It’s time for doctors to say no to drugs

The United States of America is addicted to narcotics.  I do not mean the millions of individuals who are hooked.  I mean the whole nation is jonesing for the stuff.  I also do not mean the junk that slips into our nation in coffee cans or across midnight borders.  I mean the billions of pills pouring off assembly lines.  I could blame pharma or the FDA, but the truth is closer to home.  The villains are those men and women who write prescriptions.  It is time for doctors to say no to drugs.

Now let me be clear.  I know pain.  More exactly, I know the treatment for pain.  I have fought with my cancer patients against an oppressive ocean of agony for 30 years.  I know which drugs work, when to use them and when they will fail.  I believe that pain for a cancer patient cuts deep to the soul and is a constant reminder of sickness and death.  Every patient needs access to an aggressive array of pain medications, which must include appropriate narcotics.  But come on now, things are completely out of control.

In order to treat serious pain very well takes only a few narcotics. You need a short acting pill or liquid, a long acting pill, a topically absorbed medicine, and an IV medicine.  It is a good idea to have one or two extras for allergies or reactions.  Almost all pain can be treated with some form of morphine and perhaps a little fentanyl.  High quality pain control can be achieved with less then 10 medicines.  Nevertheless, the pharmaceutical plants shower a rainbow of me-too drugs, flooding the market with deadly compounds.  Physicians fall right in line and write prescriptions for every new shiny tablet.

Here is a partial list: Actiq, Anexsia, Avinza, Bicodone, Buprenorphine, Butorphanol, Codeine, Damason-P, Darvocet, Darvon, Demerol, Di-Gesic, Dilaudid, Duodin, Duragesic, Duramorph, Embeda, Exalgo, Fentanyl, Fioricet, Fiorinal, Hycodan, Hydrococet, Hydrocodone, Hydromorphone, Kadian, Kapanol, Lorcet, MS Contin, MSIR, Meperidine,Methadone, morphine, Norco,  Nucynta ER, Opana ER, Oramorph, Orlaam, Oxycontin, Oxycodone, Percocet, Roxanol, Roxicodone, Ryzolt, Tramadol, Tramal, Tylox, Ultram, Vicodin, Vicoprofen, Xodol, Zydone,  and the newest and perhaps most controversial narcotic pain medication yet, sold in an easily abused capsule, Zohydro.  You may notice that sometimes I list both the brand name and generic … because they are both available just to add to the confusion and abuse potential.

I could blame the FDA for approving over 50 prescription narcotics when we only need a few.  However, the mandate of the agency does not allow it to consider the health of the nation as a whole.  Rather, hampered by politics, poor funding and a belief that it is just a tunnel to the consumer, the FDA views only narrow safety and efficacy concerns of individual products and takes little consideration for their affect in the real world.

I would love to blame pharma.  Why not — they are getting rich on the chaos.  However, the drug industry is burdened with the bizarre philosophy that market forces and competition is the best path to a quality care, even if it leaves a few hundred thousand bodies lying around.  Despite the blatant failure of U.S. brand capitalism to produce a healthy society, we still act as if profit and sales success equals quality.

In addition, I cannot blame patients. They are the ones in fear.  They are the ones who suffer.  We cannot say to millions of cancer patients and others who experience levels of pain beyond the wildest Kafkaesque nightmare, that they should push back and refuse the “best and newest” pain-relieving solution. That would suggests a coldness and cruelty, which I do not feel, and our society fortunately does not share.

Therefore, I blame doctors.  They should know better. They continue a humiliating history of responding to marketing instead of medical data.  Rather than use research and scientific principals to conservatively choose basic drugs and techniques that work, they kowtow to biased analysis, the easiest, the most expensive, and the latest Madison Avenue craze.  In doing so they encourage the expensive manufacturing of unnecessary products and flood our society with so many different chemicals and compounds that no one can understand the affects and our society’s health is undermined.

Doctors have always had the power of the medical order.  Nothing happens in health care unless somewhere, directly or indirectly, a doctor orders it.  Their failure to take a stand, to force medicine to be data-driven and view not only the patient on the table in front of them, but society as a whole, continues to lead us to disaster.  The misuse of narcotics threatens not only those addicted and overdosed, but the rebound deprives suffering patients of desperately needed help.

It is time for doctors to insist on the strictest standards for our patients and nation; the manufacture of medicines we truly need and outcomes based care.  It is time for doctors to say no.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • Dr. Drake Ramoray

    This article would have been salient about 10 years ago. I know two family practice docs who quit jobs and moved because they were “encouraged” to write for more narcotics because their patient satisfaction surveys were too low.

