What do hospice nurses and teenage heroin addicts have in common?

What do hospice nurses and teenage heroin addicts have in common? One may be an unintended consequence of the other.

A pair of articles published recently in two prestigious medical journals help make the case.

The Lancet reported that 47 million of the 58 million deaths occurring annually worldwide take place in developing countries, and that of these, fully 27 million die without having received proper palliative care. The article attributes this dismal performance to the overly restrictive regulation of narcotic pain relievers in an effort to help combat drug trafficking; morphine is unavailable in more than 150 of these countries. The regulatory burdens are so great that most pharmacies are reluctant to even order it. The strongest analgesic available to many cancer patients in developing countries is aspirin. Of 1 million cancer patients requiring pain medication in India in 2008, only 40,000 received morphine.

Such grisly data can’t help but make one grateful to be living in the developed world, where—in no small part thanks to Leo Tolstoy, whose short story The Death of Ivan Ilyitch greatly increased public awareness of the need for palliative care—the situation is much different. Cancer patients in the United States have widespread access to hospice programs—modern day Mercy Queens—and narcotic pain relievers. But we may be victims of our own success. The movement to relieve pain and suffering at the end-of-life has morphed into an effort to relieve pain and suffering in the general population, with extended-release, long-acting opioids the agents of choice. An editorial in The New England Journal of Medicine discusses the consequences.

There are approximately 1 million prescribers of controlled substances registered with the Drug Enforcement Administration and about 4 million patients receiving long-acting opioids annually. Deaths from unintentional drug overdoses are now the second leading cause of accidental death in the United States, with 27,658 such deaths in 2007. 41% of these—11,499—were due to synthetic opioids. Emergency room visits for opioid abuse more than doubled from 2004 to 2008, and admissions to chemical dependency treatment programs rose by 400% from 1998 to 2008, with prescription narcotics second only to marijuana as the cause of addiction. Since 1990, the medical use of opioids has increased ten-fold. Drugs such as Oxycontin “are essentially legal heroin.”

The proliferation of these drugs has put them in the medicine cabinets of citizens—and parents—all across the country. So much so that it is just as easy for a thrill-seeking 14-year-old to filch some Oxycontin from the medicine cabinet as it is to siphon some Jack Daniels from the liquor cabinet. But Oxycontin is highly addicting—and expensive. Teenagers who develop an addiction to it—whether taken from the medicine cabinet of their parents or that of their friends’ parents—soon have trouble scoring enough to maintain them. They quickly discover a much more affordable and readily available alternative: heroin, which when smoked is dirt cheap compared to Oxycontin. A two-hour exposé on local TV in San Diego this week referred to the problem of teen use of Oxycontin with subsequent migration to heroin as “epidemic.”

So there you have it: from genuine Mercy Queens to teenage heroin fiends, the rise of opioid use in America.

We should perhaps not be so quick to condemn our developing world counterparts for their reluctance to embrace our more permissive use of prescription narcotics.

Richard Barager is a nephrologist who blogs at his self-titled site, Richard Barager.

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  • April Tenhunfeld

    This post is very offensive to nurses in general. I am not a hospice nurse but I have been an RN for 25 years. I will be graduating from a family nurse practitioner program October. Your point was somewhat muddled. You seem to be lumping hospice nurses and hospice programs into one basket. Are you saying there is a proliferation of addictive pain killers in the medicine cabinet because of the hospice nurse? You have neglected to mention that the physician is prescribing these medications and signing for them. Nurses do not prescribe and NPs in many states have restrictions which do not permit them to prescribe these medications or limits their ability to prescribe more than 24 hours worth. Your point was not well made.

  • http://missingmythyroid.blogspot.com/ Jeannette

    Wow, those are very disturbing statistics. Makes one shake their head…It most certainly is a double edged sword, but I still maintain the belief that everyone should have access to the necessary medication to relieve their pain. In particular, those at the end of their lives suffering in pain should be administered whatever is necessary to control their pain. Leaving someone to die in agony is just cruel.

