Thinking About The Prescription Opioid Medication Crisis

Just a note today on the opioid overdose situation about which a lot of experts are talking including Dr. Jan Fawcett, MD in the October 2015 issue of Psychiatric Annals:

I’m really not sure it’s a great idea to recommend that psychiatrists try taking over as experts in this area. There are mandated CME courses for prescribing opioids in many states including Iowa, which tie physician renewal of medical licenses to completing these courses and this includes psychiatrists, many of whom never prescribe opioids in their practices.

I was very interested in the write up about this topic in the Summer 2015 issue of Iowa Medicine, the Journal of the Iowa Medical Society, sounding a note of concern about the growing problem of opioid abuse in our state:

As the author of the story, Kate Strickler, JD, LLM points out, at least 130 Iowans died from non-heroin opioid overdoses between 2008 and 2010. It’s becoming a familiar story that many people divert prescription opioids from healthcare professionals. About 54% get the drugs for free from a friend who got a prescription from a provider.

While Iowa remains below the overall national rate for use so far, as it relates to prescription drug poisoning, I wonder how long that status will hold:

According to the guest editor in the Psychiatric Annals issue on prescription opioids, Dr. Norman S. Miller, MD, JD, PLLC, “When the evidence is reviewed, there is minimal support for long-term prescribing of opioid medications. An extensive review of over 2,000 publications did not find evidence to justify opioid medication for chronic pain. In addition, there were few articles that researched addiction despite opioid medications’ highly addicting pharmacologic properties. In fact, opioid addiction explains why doctors prescribe and patients consume opioids continuously with substantial risks of psychiatric and medical adverse consequences—and without benefit.”

There is also an article about Opioid Induced Hyperalgesia which I believe I’ve seen as a psychiatric consultant [1]. The treatment is to discontinue the opioid.

We should think very hard before we put one medical specialty in charge of such a complicated problem.


  1. Oberbarnscheidt T, Miller N. Mechanisms of Pain and Opioid Pharmacology. Abstract: Opioid-induced hyperalgesia (OIH) is a very common consequence of pain management with opiods. Characteristics of OIH are worsening pain over time despite an increased dose of the opioid. It is often recognized neither by the physician nor the patient, and it results in increasing doses of opioid medications and continued unsatisfying pain levels experienced by the patient. The increased use of narcotics has a negative impact on patient outcome, as patients suffer from increased pain levels and often develop depression. Patients with OIH require frequent assessment for aberrant behaviors as an indicator of addictive use. Opioid-seeking behavior may complicate the clinical picture of failed opioid therapy. The treatment of OIH is to discontinue the opioid medication and to treat the patient’s withdrawal symptoms, if necessary, in an inpatient setting with medical monitoring. Psychiatr Ann. 2015; 45: 511-515. doi: 10.3928/00485713-20151001-06 [link]

Other abstracts from Psychiatric Annals October 2015 issue on prescription opioids:

Maldow D, Miller N, Matthews A. Do Current Policies and Practices for Prescribing Opioid Medications Solve Chronic Pain Problems? Abstract: Despite the widespread prescribing of opioid medications for the treatment of chronic pain, there is little or no evidence for its efficacy. In fact, the studies show that long-term prescribing of opioid medications leads to significant morbidity and mortality. The Controlled Substance Laws define prescription opioids as dangerous and addicting medications. Despite the classification and scheduling of opioid medication, their prescribing continues to be common and adverse. Most importantly, there are few studies addressing the addicting properties that drive the high rates of prescribing and adverse consequences. It is a myth that most people treated with opioids never become addicted and that addiction does not develop if you are prescribing for pain. Psychiatr Ann. 2015; 45: 500-505. doi: 10.3928/00485713-20151001-04 [link]

