Heroin

[Sensei]

21937

The picture says it all. I just worked 4 days in the emergency department starting Wednesday and kept a count of my patients; 1/4 of my patients were heroin overdoses or someone wanting detox. Two more were patients with infective endocarditis from IV drug abuse; historically IÂ’d see a couple of cases PER FUCKING YEAR. This week is not an outlier as NC EMS agencies have dispensed 20,000 doses of Narcan this year which doesnÂ’t count the many more doses dispensed by police and fire departments. One municipality in OH literally added a refrigerated container box car unit to its morgue to keep up with the volume of bodies. A local middle school is considering stocking Narcan after a near fatal overdose by a student last month.

This problem is the direct result of the medical community providing easy access to prescription narcotics for 20 years and not challenging bullshit statements like this:
1) “Patients with non-cancer related chronic pain can be safely managed on long-term opiates with negligible chance of abuse and addiction.”
2) “Pain is the 5th vital sign.”
3) “Many of patients do well on long-term opiates, so we should not be too draconian in our approach to physician who care for these patient.”
My favorite is the last one. My reply is, “Yeah, well SOME patients well with blood letting. Let me know when you can define ‘doing well’ or predict who it will be.”

All of that is self-serving bullshit used to justify a shitty approach to medicine that lines physician and Pharma pockets while resulting in 300,000 dead. In other words, thank you state medical boards, Joint Commission, and DHHS for doing a bang-up job with policing your own.


Looking beyond the deaths, we face a possibility of a lost generation to opiates. Many of the blue collar employers in my region estimate that 1/3 of their applicants fail the drug test.

Now, a word to those who want to “end the war on drugs.” You now have a little taste of what happens when we unleash low-cost, highly addictive drugs on the population. In other words, if you really want to know why you are sitting in a waiting room with chest pain or appendicitis (or if your ambulance never showed up), it’s because 25% of my beds are occupied by overdoses.

[Totem Polar]

Brutal.

[Lon]

Well said. All our OD deaths go to that morgue in OH you mentioned. I/we saw a huge spike in heroin after Ohio instituted the prescription database that doctors now have to check before writing scripts for pain and other meds. Before that doctor shopping was rampant and mostly uninvestigated since it was too time intensive.

[smithjd]

I’ve done my best to avoid posting on this subject in the past, considering there are no easy answers and lots of strong opinions, but couldn’t agree more with Sensei’s post above. I’d also consider adding overprescribing Adderall and other stimulants to young developing brains a contributing factor in methamphetamine abuse to your hate. Or prescribing strong anti-depressants to a young teenager with typical young teenager issues who then commits suicide. We are told the young’uns brains are not fully developed until they are 26 and can’t even have a beer because it damages their development... Even if the drugs themselves don’t have lasting effects, establishing a pattern of behavior where drugs are the “A” answer to your issues; what could possibly go wrong?

I did a case on a doctor deliberately overprescribing opiates to a minority group. Original complainants were other medical professionals. Had a clear pattern over years and numerous patient files evidencing he was not practicing medicine as spelled out in 1919 Supreme Court cases regarding the same subject... Could not get a criminal prosecution because ‘could not prove a motive’ (which is not an element of the crime).

In support of “This has all happened before, and will all happen again”, a good overview of what happened a century ago:

https://www.ncbi.nlm.nih.gov/books/NBK234755/

And we are told drugs need to be legalized and addiction fought with the medical model. I might agree, if that model was how we dealt with leprosy a couple of centuries ago; e.g. complete segregation from society so as not to infect others. Until then, physician heal thyself.

[blues]

Having worked narcotics cases for years both on the street side and the international trafficking side I can relate to the frustration. There seems to be no answer that comes close to solving this dilemma.

You see the devastation in the streets, in the mules that body carry at great personal peril, and oftentimes in the agents and police themselves that witness and are exposed to some brutal scenes on a day to day basis.

I've gotten so turned off by big pharma and the way drugs are advertised on TV like typical consumer products and so widely dispensed that I can barely stand to turn on the set. Five minutes of news and 25 minutes of drug commercials showing how happy folks are now that they're on Brain-Ex.

When I went in to the ER a year ago to have both my hands stitched up, despite my protestations they didn't want me to leave that night without taking a handful of Vicodin capsules home with me. I told them I didn't want them and wouldn't use them and would call for a pain killer if needed. They insisted. So, I took them home and a year later they still sit where I set them on a shelf in my medicine cabinet. But what if I had less self-restraint and personal discipline? What if I just said to myself "well, they know best and wouldn't give them to me if i didn't need them"? The potential for going down a long dark road, that's what.

Beyond whether "drugs" are legalized in this country, without a significant change to the mindset and culture from big pharma and the medical professionals on down to the public at large, this abuse and over-medication whether self administered or prescribed will just hasten our demise as a people and (formerly) great nation.

I've gotten to the point where I will only go to the doctor if I need stitches or something arising out of a traumatic onset. That's on me, but it's in large part a reaction to the "there's a pill for that" mentality which is what actually sickens me.

[Cookie Monster]

Crazy. The health care system is in lots of trouble. Sad state.

The last few years I’ve had trouble getting opiate prescriptions (legit short term ones for pain control on major injuries) filled at the pharmacy. After 5 days in the hospital with the wife and twins during the birth process I didn’t look the most professional. If I suspect I might need to get a opiate prescription I dress up now and make sure the hair is well combed, lot less issues.

[03RN]

I'm good with ending the war on drugs and I'm ok as using pain as a VS.

The problems arises when opiates are the go to. There's a lot of other pain reliever's. Nsaids, acetaminophen, plus non pharmacutical methods that take time and energy to implement. Whose got time for that when we're understaffed.

It's a whole shit show but making something illegal doesn't help. I'm of the opinion that the failure of the family in modern society along with our modern social media culture has done more harm than the war on drugs has helped.

[03RN]

As per your chart I find it interesting that it took 10 years for deaths to increase after implementing pain as a vital sign.

[Qaz98]

Sensei I disagree that physicians are having their pockets lined with the opiod crisis. You could certainly point to specific pain clinics, or pain specialists perhaps, but your typical MD isn't getting a kickback, if that's what you're alluding to.

It is true, however, when you make policy without strong evidence, as JCHAO did when they adopted pain as the 5th vital sign, you expose yourself to unintended consequences.

[Mr. Goodtimes]

I’m sure I’m the odd man out here but, I think most prescription drugs should be legal and over the counter. The FDA should only regulate their purity. I also happen to think everything class III should be cash and carry over the counter too.

Why? Because it’s a self balancing system. Eventually people will self select. I run opioid overdoses all the time, sometimes the same people, week after week, month after month, and eventually they self select which corrects the problem. Once they’re dead they aren’t our problem anymore. Drug control works about as well as gun control.


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[GardoneVT]

Broken homes leads to broken children. Broken children grow up to be broken adults,which then leads to adults coping - sometimes with violent or medicinal results.

Thinking back to black culture and the 1960s, I submit there was a very good reason divorce was considered a serious taboo. A stable home ensures kids have attentive parents -even if the parents don't necessarily like each other. Staying together for the kids isnt the stuff of romance novels,but I can't help wondering if our crime and drug use stats would be lower if couples did just that.

