the top of things it could be.

 

[Formerly Rockymtnole]

That’s because if your toe aches and you look it up, WebMD probably has cancer listed at the top of things it could be.

1. Cancer
2. Guaniria
3. Ingrown toenail

 

[Wendy79]

Physical dependency can develop within the first 1-3 days. Patients get nauseous, etc, when they stop taking the pills, so the take another one which makes you feel better, and there you go.

 

[runkpanole]

Physical dependency can develop within the first 1-3 days. Patients get nauseous, etc, when they stop taking the pills, so the take another one which makes you feel better, and there you go.

Which is why I’m all for limiting the day supply and monitoring the patient. Hearing some docs during the hearings of the Florida bill and even after it amazed me with the number of docs that complained. One complained about giving her patient a 7 day supply and the patient went to the ER after 4 days because she blew through the pain killer. Clearly the patient was abusing the drug (not necessarily intentionally).