    The horrible increase in addiction to these strong narcotics is definitely an issue, a big issue, but should someone with cancer pain be given an aspirin for relief? You may as well give them a chocolate covered almond for all the relief it will offer. There has to be a better way to police the drug addicts than to deny those with legitimate pain.

    I have chronic pain due to past cancer treatments and a workplace injury. Before taking narcotic meds, I tried absolutely everything. I spent 99% of my time in bed, unable to function due to the pain. The patch I now use was a miracle for me. I am very grateful that I live in a country where these medications are available. I can participate in my life, for now I actually have quality of life. Frankly, while suffering 24/7 with pain, I wished to die instead. Chronic pain can destroy lives and effect every facet of ones existence. I for one am so very grateful these drugs are available to me, that is not to say I don’t understand just how much of an issue of addiction it has become these days. Surely there must be a better way than to simply not have pain medication available, as they are a necessary part of life for many.

    • Hospice & Palliative Care Doctor

      Dear Jeannette,

      Thank you so much for sharing your story. Its an important one that society should hear. And I’m so glad that you found relief from your pain. You describe exactly what I see as palliative care doctor: patients in my office who have unrelenting pain that without narcotics (you have the fentanyl patch it sounds like) could not function & wish they were dead.

      Good for you that you have a compassionate doctor to prescribe your patch to you so that you can not be in agony.

      This doctor who wrote this article understands the issue of diversion well, as it is a true problem, but fails to come up with a reasonable solution. Instead he adds hysteria & more problems to the issues of pain management. That he uses words like “permissive” & suggests that the anti-pain management culture of other societies is something to look into is harmful & lacking in compassion to sufferers like yourself.

      • http://missingmythyroid.blogspot.com/ Jeannette

        Thank you for the reply to my post. You certainly sound like a kindhearted and compassionate physician of which there should be more in the world! Yes, it is the fentanyl patch I now have to control my pain and frankly, it truly was a miracle to me. My pain went from 9-10 out of 10 down to 1-2 out of 10 and only if I really overdo it does it get any worse. If I had not a wonderful doctor treating me, I would still be in bed, curled in a ball, wishing to die. I have my life back now and I will forever be grateful for that!

  • Scott Irwin

    Horribly misguided.

  • Alicia Bloom

    I find Dr. Barager’s commentary to be both inaccurate and offensive. It seems that by looking only at surface data, you have drawn conclusions with serious (negative) implications. Hospice providers have policies and regulations to ensure safe & appropriate use of opiods by their patients and put necessary protections in place to prevent drug diversion during patient care & after patient death (ie: medication checks & management; drug disposal at time of death
    visit). Long acting pain medication enhances
    quality of life and actually reduces the need for PRN medication, therefore requiring less pills out in the community. Data on addiction in
    serious illness and at end of life is present in many well respected journals; it is abundant and
    clear–it nearly never happens. Your words have implications, Dr. Barager. Please use them more responsibly.

  • AnnR

    I have to agree with April that I don’t know why nurses were brought into this article. Maybe it made the title catchier?

    It ticks me off that narcotic overdoses result in difficulties for people who need pain relief. My Dad died in a hospice and I thought they were sparing but adequate with drugs. Another relative passed away in a nursing home and I thought they were stingy with pain relief. I’d have rather a few pills been misappropriated than have her last days be as uncomfortable as they were.

  • Hospice & Palliative Care Doctor

    Dear Dr Barager,
    Im a board certified Hospice & Palliative doctor. I have cared for well over a thousand dying patients. Literally. I have to say to you. Your concern over opiate diversion, abuse, & addiction is warranted. It’s a problem in America that we are attempting to solve but a final solution escapes us. There are beneficial & helpful solutions. But there are misguided & unhelpful ones. Your article falls in the latter category.