    Medicine is continuously falling out of the control of doctors. At this stage I don’t think we are to blame for the issue which you address, but we are to blame for letting medicine get to the point where the administrators are running the show. I will do my best to stay independent till I retire (have a long way to go).

    • Patient Kit

      I acknowledge the pressures doctors are under working for Corp Med, but I disagree with the idea that it absolves you from any responsibility for writing prescriptions for unnecessary and extremely harmful narcotics. I agree that doctors should have taken a stand on this years ago but now, seeing the resulting human wreckage, it’s more important than ever for doctors to do something about this.

      You’re the only ones who have the power to write prescriptions and you’re the only ones who have the power to stop writing them. This is an issue that doctors can and should take control of. If you can’t/won’t stand up together and do this, then no wonder you’re all in an increasingly less powerful position. If you really see yourself as that powerless, game over. In general, doctors are a group of people who are used to doing many difficult things. Why is it too difficult to stand up for yourselves, your patients and what you know is right? I’m sorry. I’m just tired of hearing how powerless you all are. You’re not that powerless.

      • Dr. Drake Ramoray

        I am a specialist. Narcotics are not a part of my practice. I have written exactly zero narcotic prescriptions since I have finished residency. People inappropriately being on testosterone is a completely different matter, and something for which I take an active role. I am not in a corporate practice environment and not subjected to patient satisfaction surverys but I have received several flamingly bad online reviews for discontinuing testoserone on patients who didn’t need it.

        This article is written as if doctors practice in a vaccum, at least from a corp med standoint. The truth is that everyone wants the doctor to prescribe narcotics. Hospital admin, insurance companies (scripts are cheaper than diagnostic evals), pharma, the government (through patient satisfaction surveys), and the patient requesting them.

        My point is that the article discounts that the majority of doctors are now entering the profession in an environment that actually actively encourages the use of narcotics. Now if this article was used as a spring board to list one of many reasons that doctors in corp med should unionize then sure I would support it. Unioniziation is the only thing that will save docs from corp med. As this piece reads its just another gripe laying blame at doctors (not very different than the patient satisfaction surveys aimed at doctors. Unions and/or direct care can save docs from corp med, nothing in the forseeable future is going to save the patients from corp med, at least those who can’t afford direct care.

        • Patient Kit

          I’m not saying that doctors alone are responsible and I agree that there are numerous powerful forces in play here. But, even in our extremely difficult healthcare environment, do you really believe that doctors have zero responsibility for the prescriptions they write? If so, do doctors have any responsibility for unnecessary surgery if Corp Med pressures them to perform unnecessary surgery because it’s a lucrative revenue stream? Where do you draw the line?

          Surely you don’t believe that Corp Med totally absolves doctors from having any responsibility to do the right thing, even if there is a price to pay for doing the right thing? I agree that it would be easier to take a stand together on tough issues like this if you had a union — and not just a union, but a union with good leadership. Surely, there must be some good, courageous leadership lurking somewhere among the, what?, 880,000 doctors in US? I hope someone steps up soon. Because, as many of us agree, things are only getting worse, not better.

          • Dr. Drake Ramoray

            You are making a sweeping generalization about my point of view when I am pointing out a large factor that is not mentioned is that physicians are subjected to corporate driven surveys that effect their pay and job security (unless they want to move). This isn’t even mentioned in the article.

            I am not saying doctors aren’t responsible, I’m saying that it doesn’t take into account practice medicine in the current environment. I didn’t say they have no responsibility, I’m saying our system is moving to a place where doctors are less able to do what is right for their patients without being punished. Sometimes with a loss of their job. We haven’t moved to doctors being black balled for being “disruptive” that I am aware of but that day is coming.

            Two real world physicians who had to quit and move because their ethics dictated that they wouldn’t prescribe narcotics in an inappropriate manner. No articles about that, that part of my post is hardly acknowledged. I provide an example of doctors doing the right thing, even to the length of moving across the country, and somehow that means I said doctors are blameless?

            Sure why not. I get blamed for everything else like my patient today with a brain tumor and his “inexpensive” insurance policy with a $10,000 deductible. Blame the doctor, he/he is the most visible person. It’s my fault he needs an MRI. Ignore the politics, corp med, and decisions that make things this way. Medicine is a vacuum, anything that can possibly go wrong has to be the doctors fault.

          • DeceasedMD1

            It does get old Drake to be blamed. Real old.
            Any idea how your pt got a 10 grand deductible. Isn’t the ACA max now something around $6350?

