Some thoughts on overuse of sedatives, opiates, and stimulants

There is no good evidence that these medications are either safe or effective when used long term. In fact there is good evidence that they are NOT safe, and quite a bit of circumstantial evidence that they are not effective. We prescribe many times the number of controlled substances now than we did a decade ago, and overall Americans are not less anxious or less in pain or better able to concentrate than they were before. Those of us who prescribe opiates to patients with chronic pain very rarely see the pain become significantly more manageable though we do see the patients become less active and more likely to ask us for ever increasing amounts of the medications which don't work very well.

I, as a cutting edge physician of my generation, prescribed these drugs with enthusiasm, glad to be able to lessen the burden of anxiety, pain or distraction in my patients. Eventually I noticed that these patients were having real problems, including emergency room visits for confusion or for increased pain, worsening of their pre-existing breathing problems, severe constipation requiring hospitalization, one died by deliberately overdosing. Others' deaths were probably hastened. More subtle has been the increasing number of people who are becoming inactive, apathetic and stuck in poverty who appear to live mostly for their prescription medications. This group of people are not being identified at all by statistics on overdose.

Ok, that sounds like the problems that can come from a single doctor treating a patient.  But the problems can be compounded when a patient is seeing more than one doctor.  A 2014 BMJ article by Anupam Jena and colleagues reviewed the frequency and characteristics of opioid prescribing by multiple providers in Medicare.  They found:

Concurrent opioid prescribing by multiple providers is common in Medicare patients and is associated with higher rates of hospital admission related to opioid use.

Some doctors are bucking the trend, but it takes a concerted effort, patience, and thoughtfulness.  I note this piece from NPR on treatment of migraines, where Dr. Carolyn Bernstein notes:

“The majority of [desperate patients] have really been suffering a number of years and they're really miserable with the pain,” Bernstein says. They say, ” 'I hope you have a magic pill,' and of course there is no magic pill.”

… [P]atients receive a thorough medical history that includes headache patterns, disability and mood assessments. Then the center works with patients to try to identify what triggers their headaches and how they can avoid those triggers in the future.

Some people find relief through exercise. “I write an exercise prescription probably as often as I write a prescription for medication,” Bernstein says. She acknowledges it's sometimes difficult to encourage a patient with cracking head pain to get up and exercise. But even a little can help, and according to Bernstein it doesn't have to be jogging for miles and miles. It can be yoga, tai chi or even just a little stretching.