    To compare teenage heroin addicts to hospice nurses is not only wrong, but inflammatory and denigrating to the cadre of truly amazing group of nurses that provide care to humans who are in the dying process in the many hospice & palliative care programs in the US. Hospice nurses are angels of mercy. How is a hospice nurse like a teen heroin addict? Your analogy is just as wrong as saying a bank teller has things in common to a terrorist because s/he receives money from depositors at the bank window and some of those funds get diverted to terrorist accounts to the Taliban in Afganistan.

    In regard to diversion of narcotics in hospice programs: I certainly admit a small, VERY SMALL, amount of the narcotics prescribed in a hospice program might get diverted, but this is quite uncommon. The pharmacies that provide the patient with the pill bottles give a limited supply, usually less than 2 weeks worth. One reason is given the nature of hospice, the patient is going to die soon & giving many weeks of pills is unecessary. Preventing diversion is also an issue so giving a limited supply is done. Finally, when the patient dies, the hospice staff member who pronouces the body dead confiscates & destroys unused pills. Hospice is not a large contributor of the opiate diversion problem here in the US.

    You wrote,” But we may be victims of our own success. The movement to relieve pain and suffering at the end-of-life has morphed into an effort to relieve pain and suffering in the general population, with extended-release, long-acting opioids the agents of choice.”

    And what is wrong with relieving pain & suffering? The response by Jeannette above is a perfect example of the success of narcotics & their role in pain management. She wrote “I have chronic pain due to past cancer treatments and a workplace injury. Before taking narcotic meds, I tried absolutely everything. I spent 99% of my time in bed, unable to function due to the pain. The patch I now use was a miracle for me… I can participate in my life, for now I actually have quality of life. Frankly, while suffering 24/7 with pain, I wished to die instead.”. Narcotics have IMPROVED her level of functioning, not hurt her. She was passively suicidal
    & bedbound before, but now she can live her life. Yes, opiate diversion is a problem, even a serious problem but that is a separate issue from pain management. That you did not separate the two makes the management of pain here in the US that much more difficult. You demonize a whole spectrum of medications that bring profound palliation to suffering people.

    But you’re a doctor & should know this. There needs to be a better response from the medical community to pain management & opiate use.

    In my office I see patients where I manage their pain. Usually the same stories: I’m in terrible pain & no doctor will listen to me, believe me, or help me. Opiates aren’t the only solution but part of my armamentarium of tools, and I prescribe them where appropriate. Or my patient will suffer.

    I practice good pain management medicine. I do a urine drug in my office tox every time they come in. I only give a limited amount at a time. They need to return to the office to see me every month. I spend an inordinate amount of time documenting- God forbid I get audited by the DEA. I check state data bases to see if the pt is doctor shopping. When you write an unhelpful article like the above it makes the DEA, in all their rigid paranoiac manner, make it more difficult for doctors like me to help our patients in pain by adding more & more obstacles in prescribing. I’m not afraid of my pts diverting or overdosing- I’m afraid of the DEA.

    Dr Barager, you mean well to draw attention to the problem of opiate diversion & abuse, and that could be good, but your article did none of that. It only hurt & inflamed without helping.
    Could you respond?

    • http://missingmythyroid.blogspot.com/ Jeannette

      In light of this errant post and subsequent comments, I find it rather ironic that the ‘Institute of Medicine’ has just released a report on the cost of chronic pain (635 billion) and the extreme need for a cultural shift in the approach, prevention & treatment of pain. You may read part of it here: http://bit.ly/jt7mMi

  • J.K.

    So many good responses to this article. Thank you, Hospice & Palliative Care Doctor, thank you Jeanette, and everyone else who commented here. Most of what I felt that I ought to say in this discussion, you have all pretty much said.
    Still, I will say a little bit more: I have had both chronic pains, and pain-free phases, lasting several years. Sometimes manageable with aspirin, sometimes not. I was suicidal in my twenties because of pain, but I have not been since then, am now 60. I am glad for the availability of medium-strong prescription pain medications when I have needed them. When I don’t need them, I would not even think of using them! And when I have asked for these, it has certainly not been because, as Dr. Barager says, “the movement to relieve pain and suffering at the end-of-life has morphed into an effort to relieve pain and suffering in the general population,” No, it is a need which arose separately. A different need than end-of-life pain relief, but still very much a need.