One things for sure- we can't solve this problem by the bludgeon that is Government Policy. Legalization nor incarceration alone can fix fucked up families.

[okie john]

I’m sure I’m the odd man out here but, I think most prescription drugs should be legal and over the counter. The FDA should only regulate their purity. I also happen to think everything class III should be cash and carry over the counter too.

Why? Because it’s a self balancing system. Eventually people will self select. I run opioid overdoses all the time, sometimes the same people, week after week, month after month, and eventually they self select which corrects the problem. Once they’re dead they aren’t our problem anymore. Drug control works about as well as gun control.

I understand where you're coming from, but what happens to regular people who can't get the emergency services they need (and pay for with tax dollars) because the ambulances, cops, and EMTs are all tied up dealing with junkies?


Okie John

[scjbash]

Broken homes leads to broken children. Broken children grow up to be broken adults,which then leads to adults coping - sometimes with violent or medicinal results.

Thinking back to black culture and the 1960s, I submit there was a very good reason divorce was considered a serious taboo. A stable home ensures kids have attentive parents -even if the parents don't necessarily like each other. Staying together for the kids isnt the stuff of romance novels,but I can't help wondering if our crime and drug use stats would be lower if couples did just that.

One things for sure- we can't solve this problem by the bludgeon that is Government Policy. Legalization nor incarceration alone can fix fucked up families.

The heroin problem has moved way beyond broken homes or bad parenting. I've lost count of how many friends and classmates I've lost to overdoses, but outside of a case or two they all came from good homes. Ten years ago when someone was on heroin there was likely a fucked up home behind it. Since then it's become an equal opportunity drug.

Edit:

Sensei that chart showing traffic fatalities and overdoses reminded me of a stat our local PD released a few weeks ago. They said that 2/3 of DUI arrests here are now from drugs instead of alcohol.

[blues]

The heroin problem has moved way beyond broken homes or bad parenting. I've lost count of how many friends and classmates I've lost to overdoses, but outside of a case or two they all came from good homes. Ten years ago when someone was on heroin there was likely a fucked up home behind it. Since then it's become an equal opportunity drug.

Same as it ever was. It moves in cycles...speaking as one who has been around the drug since the early 70's.

[pangloss]

Regarding Blues' comment about the advertisements, it would be interesting to see how direct to consumer marketing has correlated with the increase in opiate abuse. I wonder what would happen if these sorts of advertisements we're prohibited.

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[peterb]

When I went in to the ER a year ago to have both my hands stitched up, despite my protestations they didn't want me to leave that night without taking a handful of Vicodin capsules home with me. I told them I didn't want them and wouldn't use them and would call for a pain killer if needed. They insisted. So, I took them home and a year later they still sit where I set them on a shelf in my medicine cabinet. But what if I had less self-restraint and personal discipline? What if I just said to myself "well, they know best and wouldn't give them to me if i didn't need them"? The potential for going down a long dark road, that's what.

I was given an prescription opiate as a "if the pain gets really bad" option after my hip replacement. There were a couple of nights when I chose to use it. I've got to admit that being able to sleep and not having pain was nice. It's really easy to see how that starts -- not "getting high", just wanting a good nights' sleep and to not hurt all the time...

And then down that road, it's not so much that you want to feel good, it's that you're constantly scared of how bad you'll feel if don't get your next hit. That's got to be a miserable way to live.

[Sensei]

Sensei I disagree that physicians are having their pockets lined with the opiod crisis. You could certainly point to specific pain clinics, or pain specialists perhaps, but your typical MD isn't getting a kickback, if that's what you're alluding to.

It is true, however, when you make policy without strong evidence, as JCHAO did when they adopted pain as the 5th vital sign, you expose yourself to unintended consequences.

Pain specialist pill mills were a problem 10 years ago. Most of those have been shut down and what remains are anesthesiologist and PMR docs doing opiate sparring procedures. The vast majority of opiates now are prescribed by primary care providers - trust me they are getting paid for those office visits. AAFPÂ’s Position Paper is a joke as it basically states that family practitioners have a role to play in chronic pain management, but doesnÂ’t give strong guidance against: long term use of opiates for non-cancer pain, combining opiates with benzos, or a definitive position for when those with chronic pain should be referred to a pain specialist for opiate sparring therapies. It is a defecto endorsement of the status quo.

So, you get what we have now which is primary doctors prescribing monthly refills of 90/60 - thatÂ’s 90 Norco and 60 Xanax. DonÂ’t get me started on the family practitioners who manage their patientÂ’s chronic pain with Norco or Percocet, the anxiety with Xanax, and ADD with Adderall - I see it all the time.

[Qaz98]

So, you get what we have now which is primary doctors prescribing monthly refills of 90/60 - thatÂ’s 90 Norco and 60 Xanax. DonÂ’t get me started on the family practitioners who manage their patientÂ’s chronic pain with Norco or Percocet, the anxiety with Xanax, and ADD with Adderall - I see it all the time.

I don't necessarily disagree with pain specialists or pain clinics - but I think you are misinterpreting family practitioners motive behind managing chronic pain. I don't disagree that the patients are mismanaged - and that goes into the whole need for better guidelines. But a family doc gets paid like $25 per visit - they're not getting kickbacks from Pharma - and these patients are often the bane of their existence. No physician sees a chronic pain patient on their clinic schedule and thinks "Cha-ching!" So yes, these patients are mismanaged because it is way easier in 15 minutes to give them refills and get them out the door than spend 60 minutes to go over a withdrawal strategy or alternative solutions. But to say that family docs are mismanaging out of greed is frankly sensational and wrong. They have 40 patients a day, 15 minutes per patient, and get reimbursed poorly by Medicare. Just because the office sends you a bill for $150, doesn't mean that's what that doc is pocketing. You're clearly in healthcare, so you know what I'm saying.

Even if they bill a 99214, which I doubt - that is equal to 1 wRVU, which on average is maybe $45. So the physician gets credit for $45 in his production box. Do you think that motivates him/her to push opiods? It wouldn't motivate me. It's more likely that it's just the easier thing to do - just like pediatricians giving the high maintenance parent antibiotics, rather than taking the extra 10 minutes to assure her that it's a viral URI and will resolve.

[TAZ]

So what else happened in 2000 where the data shows an uptick. Did it take 10 years for the opiates to take hold or just trickle down to PCP’s handing them out like candy so to speak?

I’m mixed on the whole legalization thing as I’m pretty sure that the actual impact it would have in the numbers of users and abusers would be minimal in the long term. Addiction is a symptom and not generally a root cause. At least in my experiences in dealing with addicts. What we are doing isn’t working. It’s costing trillions of tax dollars and eroding many of our freedoms and rights. Not sure if that’s a fair trade. Not sure what the solution is, but at some point I think we will need to let Darwin do it’s thing to these repeat idiots.

[YVK]

..and these patients are often the bane of their existence. No physician sees a chronic pain patient on their clinic schedule and thinks "Cha-ching!" So yes, these patients are mismanaged because it is way easier in 15 minutes to give them refills and get them out the door than spend 60 minutes to go over a withdrawal strategy or alternative solutions. But to say that family docs are mismanaging out of greed is frankly sensational and wrong. They have 40 patients a day, 15 minutes per patient, and get reimbursed poorly by Medicare. Just because the office sends you a bill for $150, doesn't mean that's what that doc is pocketing. You're clearly in healthcare, so you know what I'm saying.