Miller N, Farooq U, Matthews A. Psychiatric Diagnoses and Chronic Opioid Use. Abstract: The psychiatric symptoms, particularly depression and anxiety, associated with chronic use of opioid medications as a result of overprescribing are common and debilitating. Opioid medications are classified as depressants and induce serious depression and anxiety, particularly with chronic and persistent use. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides diagnoses for these opioid-induced conditions. Substance-induced disorders, particularly for depression and anxiety, include intoxication and withdrawal, substance/medication-induced depressive disorder, and substance/medication-induced anxiety disorder. Importantly, DSM-5 criteria indicate that diagnoses for major depressive disorder and anxiety disorder cannot be made if there is a substance, such as opioid medications, responsible for the condition. Often the way to distinguish between a substance-induced disorder and an independent major depressive or anxiety disorder is to discontinue the opioid medications. Given that opioids are not efficacious for long-term prescribing, discontinuation of the medication is the treatment of choice. Psychiatr Ann. 2015; 45: 506-510. doi: 10.3928/00485713-20151001-05 [link]

Miller N, Gold M. Prescription Opioids and Addiction. Abstract: Why are opioid medications prescribed in large quantities and high frequency when there is little or no proven efficacy for their therapeutic value? Why are opioids the most commonly prescribed medication in the United States when their adverse consequences continue to grow? Why does the medical profession continue to prescribe opioid medications that result in increased pain and increased disability? This article summarizes the inherent addictive pharmacologic properties that are the impetus and basis for America’s current opioid epidemic. Psychiatr Ann.  2015; 45: 516-521. doi: 10.3928/00485713-20151001-07 [link]

Angres D, DuPont R, Gold M. Perspectives on the Opioid Crisis. Abstract: Health care providers, addiction specialists, and legislators are in agreement that novel and more effective means of reducing opioid and other addicting substance misuse and abuse are critical at this time in our country. The statistics are dismal and increasingly alarming, with more and more individuals at risk. The widespread availability and use of the antiopiate pharmaceutical, naloxone, to reverse life-threatening overdoses is a beginning and a step in the right direction, but can only be considered an initial intervention. What should follow naloxone? We know the answer if the patient is an anesthesiologist resuscitated in the hospital. For everyone who is not a licensed health provider, it is less clear. Substance abuse treatment in the United States is predominantly outpatient, short term, and with few objective checks on the effectiveness of treatment. Substance abuse treatment of health professions is radically different in that it is not a treatment program but is a program of active care management. This management includes residential treatment and sustained monitoring of abstinence. Few addicted patients receive anything that approximates evidence-based care. Psychiatr Ann.  2015; 45: 522-526. doi: 10.3928/00485713-20151001-08 [link]

Contagious Benzophobia?

I know, I know; I’m on vacation and I should stay away from the blog, but my wife says to me this morning, “Hey, did you see the CNN article about Xanax?” So, of course, heedless of the potential consequences, I read it:

I really didn’t much care for the reporter’s sentence, “Part of alprazolam’s fast rise: It is a go-to anti-anxiety drug for psychiatrists and primary care physicians.” 

You can ask any resident in our psychiatry department and they can tell you I’m “benzophobic.” As a psychiatric consultant in the general hospital, I’ve seen the aftermath of too many of the accidents described in the story. This is because the critical care unit doctors always call me or another consultation-liaison (C-L) psychiatrist to assist in the framing of a triage and recovery plan for patients who are lucky enough to survive these episodes.

Sadly, some of these incidents are not accidents. Suicide attempts by overdosing on prescription medications are very common.

Prescribing doctors are only a part of this problem. We could point fingers in a few different directions, even at the pharmaceutical companies:

I have seen this issue of prescription drug misuse and misprescribing so often, that I often fantasize about scientists creating a new disease, “Contagious Benzophobia.” It would be a man-made malady, except it probably would be more aptly described by a neologism, say “saladrome” (salutary syndrome).

That would make it different from a syndrome like PANDAS or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. That’s a very bad thing that happens to kids who get a specific bacterial infection.

We need both passion and braaaaains!

On the other hand a saladrome like Contagious Benzophobia could create a sort of beneficial Zombie Apocalypse (Paladin Illumination?). What if you could infect doctors, patients, and pharmaceutical companies with an X-Files-type infective recombinant protein that would replace whatever redundantly recapitulated evolution-pegged cellular blob is responsibe for making us want things like benzodiazepines, oxycodone, heroin, and even cannabis?