          • Dr. Drake Ramoray

            No. I do not know how he has a 10k deductible. That’s what the patient said. Had my office manager check its 10k. I am not disclosing the company.

          • DeceasedMD1

            Amazing. It must be the wild wild west with insurance even with ACA if that is permitted.

          • Patient Kit

            And I am acknowledging that doctors are working under extreme, unfair and potentially dangerous pressure from Corp Med. I never said everything is the doctors’ fault. But I hope both doctors and patients can actually DO something about it before ethical doctors are all labeled “disruptive” and blackballed if they don’t goose-step to corporate edicts. If that time is coming soon, the time to DO something is now.

            If doctor’s are losing their jobs now solely for doing the right, ethical thing, we need to know about those specific cases. Doctors and patients need to step up and defend and support those doctors and make them known as the heroes and heroines they are. We need to put them in the spotlight, make them martyrs, if necessary.

            I do understand how demoralizing it is to work in these conditions. As a patient with a serious illness, I’m constantly terrified in this system. I just want us to start coming up with some ideas about what we can actually DO about it together. I really am not your enemy.

          • Dr. Drake Ramoray

            “And I am acknowledging that doctors are working under extreme, unfair and potentially dangerous pressure from Corp Med.”

            Yes, you have, although the author has not which was the entire point of my original post. The two docs (seperate facilities) made varying degress to right things within their institutions. Short of going to the state medical board, they had no real option but to leave.

            You get labeled as disruptive in a hospital environment and good luck with continuing to work there. Add the regional monopolies that are developing and the only defense really is unionization or go off the grid and stop going to the hospital and/or accepting insurance (this of course helps the docs but not the patients).

          • John C. Key MD

            Everyone’s goal should be to be labelled a “disruptive doctor”. If there was ever a time for disruption, it is now.

          • Dr. Drake Ramoray

            I have been one before. If God help me I find myself in the halls of corp med, I will be one again.

      • ninguem

        “…..You’re the only ones who have the power to write prescriptions…..”

        Not in my state.

        Nurse practitioners can, and do, write Schedule-2 drugs.

        Some states, even naturopaths can prescribe schedule III and IV narcotics.

        • Patient Kit

          I stand corrected on that detail. But my main point was that all the other players who share the blame for America’s prescription narcotics problems — Pharma, patients, Corp Med, etc — cannot write or stop writing prescriptions. Only docs and NPs have that particular power.

  • NewMexicoRam

    That’s what I thought. Written by a specialist, who can always say “go back to your primary care.”
    Is there a problem with too much prescribing? You betcha. I’m happy about the recent guidelines and crackdowns sweeping the country that mandate pain control CME for docs, prescription monitoring through pharmacy reporting, and patient contracts, but to put the blame entirely on doctors, more specifically primary care, isn’t right.
    In my former practice during the 90′s, I had over 2000 patients, and about 10 people on chronic opiates. Now I have 1500 patients, with about 250 on opiates +/- benzo’s. Sickening, actually.

  • Patient Kit

    I think there is enough blame to go around and the blame should be shared by Big Pharma, Corp Med, patient satisfaction metrics, patients and doctors. But I do agree that doctors, who have been writing the prescriptions for years and continue to write them, get the lion’s share of the blame for the overuse of prescription drugs. Not only for painkillers either but also for antibiotics, antidepressants and others. But, yes, I think our doctors have to take a huge share of the blame for our current huge narcotic drug problem.

  • edwinleap

    The emergency department is an endless parade of ‘can I get something stronger,’ or ‘I’m out of my pain medicine,’ and ‘my pain scale is a 12!’ It’s vastly worse due to pressure for higher satisfaction scores. And patient satisfaction is being tied to MOC and reimbursement as well. And for years, in the specialty, we were constantly berated by academics. ‘We’re doing a terrible job treating pain! You can’t create an addict in the ER!’ We all knew that people were abusing us and the system, but we seemed powerless. And then we had ‘my doctor told me to come to the ER,’ or ‘I can’t reach my pain specialist.’ And the national television shows that addressed pain and said ‘everyone with chronic pain should have a pain specialist.’ We wanted to be compassionate, but frequently had no way at all to talk to the patient’s physician, many opting not to take call. Indeed we have an epidemic of narcotic (and anxiolytic) addiction. But it does not good to blame any one group. There needs to be some sort of systemic fix. And part of that, quite honestly, will involve explaining to the public that not every pain needs to be eradicated with narcotics. (Cancer and other very painful conditions aside, of course.) And the other side will be to divorce this issue from patient satisfaction scores entirely. If not, to write on prescriptions and in the chart: prescribed as mandated by hospital administration, so that when catastrophes occur, they can share in the joy of the courtroom.

