# Pain drugs abuse requires urgent action: CDC



## MMiz (Jun 19, 2010)

*Pain drugs abuse requires urgent action: CDC*

Emergency department visits involving the nonmedical use of pain drugs such as oxycodone rose to 305,885 in 2008, from 144,644 in 2004, according to a study by the Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention.

"We urgently need to take action," CDC Director Dr. Thomas Frieden said in a statement, noting that trips to the emergency department for nonmedical use of prescription pain drugs are now as common as those for use of illicit drugs.

*Read more!*


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## JPINFV (Jun 19, 2010)

This is essentially a non-issue. 

*Drug abusers are still going to go to the emergency room for pain medication.

*The vast majority of emergency physicians would rather side on pain being real, but will try to limit abuse and will keep a sharp eye out for red flags.

*The emergency physicians who hand out pills like candy despite red flags aren't going to change their practice because of a press release.


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## Melclin (Jun 19, 2010)

JPINFV said:


> This is essentially a non-issue.
> 
> *Drug abusers are still going to go to the emergency room for pain medication.
> 
> ...



This.

And,
The typical knee jerk reaction to things like this is.."our government is commited to cracking down on pain pill pushers" and all of a sudden it becomes more difficult to get a panadeine when you have a headache. The 'increased regulation' and 'tougher laws' only prevent people who need analgesics from getting adequate care; the addicts one way or another will still find a way to get wasted.


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## Veneficus (Jun 19, 2010)

Melclin said:


> This.
> 
> And,
> The typical knee jerk reaction to things like this is.."our government is commited to cracking down on pain pill pushers" and all of a sudden it becomes more difficult to get a panadeine when you have a headache. The 'increased regulation' and 'tougher laws' only prevent people who need analgesics from getting adequate care; the addicts one way or another will still find a way to get wasted.



Exactly,

Pain control in the US is extremely conservative anyway despite a decades long drive to do more.

It make sme wonder if all the time/money spent on law enforecement, incarceration, and articles like this wouldn't be better used for rehab?

Oh well.


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## mycrofft (Jun 20, 2010)

*In my experience :*

Since late Eighties when such things were being pushed as "pain is the next vital sign" etc., while the meds prescribed for the worst off patients still tended to be a little consrvative, the more pedestrian prescribing of easy Vicodin, Oxycodone, Tylenol#3 etc has become rampant because the prevailing reasonable standard became to _*just order*_ these remarkably cheap drugs to avoid expensive lawsuits and tantrum-throwing patients. That is what has triggered this; that, and many folks don't throw out the remainder of a Rx they no longer need, "just in case". I think NEJM had an article a while back also.


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## Veneficus (Jun 20, 2010)

I think part of the problem is not having a reasonable plan to treat the pain or trying to treat pain as the only goal.

It is a system related problem. For example, if somebody walks into the ED with lower back pain or a broken tooth, since nothing can be done in the ED for the underlying cause, some pain meds get dispensed and from the ED standpoint, the problem is solved.

However pain as a physiologic response to tissue damage isn't going to go away unless the tissue damage is halted. So the short term solution of making pain go from 10-9 or 10-1 or whatever combination you like, may seem like "mission accomplished," how many of those people have the abilty to follow up with a lng term care plan, like going to the orthopod or dentist respectively? Especially in a pay cash up front for nonemergency system?

Should pain from any source just be "controlled" and the cause not addressed, it will become more and more difficuly over time to control the neuropathic pain in addition to down regulation of opioid receptors etc. Then problems are really created.

Pain doesn't make a good vital sign. It is just a symptom.


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## Meursault (Jun 20, 2010)

I was actually going to post about this. The MMWR article is here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5923a1.htm?s_cid=mm5923a1_w

For what it's worth, the article's suggestions are fairly conservative. The middle two are sensible and innocuous, and the others could go either way.



			
				 The CDC said:
			
		

> Given the societal burden of the problem, additional interventions are urgently needed, such as more systematic provider education, universal use of state prescription drug monitoring programs by providers, the routine monitoring of insurance claims information for signs of inappropriate use, and efforts by providers and insurers to intervene when patients use drugs inappropriately (9,10)



Potential systems change aside, there's some interesting practical info in here:



			
				 The CDC said:
			
		

> Notably, results from 2008 indicate that in addition to the large increase in visits compared with 2004, peak visit rates for both opioids and benzodiazepines appear to have shifted into the 21--24 and 25--29 years age groups and away from the 30--34 and 35--44 years age groups. As late as 2006, the peak mortality rate for fatal drug overdoses involving opioid analgesics had been in the 35--54 years age group (1).


This would seem to suggest either a sharp uptick in young people with undermanaged chronic pain or growing recreational use. I assume the latter is true, which means focusing on chronic pain might not be as helpful. People who are being inappropriately managed with lots of opioids are likely to use them all. 



			
				 The CDC said:
			
		

> Among opioid analgesic--related visits, 38% did not involve any other drug (including alcohol); the corresponding figure was 21% for benzodiazepine-related visits. Benzodiazepines were involved in 26% of opioid analgesic--related visits. Alcohol was involved in 15% and 25% of visits for opioids and benzodiazepines, respectively.