You are absolutely correct. If there is any financial incentive, it is one of getting everything, from interview to exam to writing Rx to finishing the dictation, done in 15 minutes so the doc can move on to their patient #21 out of 40 they need to be seeing. Relieve the productivity pressure and reimburse the time spent, and this will go away too.

Working in ED doesn't give a full prospective on managing these patients in the ambulatory settings. These patients are pain in the ass. Just like every patient who comes to ED for their pain fix is morphine-allergic and wants the dilaudid. I don't even do primary care or pain and they try to get their pain meds out of me, going on and on about their misery. If I didn't need my DEA license for the inpatient work, I'd gladly let it go. Most if not all local primary docs put their pain patients on pain management contracts and do their best to contain this shit. I can speak for 7-8 primary docs that I work with closely: if they could get rid of these patients, they would in a heartbeat, 'cause they aren't getting anything out of that other than the headache.

[45dotACP]

Didn't the AMA just publish a study that showed similar efficacy between narcotic pain meds and conventional OTC stuff for breaks, sprains etc?

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[YVK]

Late 90s and early 2000s saw a number of publications and statements, from here and Europe, stating safety of chronic opioid use. Both accuracy and implementation of these findings are a subject of intense criticism these days.

Breaks and sprains are considered an acute pathology, not chronic pain conditions that are associated with opiate abuse. I am not aware of acute diseases being a risk factor for that.

[Sensei]

I don't necessarily disagree with pain specialists or pain clinics - but I think you are misinterpreting family practitioners motive behind managing chronic pain. I don't disagree that the patients are mismanaged - and that goes into the whole need for better guidelines. But a family doc gets paid like $25 per visit - they're not getting kickbacks from Pharma - and these patients are often the bane of their existence. No physician sees a chronic pain patient on their clinic schedule and thinks "Cha-ching!" So yes, these patients are mismanaged because it is way easier in 15 minutes to give them refills and get them out the door than spend 60 minutes to go over a withdrawal strategy or alternative solutions. But to say that family docs are mismanaging out of greed is frankly sensational and wrong. They have 40 patients a day, 15 minutes per patient, and get reimbursed poorly by Medicare. Just because the office sends you a bill for $150, doesn't mean that's what that doc is pocketing. You're clearly in healthcare, so you know what I'm saying.

Even if they bill a 99214, which I doubt - that is equal to 1 wRVU, which on average is maybe $45. So the physician gets credit for $45 in his production box. Do you think that motivates him/her to push opiods? It wouldn't motivate me. It's more likely that it's just the easier thing to do - just like pediatricians giving the high maintenance parent antibiotics, rather than taking the extra 10 minutes to assure her that it's a viral URI and will resolve.

Your are correct - I'm a physician. Been doing it for about 15 years with a mixture of private practice, military, other federal, and now academics. Here is what I've seen happen since I finished residency. The use of incentive based compensation that over relies on patient satisfaction has been one powerful financial motivator for physicians to over utilize diagnostic testing, antibiotics, and controlled substances. This largely mirrors the ascendancy of large contract management groups and an over emphasis on surrogate markers of quality such as CMS core measures and patient sat.

For example, I left a lucrative practice after 7 years when our group was acquired by a large contract management group that utilized a compensation model where quarterly bonuses were predicated on 90th percentile patient satisfaction scores. While I believe that patient sat is important and I understand that no study has correlated going home with controlled substance prescriptions with good scores (that study will never be done), most of my partners adopted predictable maladaptive practice patterns when it came to resource utilization. Because one or two bad surveys in a quarter meant no bonus, my partners massively increased their controlled substance prescribing in an irrational fear of not meeting every patient's expectations. I vividly recall after having a quarter where my scores slipped and I sacrificed $10K in bonus, my own prescribing of antibiotics and controlled substances went up. That is when I realized that financial pressures were being used to drive me outside of my comfort zone and it was time to move on. I actually left medicine for 3 years to pursue other employment options because I was seeing this phenomenon across my speciality.


So, the majority of the problem is not just primary doctors churning out Level 3 visits as a some sort of quasi pill mill, although those physicians do exist and are significant. It is also not just doctors taking the "easy way out" and writing a script instead of taking the time to explain an alternative treatment plan (BTW, that is unethical as hell too). No, the lion share of prescription opiates are out there because physicians are responding to a multitude of financial pressures such as core measures, patient sat, etc. that increases their controlled substances prescribing.

So, if you want to see this drop really fast, just have CMS create a Core Measure that financially penalizes whoever they deem as over-prescribers. We both know the fastest way to change physician behavior is not through rigorous studies, but CMS core measures that affect our reimbursement.

[Sensei]

Didn't the AMA just publish a study that showed similar efficacy between narcotic pain meds and conventional OTC stuff for breaks, sprains etc?

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It was the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) Trial. It studied opiates and non-opiates for chronic pain and found no difference functional outcome at 12-months and marginally more pain in the opiate group. Predictably, the opiate group had more drug related adverse reactions.

[Sensei]

So what else happened in 2000 where the data shows an uptick. Did it take 10 years for the opiates to take hold or just trickle down to PCP’s handing them out like candy so to speak?

I’m mixed on the whole legalization thing as I’m pretty sure that the actual impact it would have in the numbers of users and abusers would be minimal in the long term. Addiction is a symptom and not generally a root cause. At least in my experiences in dealing with addicts. What we are doing isn’t working. It’s costing trillions of tax dollars and eroding many of our freedoms and rights. Not sure if that’s a fair trade. Not sure what the solution is, but at some point I think we will need to let Darwin do it’s thing to these repeat idiots.

A bunch of stuff was happening around that time. A lot more types of prescription opiates hit the market (if you make it they will take it), the ascendancy of patient satisfaction as part of incentive based compensation for physicians, etc.

[DocGKR]

"The use of incentive based compensation that over relies on patient satisfaction has been one powerful financial motivator for physicians to over utilize diagnostic testing, antibiotics, and controlled substances......No, the lion share of prescription opiates are out there because physicians are responding to a multitude of financial pressures such as core measures, patient sat, etc. that increases their controlled substances prescribing."

This is a huge issue which should not be underestimated.

Chronic pain patients are difficult to manage and often need a team approach with multiple specialties to successfully treat.

Acute pain (post-surgery or post-trauma) patients are much easier to care for.

[Qaz98]

Don't disagree with any of that. Your original statement was that physicians were lining their pockets by promoting opioid usage. That suggests a financial motivation. Everyone knows that Press Ganey is a joke. But giving opioid to avoid bad patient scores, (which would lead to loss of a bonus), is way different than "lining" one's pockets.

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[45dotACP]

It was the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) Trial. It studied opiates and non-opiates for chronic pain and found no difference functional outcome at 12-months and marginally more pain in the opiate group. Predictably, the opiate group had more drug related adverse reactions.That's the one. Must've been confused because my hospital has absolutely zero IV morphine and somehow we're managing well...patients are still saying we've been managing their pain effectively, even in ICU/post-op patients.