  • http://www.womeninpainawareness.ning.com carol

    Gee, and here I thought the doc’s job was to help relieve pain and suffering as much as they are able. As someone in chronic intractable pain the idea that the prescribing of opiods is “permissive” is laughable. Most pain management docs do not prescribe freely. The patient, depending on which med they are on, is required to see the doc up to once a month for new prescriptions.

    It is folly to blame the rise in prescription drug abuse on pain patients and their need for the only thing that may be allowing them to function. For some that means literally just being able to get out of bed in the morning.

    Shame on you for the titillating title that makes an anaology that is totally without merit, on both sides of the equation.

    Maybe what needs to be done is for pharma and the medical community to find better ways to help those who lives have been essentially taken away by chronic pain. Do not berate us. Berate Pharma for staying with the opiates that brings in tons of money for them.

  • http://www.womeninpainawareness.ning.com carol

    Add: Hospital and palliative care doc wrote “I practice good pain management medicine. I do a urine drug in my office tox every time they come.”

    This is the issue as well. The ‘war on drugs’ is being concentrated on the doc and patients because it is so miserably unsuccessful elsewhere.
    What other patient is required to prove they have not (are not) behaving in a felonious manner.?

    For many of us the narcotic med is no different than a diabetic who relies on insulin. When they have times where they must take extra insuling they are not penalized and told “No extra insulin for you this month.”
    Many pain patients must sign ‘opiod agreements’ that say just that: if you run out of your med before the 30 day period is over you will not get more until the next appointment regardless of the reason you ran out. Was the pain worse? Did you try to go to your grandchild’s birthday party or stay out of bed longer than usual? Did that require an extra pill? Well so what, better you do not do even the littlest that may mean an extra pill. You are a pain patient. The strings your doctor has on you are short and tight.
    Carol
    author A PAINED LIFE, a chronic pain journey
    http://apainedlife.blogspot.com/

    • Hospice and Palliative Care Doctor

      “The ‘war on drugs’ is being concentrated on the doc and patients because it is so miserably unsuccessful elsewhere.”

      Yes, I strongly agree. I feel like a DEA agent, not a doctor when I work with chronic pain patients. And I’m dreadfully worried about the DEA swooping down into my practice & accusing me of misconduct. I practice diligent medicine, but some of it is out of fear of the DEA, not what I would have constructed. At any time, the feds can come in, make an accusation, take away my license to prescribe schedule II drugs, & destroy me financially. All with just an accusation, not a guilty. I though long & hard before I decided to go into pain management, but I honestly feel chronic pain is a horrible existence. And I have the training to help alleviate pain. My colleagues are afraid to prescribe pain medication or do it wrong. So in I went, sorta afraid. Still am.

      Yes Carol, I hear your frustration. I feel the same way on the other side of the desk. I am obligated, after lengthy discussion with a lawyer who specializes in defending docs who are accused by the DEA, to have a pain contract w all my pain management patients. As I know I would never do anything intentionally wrong, if I am ever accused by the DEA, I need everything I can to defend myself. Like I said, I’m not afraid of a pt of mine overdosing or diverting narcotics, I’m afraid of the DEA.

      Suggestion: if you are concerned about occasionally using some extra pills cuz you want to participate more in your life, talk to your doctor. The treatment plan should reflect your goals and increase your functioning & participation in your life, not diminish it. You shouldn’t be reluctant to go to your grandchilds bday party out of fear of running out of pain pills prematurely. At least not if you were a pain patient of mine.

      Warmest regards.

