At last! No, I’m not thinking of Etta James’ version of the song that became de rigueur at weddings, reflecting the consummation of a romantic longing. Nor am I thinking about Stanley Kubrick’s A Clockwork Orange, when the prison governor sarcastically tells the newly imprisoned Alex about the ideas just put in place for reforming violent criminals using aversive conditioning, which he feels confident are misguided and certain to be ineffective.
What I’m thinking about is the “AT LAST!” that’s spoken emphatically and with tremendous relief when something too long in gestation has happened. As in FINALLY!
What has happened at last? The CDC and FDA have finally recognized that there might be something of a problem in the way opiates are prescribed (like . . . well . . . like antibiotics). I mean prescribed casually, with little thought for the undesirable but totally predictable adverse effects on individuals and populations.1
Who could possibly have imagined that lots of people would become addicted to opiates? And never could anyone have thought that such addictions would lead multitudes in every part of the country and from every socio-economic group to become heroin addicts. Just because heroin is much cheaper and arguably easier to come by than prescription opiates, who in their right mind would want to use heroin? Or did they just not realize the clawing craving that opiate addiction induces?
Did it not occur to anyone at the FDA to stop and think about the fact the opiates were revealed last year to be the most widely prescribed drug category to Medicare patients? Was there no concern when prescription opiates were recently approved for use in children?
Yes, I know that many, many patients have severe chronic pain, and I know how important opiates can be in end-of-life palliative care for cancer or in hospice care. I’m not really a puritan, but I am greatly relieved after years of exasperation that at last there is recognition that the widespread personally and societally debilitating heroin epidemic is at least in part iatrogenic. I don’t believe any physician wanted to addict his or her patients to opiates. I know only too well the conundrum for physicians when confronted with an addicted patient who didn’t intend to become one, but who is hooked and who wants us to continue prescribing an addicting medication that may not be clinically indicated.
It is reassuring that opiates are not the first treatment of choice in chronic pain recommendations. If used, they must be part of a multifocal plan that includes non-pharmacological treatments. Extended-release and long-acting formulations are not recommended for acute pain. Someone should have shown these guidelines to the surgeon who recently did laparoscopic surgery on one of my kids and then gave a prescription for 50 oxycodone tablets.
1. Fox CR, Linder JA, Doctor JN. How to stop overprescribing antibiotics. New York Times. March 25, 2016. http://www.nytimes.com/2016/03/27/opinion/sunday/how-to-stop-overprescribing-antibiotics.html. Accessed April 14, 2016.
2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65:1-49. http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed April 14, 2016.