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[YVK]

So, if you want to see this drop really fast, just have CMS create a Core Measure that financially penalizes whoever they deem as over-prescribers. We both know the fastest way to change physician behavior is not through rigorous studies, but CMS core measures that affect our reimbursement.

That leaves no alternative for the primary docs, they will either be penalized for over-Rx or penalized for low satisfaction scores. The outcome will be primary docs dropping their DEA licenses and referring out to pain specialists who will be much harder to bracket into over-prescribers.

[willie]

See this link. You may find out what your doc is doing. projects.propublica.org/docdollars

[Sensei]

Late 90s and early 2000s saw a number of publications and statements, from here and Europe, stating safety of chronic opioid use. Both accuracy and implementation of these findings are a subject of intense criticism these days.

Breaks and sprains are considered an acute pathology, not chronic pain conditions that are associated with opiate abuse. I am not aware of acute diseases being a risk factor for that.

https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

21968

So yes, a single prescription for an acute pain issue can make a difference in more instances than we wanted to believe.

This parallels a number of studies showing that most post-operative patient need only a weeks supply of pain meds (GYN procedures tend to be a little longer). Thus, surgeons who write for 90 tablets of Percocet after a lap chole need to stop.

[YVK]

From this study

The rate of long-term use was relatively low (6.0% on opioids 1 year later) for persons with at least 1 day of opioid therapy, but increased to 13.5% for persons whose first episode of use was for ≥8 days and to 29.9% when the first episode of use was for ≥31 days.

Perhaps clinical judgement what hurts for real and what doesn't, and how long it'll last, can go a long way.

A separate discussion is that, within the scope of my practice, my choices are tylenol - tramadol - controlled meds. NSAIDs and cardiovascular disease don't go well together.

[Sensei]

Don't disagree with any of that. Your original statement was that physicians were lining their pockets by promoting opioid usage. That suggests a financial motivation. Everyone knows that Press Ganey is a joke. But giving opioid to avoid bad patient scores, (which would lead to loss of a bonus), is way different than "lining" one's pockets.

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Not really. Handing out opiates to sprains and and back pain to in an attempt to keep up those scores is unethical as hell. I'm not willing to let my profession divorce itself from its role in where we are today and money has a lot to do with it.

[Qaz98]

Not really. Handing out opiates to sprains and and back pain to in an attempt to keep up those scores is unethical as hell. I'm not willing to let my profession divorce itself from its role in where we are today and money has a lot to do with it.

I think your language is harsh. Youre using really strong terms, and when you say unethical, that's grounds for disciplinary action. We're learning that Norco for aches and pains is not the best course of action. But again, I feel like you're on a really high horse. Is all bad medicine unethical? A lot of bad medicine is from survey scores, or fear of malpractice, laziness, not being up to date. Is it ethical to dialysis demented patients?

I don't absolve physician from the opioid crisis. But you're just wrong to say that physicians drove the opioid crisis for financial gain.


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[Qaz98]

Lively debate.

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[Sensei]

I know that its uncomfortable being told that our profession has a problem. I also know that its easy to point the finger at Big Pharma and say "liar, liar."

However, Big Pharma didn't put those prescriptions in patient's hands - we did. Moreover, we are not learning that norco is bad for aches and pains - we've known that for years. That is like Big Tobacco saying in 1989, "What do you mean we knew that nicotine was addictive?" The mere fact that physicians act surprised or make it seem like it's a Fox News Alert that long term opiates for non-cancer pain is bad is comical.

Dude, we still have a big blind spot on this issue and we had better start policing ourselves least we be policed. My statements about CMS Core Measures was laced with sarcasm, but we had better wise up when it comes to those among us who are still churning out the opiates and benzos. If we don't, the government will regulate us and neither of us will like it.

Here is some food for thought. What would you do if you saw a patient in the emergency department wanting pain meds and you noticed in the EMR that she was seen 6 months ago for an heroin overdose requiring Narcan, yet her PCP was still prescribing her monthly refills of Norco and Xanax in the database. Would you call the PCP? Would you warn the patient? Both?

Well, this is a very common scenario in my shop where patients with documented histories of overdose requiring resuscitation are still prescribed opiates by their PCP. So, I called the NC medical board for guidance since it seemed odd that so many PCPs knew about the overdoses when I called. Perhaps I was the crazy one and it was OK to continue the opiates once they got out of the ICU. You may be surprised as to the Board's response: I have a duty to the patient to file a compliant with the board whenever I encounter such behavior. Even if I notified the PCP or the PCP didn't know about the OD, I still must file a complaint to be in compliance with the terms of my own license. That's right, not filing a complaint risks my own license because failure to report a colleagues malpractice is a violation of my license terms. Needless to say, this is but a taste of what is likely to come if we don't get with the program.

[DocGKR]

"Would you call the PCP? Would you warn the patient? Both?"

Both, and likely refer the patient to our Pain Service--I get to do this fairly frequently...


"This parallels a number of studies showing that most post-operative patient need only a weeks supply of pain meds"

My service gets to do a number of surgeries which are known to cause moderate to severe pain--that is why oral surgical procedures are frequently used as pain models for assessing new post-op analgesics. After a surgery, we typically prescribe 10-20 narcotic analgesics (5/325 mg strength) with occasional scripts for up to 30 in more intrusive cases. No refills. After that, it is typically NSAID/APAP.

[Totem Polar]

See this link. You may find out what your doc is doing. projects.propublica.org/docdollars

Jesus H. I’m happy to say that my closest doc friend received a whopping $34 (meals) in 2015. That said, another guy I know—who I consider to be a bit of an egomaniac—received almost 160k in 2015. That link just provided about 15 minutes of seriously eye-opening entertainment, as I searched through a half-dozen + names. Sobering stuff.

[scjbash]

Jesus H. I’m happy to say that my closest doc friend received a whopping $34 (meals) in 2015. That said, another guy I know—who I consider to be a bit of an egomaniac—received almost 160k in 2015. That link just provided about 15 minutes of seriously eye-opening entertainment, as I searched through a half-dozen + names. Sobering stuff.

A well known local pain specialist who advocates one particular drug/pump combo received $273K in three years, all related to that drug and pump. Maybe he really believes it's a wonder drug. Maybe his support for it has something to do with the nearly $100K/year the companies have been paying him. I don't know and I'm not accusing him of anything, and someone I respect in the field respects him. The problem is when that kind of money is being thrown around it's really hard to know what to believe.

[YVK]

That website shows that in 2015 I received 115 bucks, with more than half for cardiac rhythm devices from St. Jude.
Not that I care but news flash: I don't do rhythm devices. Never had an interest, busy as is, and we have three full time electrophysiology docs who get 100% of my device business. So, right here, the accuracy of that data is less than 50% on a sample of one example.

[Totem Polar]

That website shows that in 2015 I received 115 bucks, with more than half for cardiac rhythm devices from St. Jude.
Not that I care but news flash: I don't do rhythm devices. Never had an interest, busy as is, and we have three full time electrophysiology docs who get 100% of my device business. So, right here, the accuracy of that data is less than 50% on a sample of one example.

Thanks for that. Good to know.

