The Swinging Pendulum of Opiate Prescribing

The Swinging Pendulum of Opiate Prescribing – June, 2016 – Cmdr John Burke

In the several decades I have been in the business of following the diversion of pharmaceuticals, I have noticed a pendulum effect regarding this issue.

In almost everything important in life, balance is usually paramount; extremes are rarely the answer

However, finding balance is difficult and requires work. Balance requires careful thought, weighing the pros and cons, and taking an action that can be accepted by most individuals because getting everyone to agree is virtually impossible.  

This holds true regarding the prescribing and dispensing of prescription drugs, especially controlled substances.

Sometime in the early 1990s, it was thought that our nation’s pain sufferers were being undertreated for pain.

Once it was determined that Americans were undertreated for pain, pharmaceutical companies began producing stronger and longer-acting medications that required fewer pills each day and that provided a steady release of pain medication

OxyContin was developed and prescribed liberally to treat chronic pain and cancer pain, and it thrived on the market for several years with little or no diversion issues.

The diversion issue started in Maine, for some unknown reason, when it was discovered that OxyContin could be compromised and then injected or snorted for a superior high.

In late 1999 or early 2000, the abuse issue hit the media and only accelerated from there.

This went on for a little over a decade until Purdue Pharma was able to reformulate OxyContin and produce an abuse-deterrent formulation (ADF) that hit retail markets in August 2010.

Around the same time as the OxyContin reformulation in 2010, Mexican drug cartels realized that if addicts were unable to achieve a good high with the ADF of OxyContin, they would need a replacement.

That is when heroin was reintroduced into our society

Purity levels of heroin exceed 50%, meaning it can be successfully snorted or injected.

Clandestine fentanyl is added for more kick and leads to even more overdose deaths

Lately, prescribers are getting suggestions for prescribing guidelines,

The CDC guidelines were suggestions but have been universally, and wrongly, interpreted as fixed rules. 

See CDC: Opioid Guidelines Not a Rule, Regulation or Law

Once again, the pendulum has swung back:

abusers are getting the attention and pain patients are left to wonder how these new guidelines will impact their daily lives if their physicians decide to cut them off.

I fear the latest scrutiny on physicians may negatively impact legitimate pain patients.

This is yet another example of how balance is so important:

physicians need to address those scamming them and procuring pharmaceuticals from multiple prescribers while safeguarding their legitimate patients who would have trouble living without their medications


3 thoughts on “The Swinging Pendulum of Opiate Prescribing

  1. Laura P. Schulman, MD, MA

    Interestingly, Medscape (the physicians’ edition) ran an article today, authored by a dentist, about how dentists are prescribing too many pain meds. I wrote a response saying that the author should have a few extractions and be sent home without pain meds, and get back to us. Medscape refused to publish my comment.

    Liked by 1 person

    1. an_angel_with_wings

      Medscape not publishing your comment doesn’t make it any less factual. I am one of those patients that doesn’t get pain meds when I have dental work. I’m in pain management, and have always been compliant, but neither my oral surgeon nor my pain management Physician’s Assistant are willing to prescribe a few extra tablets after oral surgery.

      Personally I don’t think an extra 10 tablets for having three teeth extracted is reckless. I could understand if I was a brand new patient, already finding reasons for ‘MORE, MORE, MORE’, but that isn’t the case. I’ve been fully compliant with the PM program, including having broad urine screening done (including drugs of abuse, not just the levels of my prescribed drugs). So far I’ve never failed a single drug test (knock wood against false positives – they DO exist).

      I was very ill (and it was a painful illness) back in the 90s when oxycontin was original formula. I never compromised the medicine to take it in a way it wasn’t intended to be used (crushing, snorting, injecting). I always swallowed my pills, but that didn’t leave my body any less dependent on them. Dependency is not addiction, though. I was able to stop them after my 2001 neurosurgery which resolve much of the head pains.

      I tried to take the new formulation of oxycontin somewhat recently. But, due to my gastric surgeries resulting in some malabsorption, I could even break down the medicine fully! I’d use generic MS Contin over Oxycontin any day. That wouldn’t have been the case in the 90s. The first time I got Oxycontin, I had to get a new drug within a week. At that time, I wasn’t opiate tolerant enough for oxycontin, so it was actually too strong. That is the ONLY time (including hospital stays for surgery), where I would say I had more pain medicine than I could use.

      As far as how much PM is actually *needed* is still a hot debate, since it obviously relates to the prescribing practices of the Pain Management doctors. I can’t be the only one stuck in this endless mental loop – I can’t make an income because no one will hire someone with as many health problems as I have, and for some reason (despite all they’ve found wrong with me), no doctor supports me applying for disability.

      That’s a topic for another post, though – it is definitely another subject that is interesting enough to stimulate an entire conversation of it’s own!

      Liked by 1 person

  2. david becker

    The issues isnt balance- the issue is caring. there has been a deficit of caring for people in pain by government and health care providers. Look how quickly and poorly they made decisions about the “opioid epidemic”- and golly gee whiz- didnt they forget the history of opioids and their plans(as they call them) are most amateurish-and again reflect superficial engagement and lack of caring. They had a “lets finish the job” bias-lets get er done-and just like the National Pain Strategy plans to address opioid problems reflect the same carelessness the same insensitivity, the same empathy gap- the same statism and oversimplification. Pain Care in America- Cant Get it Right- I wanted to write the book 4 years ago- but now I realize its as timely today as it would have been if i wrote it 4 years ago.

    Liked by 1 person


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