On the other hand, I have to wake up sometimes from this fantasy and think about the difficult conversations entailed by confronting the epidemic of prescription drug misuse. After all, benzodiazepines work, as Psych Practice blogger points out in the post on how psychiatry residents sometimes survive their training–which teaches many how to tolerate and cope with powerlessness.

As I reflect on my own not infrequent sense of powerlessness as a psychiatric consultant in these situations, I struggle. Yes, most of us do wrestle with these issues, we don’t just reach for the “go-to anti-anxiety drug.” I sometimes have to tell patients that I don’t think a particular prescription medication is in their long-term best interests.

This is not always met with warm enthusiasm, which I guess should make me glad that the American Board of Psychiatry and Neurology (ABPN) recently made an announcement that seems to allow psychiatrists to choose feedback surveys other than from patients in order to satisfy Maintenance of Certification (MOC) requirements,

I have this other fantasy. Wouldn’t it be great if giving in to an impulse to protect ourselves and our patients from harm were as easy as it seems to be to give in to other impulses which can injure and even kill us?

Iowa Physician Honored for Fighting Prescription Drug Abuse

The AMA MorningRounds recently contained sobering news about children dying of prescription drug overdoses in California. It was front-page news in the Los Angeles Times. The legislature called for more action by the Medical Board of California to mine a statewide database of prescriptions to identify doctors who “recklessly prescribe narcotics.” The medical board only investigates in response to complaints. The public perception is more proactive measures are urgently needed to protect people from prescription drug overdoses–which include children. California has a state database called CURES which could be mined for patterns of reckless prescribing, and the emotional testimony from parents about how their children died from accidental overdoses led to lawmakers calling for the medical board to change how it initiates investigations of physicians who might be prescribing narcotics recklessly.

Another item was about how 48 State Attorneys General called on the U.S. Food and Drug Administration (FDA) to make it harder for generic pain pills to be abused. The push is on to modify drug formulations that discourage abuse in order to prevent deadly consequences. The fight against prescription drug abuse is a team effort, requiring strong law enforcement, prescribing pattern monitoring, pharmaceutical company collaboration–and individual physicians who do their part.

Dr. Gary Hemann, MDphoto credit RadioIowa
Dr. Gary Hemann, MD
photo credit RadioIowa

Well, one Iowa physician was honored on March 12, 2013 for his efforts to stem the tide of deaths from prescription drug misuse. Dr. Gary Hemann, D.O., a Des Moines, Iowa emergency room physician was presented with a special state award for designing a program that could prevent prescription drug abuse, see link for details: Doctor wins award for program to reduce prescription drug abuse. The program combines Iowa’s Prescription Drug Monitoring Program (PMP) with clinical guidelines for doctors on prescribing painkillers. The program will be available in future to other hospitals in Iowa.

This is yet another step on the path to real change in preventing prescription painkiller misuse.

Walking the Tightrope to Prevent Prescription Drug Addiction

By now a lot of people have viewed the CBS News video of reporter Mark Strassman’s interview with a real estate executive’s struggle with addiction to a prescription analgesic and anxiolytic. A recent AMA MorningRounds item also highlighted the steady rise in deaths “for the 11th straight year” (from an ABC World News story aired on February 19, 2013) from drug overdoses, many of them from prescription painkillers and most of them accidental, although a significant minority include antidepressants, benzodiazepines, and antipsychotic drugs as well, attesting to the role of mental illness in the epidemic.

And we’re back to the cycle of assigning blame for the prescription drug abuse epidemic.

It seems we’re all walking a tightrope in our efforts to make amends to stakeholders, including patients who need these medications and are not abusing them, while trying to prevent the deaths and impairment often attributed to their misuse.

Dr. David Sack, MD has already made a great effort to draw our attention to this tendency in his excellent on-line article, “The Prescription Drug Epidemic Sparks Blame Game”, The Prescription Drug Epidemic Sparks Blame Game | Addiction Recovery. I don’t think it’s necessary to draw attention to the many articles whose authors blame pharmacists, doctors, patients, and others. Just Google (or Bing if you’re into the faceoff between the search engine giants) the issue and you’ll have more reading than you can do in a single day about who should be accountable for this crisis.