  • http://www.pallimed.org Christian Sinclair

    I truly do not know why this article was selected to be put on Kevin MD. The increase in deaths from prescribed controlled substances is a substantial concern that needs to be addressed wisely. But to place a blame through a very weak argument on hospice nurses is ridiculous. Interestingly the original post on Dr. Barager’s blog is titled “From Mercy Queens to Heroin Fiends” which is not much better. So whomever chose the new revised title deserves part of the blame as well, not that the original title was that much better.

    And what is only slightly ironic is the first link ‘hospice nurses’ goes to a supportive article about the role of hospice nurses and nurse practitioners.

    There are numerous problems with the weak correlations in the article that are much better addressed in the link to the NEJM article. So if you are interested in the topic I suggest you completely ignore this blog post and go read that.

    Dr. Barager, I would encourage you to reply to some of the comments above. Embrace the social part of the web and take responsibility for your words.

    • Niamh

      I would recommend Dr. Barager join the #HPM tweetchat on Wednesday evenings (9pm EST) where he might get to know some of the people that he is referring to & some of the topics related to end of life care that he is talking about.

  • Alicia Bloom

    One additional thought on the reference of hospice RNs as “Queens of Mercy.” Hospice clinicians on the interdisciplinary team are skilled, compassionate healthcare providers providing aggressive symptom management & psychosocial support to enhance quality of life when serious illness enters it’s advanced stages. To compare such comprehensive care to heroin addicts and draw conclusions that Dr. Barager did is wrong and concerning.

    • Niamh

      Alicia….our work is never done talking about the value and benefit of hospice and palliative care. I’m grateful to have the chance to comment when a flawed perspective is presented. If not influencing Dr. Barager in a positive way, I’m sure your comments and other hospice & palliative care experts comments here will influence the readership to make their own decision about what is real & appropriate or at least make them think about it.

  • LisaMarie

    I hear over and over about the pooooor addicts who have too much access to pain medicines (usually with a healthy dose of “WHAT ABOUT THE CHILDRENS?!!!!) You know what? I. Don’t. Care. I’m a chronically ill patient. I did nothing to make this happen. I did nothing to deserve this. There is NO reason my well-being should somehow be balanced against that of junkies. None. To suggest that people in pain should do some more suffering because otherwise poor poor addicts will be able to score drugs is horrible. It is not my responsibility to suffer so that it’s harder for some junkie to score. Not even if it’s your kid.

  • Niamh

    I think we have to remember that addicts are humans too, using pain medication and everything else to quiet their minds and block out whatever trauma has caused them to start using in the first place. There are many people who use alcohol, food, xanax, ativan, sleeping medications and other drugs for the same reason….all leading functional lives without the label of an addict. We should not be so focused on denying them access to drugs…they will figure out a way to get them anyway….we should focus on accepting that this is a reality and create treatment options that will change the outcomes. How logical is it to deny everyone access to medications by not prescribing them because of fear about addicts getting their hands on them. The solution is really that simple….lots of treatment options for addicts and destigmatizing the reality. We are doing more damage to the teens who are pill popping for a thrill by tsk tsk ing, shaking our head and turning our back on the problem. Anyone of us here including Dr. Barager might have taken a step in the wrong direction that led us to addiction & I would hate to be the addict that is kicked to the curb because of some misguided clinicians judgments.

    • http://www.pallimed.org Christian Sinclair

      Excellent point Niamh

  • solo fp

    I do some hospice, usualy 2-3 patients a month max. I also do housecalls. The Class II and other narcotics are signed off by multiple hospice nurses. Accurate logs and counts are kept on the liquids/pain patches/pills. When a patient dies, the counts are done. The meds are then disposed of properly in medical waste. So far no meds have been diverted to the patient’s family or hospice nurses. I would wager that hospice does a much better job of preventing diverstion than the average doc/PA/NP or gives a patient yet another 150 vicodin without doing pharmacy or state database checks.

  • buzzkillersmith

    Dr. Barager was not literally blaming hospice nurses for heroin addiction. He was pointing out the unintended consequences of societal tolerance of prescription opiates. Except for his last paragraph in which he indirectly stated his preference, his post could have come from a first-year sociology reader–hardly controversial.
    By the way, society is full of these effects. The internal combustion engine comes to mind.