			
				 The CDC said:
			
		

> The relative magnitudes of the rates shown generally reflect prescription volumes.


 I.e., perceived "riskier" drugs aren't being prescribed as much and/or the drugs studied have about the same abuse potential.

Anyone care to speculate on why this isn't lining up with what we're getting from NSDUH? The authors don't really seem to have much of an idea, either.


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## 1badassEMT-I (Jun 21, 2010)

I say piss them off and give NARCAN......as a opps my bad I tought I was giving a NARC for your pain.....send them into DTs.......no seriously this a bad epidemic that is only to get worst......I dont think here in some time during my shift I have not pick up a seeker.....pill snorters are bad here in WV....and the other day the governor said we need to crack down on it....AGREED but you got to shut down the pain clinics that the doctors are running......FIRST


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## Aidey (Jun 21, 2010)

I think you guys misunderstood, this isn't about people getting pain meds at the ER its about the number of people going to the ER because of complications from abusing pain meds. 

Basically the number of ODs is increasing at an alarming rate. Now, over-prescribing by ER docs may be contributing to that, but that isn't what the CDC is talking about.


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## 1badassEMT-I (Jun 21, 2010)

Aidey said:


> I think you guys misunderstood, this isn't about people getting pain meds at the ER its about the number of people going to the ER because of complications from abusing pain meds.
> 
> Basically the number of ODs is increasing at an alarming rate. Now, over-prescribing by ER docs may be contributing to that, but that isn't what the CDC is talking about.



You are right but the abuse starts with the one prescribing the meds dont you think..... Now before anybody get upset.....I know some need pain meds and others  will abuse them....as for others that seek them daily what are you to do about it..... We got to some how got to educate or stop issuing the meds or both....it will never stop....


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## mycrofft (Jun 21, 2010)

*Many abusable drugs not ER scrips. Some not for pain.*

Seroquel and Ambien come to mind. Testosterone. Lomotil (diphenoxylate, the pharmacoactive metabolite of Vicodin). Compazine. Scopolamine ("Scope"). Cough suppressants.

But, back to track. The docs feel abuse is not their business, it is the patient's until they bring it up as a complaint. THEN some docs write walkaway scrips for controlled substances to detox on, some of which are abused or sold.

The EMS issue is that people who live in nice houses and look middle class can be experiencing an OD due to doseage error, unwitting overuse, syngergistic amplification, or sampling Dad and Mom's medicine cabinet.


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## Veneficus (Jun 21, 2010)

*square block, round hole*

Drug abuse is a social issue. Trying to find medical solutions to it is both a waste of money and a waste of time.

The CDC idea of universal prescription registry is a bit misplaced. Most ER docs know who the seekers are. They are powerless to do anything about it.

EM is not my thing, but if it was and I had to choose between giving a seeker a narc script or getting sued for pain and suffering for not giving it, it doesn't take a rocket scientist to figure out how that situation will play out.

We once had an amendment that outlawed one of the most common drugs of abuse, it didn't really work out to our benefit and was repealed.

Alcohol, nicotine, and caffeine are abused quite frequently. I'll bet even by many of us.

Student favorites include Adderall, THC, and Cocaine.

How about ED patients using nitro paste instead of viagra or another name brand because it is too expensive?

Or the power combination of prozac and viagra?

How about some "natural" products like creatine or protein drinks?

a depressed person or a "victim" of the stresses of today's society, wars, etc, may have legitimate pain. They may not, but they will always find something to ease that pain. Whether it is from  a prescription or cooked up in the home lab is really irrelevant. 

If you want to prevent abuse, there needs to be an alternative to medication. In the Us, such alternatives do not exist. Nobody wants to pay for them.

Rehab is the same way.In order for it to be effective, it has to be constant, if not inpatient, and probably life long counciling. Incarceration is not going to be an economically viable solution. 

I saw a suggestion for reversal agents which is used with methadone treatment. It doesn't work. They just take the methadone until they can score some more street drugs.

I am not sure that letting somebody go into withdrawel constitutes "do no harm." That seems to me similar to letting a kid wander out into freeway traffic to teach them not to do that or to look both ways. While it definately sounds like the moral high ground to say "drug abusers deserve..." where does the moral high ground end? What if I started advocating taking away voting rights for anyone who didn't graduate from college? Seems reasonable to conclude for the continuation of our society and species that it should be the educated that are making the decisions. 

Look at ancient Greek and early US history, the ones who could vote were "citizens" which in the former included males who were both physically fit and educated and in the later included white males with considerable education. Is there doubt that early America and ancient Greece (and even Rome) were not the pinacle of human society? What about martial societies like feudal Japan?

Anyway the point of all of this is that we cannot legislate morals. Nor can we base medical treatment off of morals not consistant with the long standing traditions of the medical and nursing professions.

What's next, we decide anyone who makes less than a middle class living is not entitled to medical care?

Anyway, the point still stands. If you want to solve the problem of drug abuse, you can't single out certain drugs or populations, you must remove the social issues that drive people to abuse in a responsible way.


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## mycrofft (Jun 22, 2010)

*The only social issue you can remove is one you caused..and not always then.*

The post is about OD's of legal meds. I wonder if they are supplanting illegal meds OD's, or if they are in addition, or a degree of both?


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