And there are numerous news reports about it, see the following links for just a sample:

The anguish of taking painkillers at work – Business – Careers | NBC News

Prescription Painkiller Overdose Deaths on the Rise – ABC News

Much of what I read on the internet and see in these reports indicate a need for comprehensive approaches to the challenge of reducing prescription drug abuse. The news reports sometimes give readers the impression that next to nothing is being done. As usual, I ran a quick PubMed search and found a thorough review about what is being done, about which many individuals and organizations might not be aware [1].

The Manubay et al review contains a section on regulatory efforts and mentions the Prescription Drug Monitoring Programs (PMPs) to detect and prosecute drug diversion, including one in Iowa (Prescription Monitoring Program (PMP) Advisory Council), which some believe are helpful.

The Iowa Board of Medicine also makes available to primary care physicians licensed in Iowa, free of charge, the book “Responsible Opioid Prescribing: A Clinician’s Guide, by Scott M. Fishman, MD ( This newly revised edition can be used in Iowa for the new mandatory CME requirement on pain management. And yes, I noticed that the book is promoted by the Federation of State Medical Boards (FSMB). I may not agree with the FSMB about the Maintenance of Certification (MOC) and the Maintenance of Licensure (MOL), but I agree with its policy on the critically important issue of educating prescribing clinicians and patients about rational pain management.Responsible Opioid Prescribing by Fishman

The paper also describes a patient risk assessment instrument called the Pain Assessment and Documentation Tool (PADT) which incorporates the “4 A’s”: analgesia, activity, adverse effects, and aberrant behavior. It’s also important to screen for common, treatable psychiatric illnesses which can be associated with problematic prescription use, including but not limited to depression and anxiety.

Iowa researchers also recently published an article showing that community-based prevention programs could lead to fewer adolescents and young adults abusing prescription drugs–years after the interventions [2]. Prevention efforts focused on youth reduce prescription abuse into adulthood.

We all have a long way to go in being accountable for the prescription drug abuse epidemic–but most of us are not sitting on our hands. In fact, it looks like many are saying, in effect, “It may not be my fault, but it’s my problem”. Adopting that attitude can help us begin to make amends.

1. Manubay, J. M., C. Muchow, et al. (2011). “Prescription drug abuse: epidemiology, regulatory issues, chronic pain management with narcotic analgesics.” Primary care 38(1): 71-90, vi.
The epidemic of prescription drug abuse has reached a critical level, which has received national attention. This article provides insight into the epidemiology of prescription drug abuse, explains regulatory issues, and provides guidelines for the assessment and management of pain, particularly with long-term opioid therapy. Using informed consent forms, treatment agreements, and risk documentation tools and regularly monitoring the 4 A’s help to educate patients and guide management based on treatment goals. By using universal precautions, and being aware of aberrant behaviors, physicians may feel more confident in identifying and addressing problematic behaviors. Public Access Article:, Prescription Drug Abuse: Epidemiology, Regulatory Issues, Chronic Pain Management with Narcotic Analgesics

2. Spoth, R., L. Trudeau, et al. (2013). “Longitudinal Effects of Universal Preventive Intervention on Prescription Drug Misuse: Three Randomized Controlled Trials With Late Adolescents and Young Adults.” American Journal of Public Health.
Objectives. We examined long-term prescription drug misuse outcomes in 3 randomized controlled trials evaluating brief universal preventive interventions conducted during middle school. Methods. In 3 studies, we tested the Iowa Strengthening Families Program (ISFP); evaluated a revised ISFP, the Strengthening Families Program: For Parents and Youth 10-14 plus the school-based Life Skills Training (SFP 10-14 + LST); and examined the SFP 10-14 plus 1 of 3 school-based interventions. Self-reported outcomes were prescription opioid misuse (POM) and lifetime prescription drug misuse overall (PDMO). Results. In study 1, ISFP showed significant effects on POM and PDMO, relative reduction rates (RRRs; age 25 years) of 65%, and comparable benefits for higher- and lower-risk subgroups. In study 2, SFP 10-14 + LST showed significant or marginally significant effects on POM and PDMO across all ages (21, 22, and 25 years); higher-risk participants showed stronger effects (RRRs = 32%-79%). In study 3, we found significant results for POM and PDMO (12th grade RRRs = 20%-21%); higher-risk and lower-risk participants showed comparable outcomes. Conclusions. Brief universal interventions have potential for public health impact by reducing prescription drug misuse among adolescents and young adults. (Am J Public Health. Published online ahead of print February 14, 2013: e1-e8. doi:10.2105/AJPH.2012.301209).;