    • pj

      Strange, though how he won’t respond for himself…

      The ignorance of my fellow physicians on chronic pain is astounding- I’ve encountered hundreds of cases where a pt with severe chronic low back pain is told surgery is the better option vs. long term opioid use (lortab, percocet, etc.)

      Yes. these meds are far from ideal, especially regarding long term use. But after seeing hundreds of people whose lives were ruined by the advice of a well meaning Doc who told them , “Just get it fixed.” – meaning they now have to live with worse back pain than before- I had to speak out.

      I wonder if the author is familiar with the diagnosis, “failed back surgery syndrome.” I am, all too well.

  • http://www.howlandhealthconsulting.com whhhc

    As an additional comment on the “Mercy Queen” thing: The image of nurses as caring, merciful, angelic, and so forth is outdated and, frankly, not really appreciated by most of us. Specific to this discussion, hospice nurses are deeply well-educated on symptom recognition, prevention, and management; they are not dependent on physicians for these actions even though they do need to obtain MD/DO prescriptions for many medications for purposes of insurance coverage and other legal reasons. I know no intelligent physician who would argue with a hospice nurse on matters of management, including medication details.
    Further, despite what you see on TV and the comic strips, nurses are not hired, educated, or evaluated by physicians but by nursing. Our autonomous professional practice is based on an extensive scope and standards document by the ANA, and by our state nurse practice acts. I commend these to your readers, as it appears there is some knowledge deficit in this regard.
    Pain is what the patient says it is. Essayists such as this may write rxs for medications in the medical disease management model, but they demonstrate lack of experience with genuine pain management. Perhaps they should spend some time with professional nurses; they could learn something there.

  • BobBapaso

    So, the idea is to let our cancer patients die in pain so we can prevent narcotic addiction in our teenagers?

    Some intelligent thought could certainly come up with a better idea.

  • http://www.womeninpainawareness.ning.com carol

    BobBapaso wrote “So, the idea is to let our cancer patients die in pain so we can prevent narcotic addiction in our teenagers?”
    I can only say the same thing relative to those with chronic intractable pain. As someone who was advised ‘rational suicide’ was acceptable in her case because all surgeries, drugs, etc had been tried and failed (long story as to why that ended up not being my choice) I need to ask: So, the idea is to let our chronically pained patients live in disabling, sometimes suicidal levels of pain so we can prevent narcotic addiction in our teenagers?
    Carol
    http://apainedlife.blogspot.com/

  • Dorothy Green

    From a not- for- profit drug rehab program and a TV documentary.

    “Pain clinics have mushroomed across South Florida in the last decade, with many dispensing prescriptions and drugs to cash-paying customers after cursory exams”. 7 deaths a day from prescription drugs”.

    South Florida prescription “pill mills” – 2/3 of top 50 prescribing oxycodone in US. 42 states have databases to tract the sale of opiates – Florida is not one of them. The Govenor has nixed the plan.

    DOCTORS OPERATE THESE CLINICS – for easy profit – customers can go to many different clinics easily. So where is the DEA here or the legislature (guess it would hurt tourism). Why would DEA be hitting on honorable doctors if it is known already where the top 50 prescribers are and 42 states have a tracking system?

    Hospice indeed – hospice nurses and teenage addicts – ridiculously ignorant. The assessment of hospice nurses regarding a patient’s pain, possible drug interactions, and helping the patient get what they need is critical – nurses do not order or deliver home hospice medication . It was rare (from what I experienced) to even have to consider the possibility of addiction.

    I ask you this, Richard Braager, MD – do you, as a member of the physician community take part in helping to purge dishonorable members – “the pill mill” owners described above. And just as important, I hope there has been a strong message to physicians through this post about the important of hospice and pain control, decreasing hesitancy of patients in seeking hospice care, referring patients sooner, not waiting unitl the “last couple of days”.

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