[Casual Friday]

Jesus H. I’m happy to say that my closest doc friend received a whopping $34 (meals) in 2015. That said, another guy I know—who I consider to be a bit of an egomaniac—received almost 160k in 2015. That link just provided about 15 minutes of seriously eye-opening entertainment, as I searched through a half-dozen + names. Sobering stuff.

LMAO. My PCP received $16 between 2013-2015. The first orthopedic surgeon I saw who wanted to throw all kinds of pain meds at me and jump straight into major back surgery received $438,000 in that same time frame.

[Sensei]

For those of you wanting a succinct and entertaining expose of how we got to where we are, this video is pretty accurate:
https://youtu.be/5pdPrQFjo2o

I’m generally not a John Oliver fan and lump him in with the other HBO liberal comedian, Bill Mahr. However, both Mahr and Oliver are accurate on certain issues and Oliver hit the ball out of the park on opiates.

For those wanting a little more detail, the landmark paper that started all of this can be found here:

https://www.ncbi.nlm.nih.gov/pubmed/2873550

That’s right, a landmark study that essentially amounted to a 38-patient case series got the opiate ball rolling. How does such shitty science overwhelm decades of practical experience and common sense among medical professionals with at least 8 years of higher education and 3 years of training you ask? Very simple, money. That is to say, a dinner here, a trip there, and most of the medical community was willing to roll over and play brain dead.

You see, companies like Purdue Pharma paid billions of dollars to doctors in the form of speaking fees, free meals, expense-paid travel to conventions at resorts, etc. Back in the 90’s that shit was legit and most of the medical community was willing to sacrifice its ethics for a buck. Even after the clamp down on Pharma-doctor perks (my shop banned all pharm-sponsored events 6 years ago), the industry shelled out $2.4 BILLION to HALF of the country’s 900,000 doctors in 2015 - that’s an average of over $5,000 to each doctor on the take. So, anyone still thinking that I’m being too harsh on my colleagues, half of whom are being paid to prescribe what they are told, needs to wake up and smell the blood.

As for the lead author in that ‘86 Paper, Russell Portenoy, he is still a renowned leader in the field: https://www.practicalpainmanagement.com/author/16278/portenoy

[Mr. Goodtimes]

I understand where you're coming from, but what happens to regular people who can't get the emergency services they need (and pay for with tax dollars) because the ambulances, cops, and EMTs are all tied up dealing with junkies?


Okie John

John, I honestly don’t know. The EMS system (at least ours) is already over burdened. I can tell you, though, that my solution is to move to the sticks. These issues we have are largely seen in urbanized areas.


Sent from my iPhone using Tapatalk

[Sensei]

John, I honestly don’t know. The EMS system (at least ours) is already over burdened. I can tell you, though, that my solution is to move to the sticks. These issues we have are largely seen in urbanized areas.


Sent from my iPhone using Tapatalk

That is absolutely NOT the case in NC and most of the US. The shift in my original post was worked at one of our community affiliates in Davidson County, NC. The population is 164,622...

[TGS]

John, I honestly don’t know. The EMS system (at least ours) is already over burdened. I can tell you, though, that my solution is to move to the sticks. These issues we have are largely seen in urbanized areas.


Sent from my iPhone using Tapatalk

My best man used to be a cop in Appalachia and I guarantee you their 911 response system is just as fucked as an urban one, if not more due to distance of mutual aid, reliance on volunteers, lack of commercial transport agencies that can be quickly contracted to backfill 911, etc.

I get the overburdened thing, though. I used to work urban/suburban EMS, and I left before the opiate crisis really hit America. Even without the opiate crisis 45-50 minute response times due to calls stacking up was not infrequent.

[Sensei]

My best man used to be a cop in Appalachia and I guarantee you their 911 response system is just as fucked as an urban one, if not more due to distance of mutual aid, reliance on volunteers, lack of commercial transport agencies that can be quickly contracted to backfill 911, etc.

I get the overburdened thing, though. I used to work urban/suburban EMS, and I left before the opiate crisis really hit America. Even without the opiate crisis 45-50 minute response times due to calls stacking up was not infrequent.

Ambulances are so ‘90s. You guys need to catch-up to the 21st century:

http://www.jems.com/articles/news/2017/04/uber-or-ambulance.html

[TGS]

For those of you wanting a succinct and entertaining expose of how we got to where we are, this video is pretty accurate:
https://youtu.be/5pdPrQFjo2o

I’m generally not a John Oliver fan and lump him in with the other HBO liberal comedian, Bill Mahr. However, both Mahr and Oliver are accurate on certain issues and Oliver hit the ball out of the park on opiates.


Thanks for sharing this.


Ambulances are so ‘90s. You guys need to catch-up to the 21st century:

http://www.jems.com/articles/news/2017/04/uber-or-ambulance.html


:cool:

You're absolutely right. America's EMS system is in need of an overall, to include the right to refuse treatment/transport as Australia is currently piloting, and the whole Uber deal.

The solution isn't more ambulances, or using even MORE police and fire resources as a first-responder stop gap. The solution is to delete a vast majority of the ambulance calls that don't actually require an ambulance.

That's a whole different thread, though......

[Casual Friday]

John, I honestly don’t know. The EMS system (at least ours) is already over burdened. I can tell you, though, that my solution is to move to the sticks. These issues we have are largely seen in urbanized areas.


Sent from my iPhone using Tapatalk

I live in the sticks, the meth use and heroin is everywhere. Luckily the area I live in is mostly hard working folks and retired people, but just down the road a couple miles is a town made up of career junkies.

[willie]

...just down the road a couple miles...town...junkies. Birds of a feather flock together. That reminds me, I once knew a junkie who could no longer get pills from his doctor so he went from vet to vet saying that his hog was nervous.

[Nephrology]

21937

The picture says it all. I just worked 4 days in the emergency department starting Wednesday and kept a count of my patients; 1/4 of my patients were heroin overdoses or someone wanting detox. Two more were patients with infective endocarditis from IV drug abuse; historically IÂ’d see a couple of cases PER FUCKING YEAR. This week is not an outlier as NC EMS agencies have dispensed 20,000 doses of Narcan this year which doesnÂ’t count the many more doses dispensed by police and fire departments. One municipality in OH literally added a refrigerated container box car unit to its morgue to keep up with the volume of bodies. A local middle school is considering stocking Narcan after a near fatal overdose by a student last month.

This problem is the direct result of the medical community providing easy access to prescription narcotics for 20 years and not challenging bullshit statements like this:
1) “Patients with non-cancer related chronic pain can be safely managed on long-term opiates with negligible chance of abuse and addiction.”
2) “Pain is the 5th vital sign.”
3) “Many of patients do well on long-term opiates, so we should not be too draconian in our approach to physician who care for these patient.”
My favorite is the last one. My reply is, “Yeah, well SOME patients well with blood letting. Let me know when you can define ‘doing well’ or predict who it will be.”

All of that is self-serving bullshit used to justify a shitty approach to medicine that lines physician and Pharma pockets while resulting in 300,000 dead. In other words, thank you state medical boards, Joint Commission, and DHHS for doing a bang-up job with policing your own.


Looking beyond the deaths, we face a possibility of a lost generation to opiates. Many of the blue collar employers in my region estimate that 1/3 of their applicants fail the drug test.