“It Ain’t Me”

One of the medical students rotating through the psychiatry consultation service recently asked a very astute question. It was about the epidemic of opioid pain medicine overprescribing and the related deaths from overdoses. She asked, “Why do doctors prescribe these drugs to people who are obviously misusing them?” Connected to this issue is the way to find out if patients are abusing prescription drugs and that’s by using Prescription Monitoring programs (PMPS), which I’ve posted about in the past:

State Mandated Opioid Management CME Requirements for Psychiatrists – The Practical Psychosomaticist: James Amos, M.D.

Do State Prescription Monitoring Programs Influence the Therapeutic Alliance? – The Practical Psychosomaticist: James Amos, M.D.

I didn’t have a good answer. I realized I shouldn’t say “I don’t know,” because many people say that’s ducking responsibility. The correct answer is “I’ll look into that and get back to you.” I can’t speak for those who write the prescriptions for drugs like opioid painkillers. There’s a legitimate reason and that’s to help people in constant, chronic, disabling pain. But there are ways to recognize when patients are misusing opioids. There was an excellent review in the August issue of Current Psychiatry, Prescription opioid use disorder: A complex clinical challenge — Current Psychiatry Online [1].

Maybe some doctors would have an “It ain’t me” defense, though when the PMP says more than a dozen doctors are being duped, it begs the question of how so many could be fooled. I suppose I could say “It ain’t me” too–but that’s because I don’t prescribe opioids. I remember hearing an addictions specialist telling an audience that some patients “connive” in order to obtain prescriptions for controlled substances from doctors. So if psychiatrists don’t write prescriptions for opioids, then the patient has to go to a primary care physician or a pain medicine specialist. That way some psychiatrists can say, “It ain’t me” when state medical boards announce mandated pain medicine CME programs that are compulsory for all primary care doctors and psychiatrists.

Does that mean I’m passing the buck? Or does it mean I’m dodging the draft? This problem can’t wait for a new drug, We Want a New Drug… – The Practical Psychosomaticist: James Amos, M.D. There’s probably more to this than meets the eye and addressing the problems of prescription drug abuse means more than one stakeholder group needs to be accountable.

1. Miller, S., C., MD, FASAM, FAPA, CTTS, and D. Frankowski, MD (2012). “Prescription opioid use disorder: A complex clinical challenge.” Current Psychiatry 11(8): 15-21.

Understanding patients’ aberrant medication-taking behaviors can greatly aid treatment

Another Mother’s Little Helper?

It pays to watch the AMA MorningRounds news items because I found out about another Mother’s Little Helper, an issue I posted about on November 19, 2011, “Mother’s Little Helper” in the New Millenium « The Practical Psychosomaticist: James Amos, M.D.

Back then it was about sleeping pills. The most recent item highlights the new role of Adderall, which apparently is being called “mother’s new little helper.” This was originally aired on ABC World News on June 26, 2012. ABC received a large number of anonymous voice mails and e-mails from women who admitted to using the drug, even though they’ve not been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). They said they need Adderall “to be better mothers.” Funny, I thought it took love to do that. Dr. Marvin Seppala of the Hazelden Clinic (an addiction treatment center) remarked that the use of Adderall and other amphetamines by women is on the rise. He cautioned that it can cause “seizures, strokes, heart attacks, and death.”

So it looks like Mother’s Little Helper could be a variety of drugs which women may be using as a means of support in child care. I think one question it raises is, at least in my mind, “Where’s Dad?” And of course the other question is similar to the one raised in my earlier post, regarding what our expectations are of women generally in our society:

Our culture expects women to work at mach speed both inside and outside the home and this expectation of perfectionism tends to get internalized. That’s not a mental illness; that’s a systems problem. And there’s no little helper for that. Fixing that involves an honest reassessment of our expectations of each other and working together to reset unrealistic, unhealthy, and impractical goals.

