Prescription Drug Abuse Is an Equal Opportunity Epidemic

This article originally appeared online at Dr.Pullen.com, part of the HCPLive network.

In looking at drug abuse issues over my 30 year family medicine career there have been wide swings in what drugs have been popular. The recent prescription drug abuse epidemic, especially the opioid class of drugs, has been the biggest problem for the practicing primary care physician. Unlike many prior drug abuse problems it affects all socioeconomic classes, urban, suburban and rural areas alike, the young and not-so-young, and involves drugs with very legitimate uses. There is limited medical use of marijuana, and none for most other drugs of abuse. Prescription opioids are the mainstay of pain treatment, and the dilemma of treating pain adequately and not participating as a supplier of the abuse epidemic is a problem that makes Rubik’s cube look simple. Let’s look at prior epidemics for comparison.

In the 1970’s and 1980’s the new epidemic was Angel Dust (PCP or phencyclidine). This synthetic hallucinogen was very popular but only for a relatively short time, and as its reputation for leading to violence and death made it a problem for physicians, but more a problem for the ER doctors than in the office. As crack cocaine came to market in 1984-85, cocaine users now had an easy way to free-base cocaine. The crack epidemic of the late 1980-1990s escalated the gang warfare and crime issues in our cities and suburbs. This epidemic has seemed to fade somewhat recently, giving way to crystal methamphetamine abuse. Multiple designer drugs, from ecstasy to date rape drugs have become problems, but for the primary care doctor none have had the impact of prescription drug use.

The information age has escalated the ease of acquiring prescription drugs. You just need to search for “vicodin without a prescription” and Google returns hundreds of offers to sell this medication on-line without a prescription. Oxycontin has become known as Hillbilly heroin. Far more patients die each year from prescription opioid overdose than from heroin use each year in America. (see “Can’t find a doctor to prescribe pain meds?”) In the office when I see a new patient who takes chronic opioid medication I have to consider the possibilities that this person is either abusing the medication themselves or diverting the drug for illegal sales on the black market. This epidemic has had far more impact on the practicing primary care doctor than any of the other drug abuse epidemics to date.

How can we address this epidemic?

I think we have to do several things:

• We need a nation-wide controlled medication database. As a physician I need to be able to check on whether a given patient is getting opioids from other physicians easily and quickly.
• We need real pain management clinics. I don’t mean physicians who will do well compensated invasive procedures like corticosteroid spine injections, but places set up to treat chronic non-cancer pain where safeguards can be in place to minimize abuse and diversion of the drugs, and where non-pharmaceutical pain management can be integrated into the pain management care plan.
• Primary care physicians need to be especially diligent to try to prevent unintentional creep from occasional intermittent pain medication use to escalation of dose and addiction.
• We need to close down and stop the drug-pushing online and at the few clinics abusing the prescribing privilege for profit. (How? I don’t know)
• We need to teach parents and other adults to keep their prescription meds locked up and away from teens. Many teens abuse their parent’s drugs.
• Physicians need to stop prescribing Oxycontin for non-terminal pain. See Oxycontin: What’s the big deal?
• We need to recognize prescription drug abuse when it’s happening, and rapidly get abusers into rehab or stop supplying their habit when they are using physicians to get the drugs.

In the meantime family physicians are being worn out by this epidemic, and those patients in pain and needing opiates are bearing the brunt of our reluctance to prescribe opioids.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at DrPullen.com — A Medical Bog for the Informed Patient.