  • http://www.amerechristian.com/ Ron Smith

    Hi, James.

    ” I believe that pain for a cancer patient cuts deep to the soul and is a constant reminder of sickness and death.”

    Lewis says it best:

    “Pain plants the flag of truth within the fortress of a rebel soul.”

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • http://thestoryofhealth.com Anoop Kumar, MD @StoryOfHealth

    Thanks for the great article Dr. Salwitz. I’ll take it a step further. It’s not just that we need to say no to drugs, we need to say yes to the common sense things that can replace certain drugs, like non-allopathic therapies that help people with chronic pain. Like changes in nutrition that can halt or even reverse heart disease. When you say that we doctors “continue a humiliating history of responding to marketing instead of medical data” it makes me cringe, because it’s true.

  • Patient Kit

    OK, I acknowledge that doctors do have a true dilemma, when it comes to patients who say they are in a lot of pain. You are right — unless you have real reason to believe that your patient is lying to you just to get painkillers from you, giving them the benefit of the doubt is preferable to going CSI on them. Since pain is subjective and difficult to measure, it really is a dilemma. So, I’ll take back my “lion’s share” comment when it comes to the fuzzy area of narcotic painkillers.

    That said, we do know that many doctors do write way too many prescriptions for antibiotics for patients that they do know don’t need them. If we accept that, it’s not too big of a leap to think that those same doctors “knowingly” write scripts for unnecessary painkillers. The whole situation is a huge complex problem in many ways — for doctors, for patients in legitimate pain, for addicts, for victims of addicts, for society in general. I don’t know what the solution is.

  • Bob

    And not a single word about marijuana, perhaps mundane now as many states have legalized it, yet still classified as Schedule II alongside the drugs listed in the article; along with morphine, cocaine and opium; while heroin as a schedule I drug that can’t even be subscribed is now reaching epidemic proportions.
    Go back in history and these drugs weren’t controlled since they were used then as now for mental health as much as for physical health, but their use and abuse can’t be controlled by persecuting prescribers since users will find ways to get or make synthetic “home made drugs”.

  • medicontheedge

    If you deny customers what they want, your Press-Ganey scores will suffer. Can’t have that. Dr. Drake hit the nail on the head. As long as unsatisfied customers are driving this, there is no real way to talk about reform. We will continue to help people become addicted to narcotics, then watch as they turn to heroin, as it is cheaper and easier to get, then follow the natural progression into the mental illness game where they will invariably end up.

    • Mark S.B.

      medicontheedge,
      There is no way I putting a needle in my arm with heroin in it.
      I’m not addicted to this long acting pain med I’m dependent upon it to give me a better quality of life for the last 24 years. There is a huge difference between addiction and dependency. Addiction is abusing drugs despite harm. Dependency is getting by on a certain long acting pain med so I don’t suffer my life away. Which would you want if you suffered and tried all alternative therapies and nothing worked. The media is blind to this all.

  • Mark S.B.

    Dr. Salwitz,
    How do you say no to pain relief to a person suffering with a spine that’s collapsing on them from a roll over car accident, where the roof collapsed down on their head compressing their spine. Pain is pain cancer or not it hurts like being paralyzed with a stun gun. The out of control problem was not started by doctors it was started by the people that lie good enough to talk a doctor out of a script for pain medication, even though they don’t suffer. Things have spiraled out of control with giving pain meds to anyone that ask. Don’t you tell me I don’t deserve pain relief when I tried everything under the sun to no avail, then when I was properly titrated up on a long acting pain med my life was given back to me that the intractable pain had stolen away.
    Yes lets just say NO to all that suffer cancer and chronic pain.
    You people who think you have all the answers sicken me.

  • Karen Ronk

    Hi Annie, I have recently been diagnosed with CRPS following brachial plexus damage sustained during shoulder surgery 18 months ago. Have you found any treatments that are effective? I have a good pain management doc who is open to my input and I am just starting on my journey. In my case, there are visible physical changes to my arms so in a way I am “lucky” in the sense that I have not gotten any attitudes regarding my need for pain relief. I wish you all the best.

  • Mark S.B.

    It is the FDA’s view that a patient without cancer ,like a patient with cancer, may suffer from chronic pain.

    The FDA knows of no physiological or pharmacological
    basis upon which to differentiate the treatment of chronic pain in a cancer
    setting or a patient from which the treatment of chronic pain
    in the absence of cancer .