So it probably should come as no surprise that “speed” get internalized as well.

Bath Salts Induced Hyperthermic Face Eating Delirium, Tip of the Iceberg

I’m going to revisit the story about the Miami naked man who was shot dead by police because he wouldn’t  stop chewing off the face of a homeless man on a highway ramp. The latest report is that he had been delirious from abusing a new hallucinogen known as “bath salts.” See the story at link, Reports: Miami ‘zombie’ attacker may have been using ‘bath salts’ – This Just In – Blogs. Bath salts are stimulants that have been in Europe for several years and American authorities and physicians are struggling to get their heads around this latest entry in the drug of abuse [1]. They contain a natural stimulant derived from the khat plant and it is structurally a lot like amphetamines. The authors of the article cited say in their discussion section: Bath salts are often deceptively labeled in retail environments as “not intended for human consumption” with packaging suggesting they are legitimate products with ordinary uses. However, the consumers who patronize these establishments and purchase these products are well aware of their recreational uses. From both an ethical and safety standpoint, these products should be explicitly labeled in a way that would overtly distinguish them from the legitimate household and medicinal items whose packaging they counterfeit. Online, the drugs are vaguely referred to as research chemicals, incense, herbs, or party powders.

As a consulting psychiatrist and in my role as co-attending on our Medical-Psychiatry Unit, I see patients every day who are delirious and we often suspect intoxication states as a cause for delirium. Unfortunately, most urine drug screen assays won’t identify bath salts and we only find out later that they caused or contributed to the delirium. They’re part of the new wave of substances of abuse which also include synthetic cannabinoids.

The new drugs get a lot of attention, and deservedly so. But in my experience physicians on the front lines are still struggling to keep up with the abuse of prescription drugs that have been around for many years. They include opioid pain killers and benzodiazepines, such as Diazepam (Valium). A combination of alcohol and Valium is what killed the popular artist Thomas Kinkade, Autopsy: Thomas Kinkade died from overdose of alcohol, valium | And a grand jury investigation in Suffolk County about the prescription painkiller epidemic seems to squarely put the responsibility for it on physicians and pharmacists, New York grand jury targets painkiller abuse epidemic |

In my opinion, blaming physicians and pharmacists is probably going to turn out to be short-sighted. Not infrequently I see the aftermath of overuse and frank abuse of prescription drugs and the context in which they arise are not always clearly explainable in good guys versus bad guys terms. This is probably a both/and problem with many pieces to the puzzle including bad apple physicians, patients who lie to doctors in order to obtain prescription drugs with abuse potential, a society which tolerates intoxicants sold legally, and a demand for mind-altering substances for which our brains have been tooled by evolution to accommodate dopamine secretion as part of the intrinsic reward system that contributes to the survival of our species.
Update: An article in GQ raises doubts about whether anyone can truly rule out bath salts; doubts have been raised since the story first broke, Bath Salt Drugs and the Zombie Face Eater: Big Issues: GQ

1. Winder, G. S., N. Stern, et al. “Are “Bath Salts” the next generation of stimulant abuse?” Journal of Substance Abuse Treatment(0).

“Bath salts” are stimulants with high abuse potential that are known to contain agents such as 3,4-methylenedioxypyrovalerone and 4-methylmethcathinone (mephedrone). They are marketed locally and through online retailers as legitimate products in order to evade legal control and facilitate widespread distribution. They have been present in Europe since 2007 but are now becoming a burgeoning presence in American hospitals. Though preliminary efforts are underway in the United States to restrict their usage and distribution, there remains a general unawareness on the part of physicians regarding the drugs’ physiological effects. While they mimic the effects of other known stimulants, they are not detected on standard urine screens. We present a clinical case that illustrates a typical pattern of usage along with a description of their basic chemistry, appearance, methods of delivery, withdrawal and intoxication characteristics, treatment recommendations, and areas for further research.