Now, a word to those who want to “end the war on drugs.” You now have a little taste of what happens when we unleash low-cost, highly addictive drugs on the population. In other words, if you really want to know why you are sitting in a waiting room with chest pain or appendicitis (or if your ambulance never showed up), it’s because 25% of my beds are occupied by overdoses.

I just did tandem Fri-Sun day shifts. We don't have that much heroin out here, yet. We still get a lot more meth/ crack. Yesterday we got a 60s yo female jumper from 3rd story balcony. Her femurs were fucking jacked up bilaterally, rib fractures with pneumothorax, soft blood pressure with mental status changes pre-hospital etc. we do like 90 minutes of resuscitation to prep for ortho OR. Undressed fully examined multiple CT scans 300mcg fentanyl. On the way to OR they find, in her tightly clenched fist, a crack rock and pipe. I love humanity.

[willie]

A google search revealed that Purdue Pharma had $35 billion dollars in profits in 2017. Further the article said that the families owning it have a net worth of $13 billion. My interpretation of these facts is that a few million dollars in fines here and there are merely a cost of doing business. If the article's facts are accurate, Purdue is an evil empire. Oddly one of their manufacturing facilities is in North Carolina, a state mentioned in this thread. So, money does talk.

[TC215]

Are any of the medical guys on here familiar with the Porter and Jick letter? Our state’s narcotics officers association conference was a couple weeks ago, and it was brought up there in a presentation on opioid addiction as the “letter that started it all”.

http://beta.latimes.com/science/sciencenow/la-sci-sn-opioid-addiction-letter-20170531-story.html

[Nephrology]

I just did tandem Fri-Sun day shifts. We don't have that much heroin out here, yet. We still get a lot more meth/ crack. Yesterday we got a 60s yo female jumper from 3rd story balcony. Her femurs were fucking jacked up bilaterally, rib fractures with pneumothorax, soft blood pressure with mental status changes pre-hospital etc. we do like 90 minutes of resuscitation to prep for ortho OR. Undressed fully examined multiple CT scans 300mcg fentanyl. On the way to OR they find, in her tightly clenched fist, a crack rock and pipe. I love humanity.

to add: I did see a case of endopthalmitis 2/2 septic emboli flicked off his tricuspid and mitral valve (both had vegetations).

[scjbash]

to add: I did see a case of endopthalmitis 2/2 septic emboli flicked off his tricuspid and mitral valve (both had vegetations).

I'm usually pretty good at deciphering medical lingo but you've stumped me. I get parts of it, but as a whole I'm not picking up what you're putting down.

[peterb]

Are any of the medical guys on here familiar with the Porter and Jick letter? Our state’s narcotics officers association conference was a couple weeks ago, and it was brought up there in a presentation on opioid addiction as the “letter that started it all”.

http://beta.latimes.com/science/sciencenow/la-sci-sn-opioid-addiction-letter-20170531-story.html

Yup. It was the "study" that "proved" opiates were not addictive. Because, of course, unsupervised outpatient use for chronic pain is just like supervised inpatient use for acute pain.....

To be fair, the doc that wrote it wasn't trying to deceive anyone. As I read it, he had access to one of the first databases of hospital data, he ran some numbers on addiction, got a result he thought was interesting, fired off a letter to the editor of the journal, and went back to crunching different numbers. He had no idea how it would be misused.

[Nephrology]

I'm usually pretty good at deciphering medical lingo but you've stumped me. I get parts of it, but as a whole I'm not picking up what you're putting down.

Endopthalmitis is an infection of the rearmost portion of the eye. It looks kind of like this (https://img.medscapestatic.com/article/764/374/764374-figure-3.jpg). Basically the only way you can get an infection there is by having a foreign object introduce bacteria to that region - i.e. recent ophthalmological surgery.

My new friend had contracted this disease in a very different way. He had something called bacterial endocarditis, or a bacterial infection of the heart - specifically, the mitral and tricuspid valves, which are the two valves that separate the top and bottom chambers of your heart. These infections grow sort of like barnacles on your heart valves, eventually causing the valves to fail. These "barnacles" can also be sheared off off from the mechanical stress of the cardiac cycle, entering your circulation and landing in distant parts of our body - which is likely what happened in this case.

How did he get the endocarditis? Shooting up with dirty gear. The more you know....


Yup. It was the "study" that "proved" opiates were not addictive. Because, of course, unsupervised outpatient use for chronic pain is just like supervised inpatient use for acute pain.....

To be fair, the doc that wrote it wasn't trying to deceive anyone. As I read it, he had access to one of the first databases of hospital data, he ran some numbers on addiction, got a result he thought was interesting, fired off a letter to the editor of the journal, and went back to crunching different numbers. He had no idea how it would be misused.

Anecdotally, I do believe that it is probably way less addictive in an inpatient setting. Having gotten plenty of narcotics as both an inpatient and an outpatient, it's a thoroughly different experience. As an inpatient, you're in a lot of pain (which certainly takes the euphoria away), you are confused, and unless you have a pain control pump you have no way to self administer the narcotics, so there isn't much of a "habit" you get into. As an outpatient, when you're convalescing and likely in less pain and can self-dose... different story.

[scjbash]

Nephrology Thanks. A friend of mine died from bacterial endocarditis a few months ago. It was from heroin use. The endopthalmitis is where I got lost. I googled it and couldn't figure out how that could be connected to endocarditis. Makes sense now that you've explained it. I think it was the vegetation breaking loose that caused my friend to have strokes while he was in the coma.

[willie]

Embalmers discovered a long time ago that some addicts(maybe IV shooters)were much more difficult to embalm because of damaged circulatory systems.

[Nephrology]

NephrologyI think it was the vegetation breaking loose that caused my friend to have strokes while he was in the coma.

Yes, this is likely true. I'm sorry to hear that happened to your friend. No matter how dumb someone's decisions, it's always sad thing to see.

[Sensei]

I got off my shift last night at 1AM and Coast to Coast AM was playing on the local radio station. Normally, I immediately switch to XM or an educational Podcast rather than listen to the tinfoil hatters, but the topic was opiates so I decided give it a few minutes. The host and his guest, a pain specialist, were firmly in the pro-opiate category. The tone was very slanted toward opiates being a wonder drugs, now lots of patients with chronic pain will suffer, and most of the opiate skeptics don’t believe their patients and think that pain is “just in their head.” This is crap.

All of us understand that pain is real. We also understand that poorly controlled chronic pain has deleterious, multi-system effects. We even agree that opiates are a cornerstone treatment for many acute pain conditions until opiate-sparring therapies can be instituted.

Where my side departs from the show’s host and his guest is in their approach to chronic pain as they think that long-term opiates are appropriate for select patients with non-terminal conditions. My side of the argument believes that 1) opiates are less effective than other modalities for controlling most causes of chronic pain, 2) opiates do not improve (and likely worsen) functionality, and 3) opiates have higher adverse reactions. Moreover, we feel the current methods used to screen candidates for long-term opiate therapy are fundantally flawed as too many patients thought to be good candidates, go on to develop aberrant behaviors or accidental overdoses. Thus, long-term use in non-cancer pain should be exceedingly rare and administered only by anesthesiologist trained in pain management. It’s really very simple - primary doctors shouldn’t give chemotherapeutics, general anesthesia, tPA, or chronic opiates because they kill too many people when they try.

