Opiate painkillers: Can a balance be found?

AT BUFFALO

Jerrold Winter: I’m a pharmacologist. I teach five hours of the principles of pharmacology to the first-year students. One of those hours I devote to tolerance, physical dependence and addiction. I try to get them to have an appreciation for the particular hazards that are out there for physicians because of their easy access to the drugs and so forth. It became a little more personal recently. Six years ago I developed sciatica, and at that time, I was treated with hydrocodone. It worked wonderfully. Recently, I had a recurrence of it and, lo and behold, when I left my primary care physician’s office, my prescription had been cut by two-thirds. That prompted me to write a letter to The Buffalo News, which basically expressed my personal view that there is a tendency to believe that addiction is going to be prevented by denying patients who need the drugs. But no addict will be saved by putting someone else in pain.

Richard Blondell: Like a lot of things, there’s an upside and a downside. Fire, for example, cooks our food, but if you have burns over 90 percent of your body, it’s not a good thing. When I was in training, I never wrote prescriptions for narcotics. If I had written one for more than 10 days, I would have gotten a call from the pharmacist asking what I was doing. So we probably underprescribed at that time. And now it is clear we’re overprescribing. For the first time in decades, unintentional overdose deaths from drugs exceed deaths from car accidents. So maybe there are some people undertreated for pain, but there are certainly a lot of people overtreated.

JW: I would like patients to have a pre-check, like at the airport. I believe there are people who simply are not likely to become addicts, and yet every patient who walks into some doctors’ offices is looked upon as a drug-seeker and potential addict. There are pill-seekers, doctor-shoppers, who do that, but there are also people who are never going to become addicted.

RB: How do you predict who’s going to become addicted and who is not?

JW: If a patients says, “I’m depressed or I have some other form of mental aberration. I’m unemployed. I have relatives who have had problems with alcoholism,” and so forth, then they are more likely to become addicts.

RB: Patients I see have few of those characteristics. They have jobs, they’re educated, they have money, they haven’t had trouble with the law, but somehow they get prescribed into an addiction. The vast majority of my patients are like that.

JW: Do you believe what has been suggested by some, that more stringent regulations with opiates will drive people into the illicit market?

RB: We already do that now. You’re familiar with I-STOP, the New York State prescription monitoring program. When those systems went into effect, people were cut from their supply of licit opioids. This did not go unnoticed by the businesspeople in the illicit drug market. Ahead of I-STOP, they actually shipped in extra heroin and fentanyl to New York and stockpiled it because they were ready for the anticipated uptick in their market. Now, our political leaders are saying, “Oh, we didn’t see this coming.” If we’re going to get our hands around this, we have to be smart.

JW: Are you suggesting more stringent controls on prescriptions are doing more harm than good?

RB: It remains to be seen. It certainly has caused more problems in the short term, but in the long term we have to get our hands around overprescribing.

JW: Let me raise another issue. In various countries, like Portugal, the prevailing notion is: Let all drugs be available, they let people use them. They had a transient increase in some drug use, but that has settled down, and they had a decrease in the adverse effects of infection.

RB: Drugs have now so permeated society that they are widely available, but it’s clear that if a drug is not available, people don’t get addicted to it. When I was growing up, if I wanted to use heroin, I couldn’t get it. You had to go into the inner city, in the impoverished neighborhoods, etc. Now, you’re 17 years old, you get your wisdom teeth out, and you leave the dentist’s office with a prescription for 30 tablets of hydrocodone. You need maybe two, three, five max after a wisdom tooth. So you now have a 17-year-old with an extra 25 tablets of hydrocodone. No good can come from that.

JW: My fear is that we’re going to swing too far the other way and there are going to be countless people who, when their pain gets bad, they’ve got this opiate, which treats it — for many people miraculously — and we’re going to say to them, “We’re going to sacrifice you on the altar of stopping addiction.”

RB: It’s not a dichotomous decision, overprescribe or underprescribe. It’s “prescribe smartly.” If a patient has sciatica, write what is appropriate. If a patient comes in with a bogus complaint, don’t write a prescription.

JW: We can’t argue about that. That’s perfectly reasonable.