[DocGKR]

Wait--so you are suggesting that only folks with the appropriate training, experience, and judgement should be prescribing potent medications and not just people who "feel" like they can??? That is downright heresy these days....

[Sensei]

Wait--so you are suggesting that only folks with the appropriate training, experience, and judgement should be prescribing potent medications and not just people who "feel" like they can??? That is downright heresy these days....

No kidding. What pisses me off is the typical response to to my position falls along the lines of, “we are filling gaps in a broken system and providing pain relief to those who can’t afford pain specialists.”

Well, thanks for breaking the system, but we now have a body of literature that challenges the notion that opiates are better at controlling chronic pain than non-opiates. So, I’d say that people had better know what the hell they are doing if they are going to adopt a treatment approach that has no real advantage for the patient and significantly higher risks to society than the alternative - especially when that alternative can be found over the counter at Walmart. I know, that’s just crazy talk.

[Nephrology]

Thus, long-term use in non-cancer pain should be exceedingly rare and administered only by anesthesiologist trained in pain management. I

It's not a bad idea.


Wait--so you are suggesting that only folks with the appropriate training, experience, and judgement should be prescribing potent medications and not just people who "feel" like they can??? That is downright heresy these days....

I am tempted to make a joke about surgeons & inpatient management...

[Webb297]

Prescription opiates really scare me. I have an addictive personality. Both Grandfathers, most all my Uncles and my Father are/were Alcoholics/Drug addicts (most in recovery). I had a surgery on my elbow, where they had to pull some foreign bodies out that had become lodged inside. I was in college at the time. When released, they gave me a bottle of 40 Vicodin, and told me to take 1 every 4 hours and 2 if it hurt really bad. The next morning, the local had worn off and the pain was really bad, and I had a Chemistry quiz, so I took 2 about 30 mins before I had to leave for class. For some reason, they did not kick in before it was time to go, and I still really hurt, so I too 2 more (I know, I was a stupid kid). A half hour later, I felt much less pain, and was good, participating in class. 30 minutes after that I was being removed from the lecture hall by my study group becasue I was totally non functional, barely able to walk. But what a great feeling, no pain, no cares. They got me back into my bed, and 4-5 hours later I woke up, no hang over - nothing. What a great feeling, all the best parts of being drunk, with no apparent side effects.

It terrified me.

2 weeks later when I went to get my stitches out, I had 36 pills left in that bottle. I had a buddy get me a bottle of Aleve, and I hurt. That surgery was in the grand scheme a pretty small one. The pain bad, but not unendurable. I had a buddy that became hooked on Oxy after being pretty badly injured in a car accident, and not being able to stop taking pills after the doctor stopped prescribing them. The fall out of that addiction truly destroyed more than a decade of his life. I am truly worried about a back accident, or a car accident, where I HAVE to take narcotics for a period of time.

I am a firm believer that everybody needs to be accountable for their actions and the consequences of them, but addiction is a really scary thing. I think my willpower is strong enough, however I cant help but think sometimes, but by the Grace of God, there goes I.

[DocGKR]

"I am tempted to make a joke about surgeons & inpatient management..."

Which is why we have our in house Med Team Hospitalists manage all non-surgical aspects of our inpatients' care.

[trailrunner]

https://www.theatlantic.com/health/archive/2017/11/an-epidemic-from-which-no-one-is-safe/546773/

[RoyGBiv]

Connecticut man had sex with girlfriend's corpse in hope of reviving her, police say (http://www.foxnews.com/us/2017/12/08/connecticut-man-had-sex-with-girlfriends-corpse-in-hope-reviving-her-police-say.html)


Aaron Gaser, 39, of Willimantic, told police in January that he decided to have sex with his girlfriend in attempt to wake her up after finding her unresponsive with heroin needles in her lap, the Hartford Courant reported.

[willie]

Opioid addiction is nothing new so I wonder if great increases in its frequency has as much to do with changes in societal attitudes toward drugs as it does with prescribing habits? My last two primary care docs did not hand out pain pills. One said that she would give one and only one Vicodin prescription for my back pain. I had surgery after I could no longer cope. The other would prescribe only Gabapentin for pain sufferers. I'm overdue for total shoulder replacement surgery. I fear that backlash against opiates will cause "somebody" to send me home from the hospital with a bottle of Tylenol and a Bible.

[Sensei]

Opioid addiction is nothing new so I wonder if great increases in its frequency has as much to do with changes in societal attitudes toward drugs as it does with prescribing habits? My last two primary care docs did not hand out pain pills. One said that she would give one and only one Vicodin prescription for my back pain. I had surgery after I could no longer cope. The other would prescribe only Gabapentin for pain sufferers. I'm overdue for total shoulder replacement surgery. I fear that backlash against opiates will cause "somebody" to send me home from the hospital with a bottle of Tylenol and a Bible.

Take a close look at the graph in my original post. Notice that 1996 was the year that overdose deaths started to rise. That was the year that Perdue Pharma released OxyContin on the US market. Within 2 years it was the best selling prescription pain reliever in the US. Since that time, the number of different opiate analgesics has skyrocketed. Now, Americans represent 5% of the world’s population and consume 80% of its prescription opiates; about 350 million prescriptions per year or 1 for every American.

So, the answer to your question is - yes. Society’s attitude toward drugs has changed. That is because the pharmaceutical, medical, and regulatory industries have worked very hard to remove the stigma accociated with these drugs and make you think they are safe.

As for your personal predicament, a 7-10 day course of a prescription opiate is probably appropriate for shoulder surgery. Keep in mind that your chances of developing a problem with the drugs takes a very small, but measurable tick up after just 5 days. So, your surgeon is not doing you any favors if he writes you for 90 tablets of Norco or Percocet.

[scjbash]

Some of these numbers are insane.

https://www.wvgazettemail.com/news/health/drug-firms-shipped-m-pain-pills-to-wv-town-with/article_ef04190c-1763-5a0c-a77a-7da0ff06455b.html


There are less than 400 people in Kermit, WV. One wholesaler sent one pharmacy there 5.8 million pain pills in 6 years. In 2008 they sent that pharmacy almost 6000 pills per person. There are a few other pharmacies down there so that's not everything that was prescribed.

10.2 million hydrocodone pills and 10.6 million oxycodone pills were sent to two pharmacies in Williamson, WV in ten years. Williamson's population is 2900.

There are less than 1800 people in Mt Gay. One pharmacy dispensed 3000 hydrocodone pills a day.

[RevolverRob]

I understand where you're coming from, but what happens to regular people who can't get the emergency services they need (and pay for with tax dollars) because the ambulances, cops, and EMTs are all tied up dealing with junkies?


Okie John

No more fucking Narcan.

No more fucking detox intakes.

If someone shows up OD'ing and flat-lining? Let 'em drop and call the morgue. If they come out of it? Off to the OD ward where they can get all the dope they want or quit.

Let the folks arrested for DUIs while on drugs serve as morgue aids as their community service.

Busted for narcotics possession? First offensive, community service -> morgue duty. Second offense? Community service -> Giving drugs to the addicts at the OD Ward and tending to those dying.

___

It's brutal and damaging - So let's just be brutal as fuck about it.

[Dr_Thanatos]

No more fucking Narcan.

No more fucking detox intakes.

If someone shows up OD'ing and flat-lining? Let 'em drop and call the morgue. If they come out of it? Off to the OD ward where they can get all the dope they want or quit.

Let the folks arrested for DUIs while on drugs serve as morgue aids as their community service.

Busted for narcotics possession? First offensive, community service -> morgue duty. Second offense? Community service -> Giving drugs to the addicts at the OD Ward and tending to those dying.

___

It's brutal and damaging - So let's just be brutal as fuck about it.

I get where you are coming from and I'm angry about it too, but let's think about the unintended consequences of that plan.

If we did not attempt to resuscitate overdoses, we will take our already struggling death investigation system and crush it. No room in the morgue, no ME/C coming to investigate your homicide, or babies death. No autopsies for your 30-40 year old sudden death. There are already massive shortages in the needed numbers of forensic pathologists. And toxicology turnaround times are increasing. It's already bad out there, this would destroy the current system.

And more importantly, what makes anyone think I want an addict "working" in my morgue while I'm trying to work. Working in a morgue is not punishment. If it were, then I've been a very bad person. Additionally, who's going to take care of them while they are here. We're understaffed, and would have to assign someone to babysit them. And have to clean up the mess they make when they vomit, pass out or hurt themselves. The morgue is a hazardous environment, and is inherently dangerous if you don't know how to manage in it. I don't want addicts near the needles, or more importantly the drugs that we have brought in, or find on decedents. I don't want addicts near the routine amounts of jewelry and cash that decedents are carrying. We don't let anyone without a completely clean background check, why would we let criminals in as community service.

Like I said, I get the anger and frustration. I see it more often and better than most. We had a 100% increase to our annual rate of increase this past year from OD's. I'm months behind because of it. But to attempt to use what we do as respectful and dedicated public health professionals as punishment irks me to no end. Working in a ME/C office with decedents requires respect and professionalism, neither of which the average addict has in abundance.

[RevolverRob]

I get where you are coming from and I'm angry about it too, but let's think about the unintended consequences of that plan.

<Snip>

I'm months behind because of it. But to attempt to use what we do as respectful and dedicated public health professionals as punishment irks me to no end. Working in a ME/C office with decedents requires respect and professionalism, neither of which the average addict has in abundance.

First, let me say - I meant no offense to you, or the emergency personnel or doctors doing good work. Thank you for your efforts and professionalism.

Second, in my (purely) theoretical vision of vehemence and rage, there are two morgues. One where junkies go and one where non-junkies go. It's a harsh world, but one which may eventually become a reality if things continue in like fashion. The one where non-junkies go? That's the one that gets public health professionals. The one where junkies go? It doesn't.

If we want to treat drug addiction and as a result addicts as non-productive members of our society, then we push them to the periphery and let them burn out. It won't be ethical and certainly won't be moral, but it is a fast and hard solution to a complex problem.

____


Now...if we want to solve the problem, properly, without marginalizing addicts and drug users as second-class citizens - We have to start solving the problem, properly. The first step is to start by eliminating the individuals who push the product, from the TOP -> DOWN and not from the bottom -> up (which is what the so-called war on (some) drugs does). Top-down means politicians, pharma companies, corporations, and big investors who spend billions lobbying and creating artificial need to drive demand up, go away - forever not to jail, not to some Federal Vacation Facility. They go out, get a bullet in the head, and we move on.

It means eliminating the drug trade in a fire-sale kind of way (I mean that literally and figuratively). It means investing billions of dollars into healthcare infrastructure, education, and improving quality of life and that means shifting our collective spending from violence to peace (i.e., cutting the defense budget and reallocating those funds). It'll take another 30-years, but eventually the structure will change. In the meantime we have to just keep refreshing the tree of liberty with the blood of those who seek to kill our fellow citizens. And we must do that all while walking a fine line between "temporary safety and essential freedom" (Because we can swing the pendulum the other way too hard and too fast).

And frankly, my perspective is - that Americans as a cultural whole, are not currently invested in this approach. And that one of two things will happen (and one is more likely than the other). In the first scenario, the scourge of addicts are pushed further to the margins of society and ignored even more, perhaps to the point of creating the hard and fast solution I mentioned above. Or two, the populace wakes up, realizes the need for change and a rebellion begins. - Idealists think the latter will happen. Me? I think it's the former.

[scjbash]

It means investing billions of dollars into healthcare infrastructure, education, and improving quality of life and that means shifting our collective spending from violence to peace (i.e., cutting the defense budget and reallocating those funds).

I don't think throwing money at the problem is the solution. It doesn't cost money for doctors to change how they treat patients. Hell half the people on taxpayer funded narcotics would probably be better off doing yoga instead of pills, if they actually need to do anything at all.

The over-prescribing of pills has slowed somewhat but not nearly enough. It's not just pain pills either. The number of people I know who have been fed a never ending supply of xanax and paxil is stupid. The healthcare system seems to be based around dulling the symptoms instead of fixing the problem, or manning up and telling people they don't have a problem in the first place. Then after they are addicted the solution is to give them methadone or suboxone for as long as they want it. Maybe some xanax to help with the stress of being on suboxone instead of oxy. It's absurd. Changing how patients are treated would not only reduce the number of addicts but also start changing society's notion that all of our problems should be fixed with drugs, prescription or street.

I would vote to get rid of narcan, but that ain't happening. Nor are most of the other things we would like to see happen. At least not anytime soon.

[RevolverRob]

Changing how patients are treated would not only reduce the number of addicts but also start changing society's notion that all of our problems should be fixed with drugs, prescription or street.

Changing how we treat patients will require much more money than you may think. One of the reasons we're over-prescribed is that we're over booked to treat common medical problems. Partly, because we're not addressing the underlying issues of our society (e.g., obesity and a culture of insta-X). It's not just addicts that are adding to the system. Our healthcare infrastructure was taxed before Obamacare and the Individual Mandate passed. That only increased the pressure on it. We not only have issues with medical problems generating addiction, we have illegal narcotics (not counting the illegal use of RX narcotics) coming in. And a crumbling infrastructure that contributes to the general decline of our society overall.

Solving addiction isn't just about eliminating (one) of the sources. Since, as we've seen, addicts will just manufacture their own - and there will always be a blackmarket supply to meet a demand. We have to look at the demographics of the addicted and treat the underlying causes not treat the symptoms. There are a ton of cultural influences playing into drug addiction and narcotics abuse in this country. Access to prescription narcotics is one, important aspect, but not the sole one. To solve the "drug problem", will require fundamental transformations to our culture, society, and the way we value things. - I, unfortunately, believe that it is really untenable.

[OlongJohnson]

According to press released-derived reports citing the CDC, 64,070 people died from drug overdoses in 2016. Haven't seen numbers yet for 2017, but it's certainly higher.

All firearms-related deaths (including the ~60 percent suicides) and traffic fatalities put together add up to about that number each year. What I'm wondering is, when are some people with power to act going to start freaking the hell out?

(Although, I'm not really a fan of people in power freaking the hell out - it rarely does good and often goes very wrong.)