Opiates have been a part of the medical and social landscape for thousands of years. Their significance, even in ancient times, is indicated by the fact that there were records of their use by the Sumerians in 3400 BC, who used opium for its euphoric effects; by Hippocrates, who used it around 400 BC for diseases of women, internal diseases, and for epidemics; by Alexander the Great, who used opium to treat his troops’ pain; and by the Chinese, who used it as a pre-operative treatment for major surgery.
In some ways, the story of opium and its derivatives is the story of medicine, at least up until the discovery of antibiotics and other disease-specific treatments. For example, the use of morphine in the United States in the 1800s played a large role in the separation and development of allopathic medicine as the predominant healthcare model in modern times.
Many of us remember being taught that addiction due to narcotics prescribed for legitimate pain was rare, and that it was essentially unethical to withhold narcotics from patients who complained of pain. Despite the benefits narcotics have conferred upon mankind, however, there are parallel stories of suffering and death due to their unique side effects and profligate use. Take, for instance, the situation in 1898 when Bayer offered heroin as a “non-addictive” substitute for morphine, and community groups followed suit by providing free heroin to morphine addicts who were trying to overcome their narcotic addiction. More recently, medical narcotic use soared in the early 2000s when The Joint Commission rolled out its Pain Management Standards, growing the idea of pain as the 5th vital sign. This was accompanied by a similar increase in illicit narcotic use.
In response to the increased and widespread use and abuse of narcotics with associated complications, various government agencies have promulgated laws and regulations attempting to bring a balance to the seeming chaos, from the anti-opium laws in the 1870s, to the “War on Drugs” that Nixon began in 1971, to today’s thousands of federal, state, and local laws and regulations attempting to stem the tide of illicit drug abuse.
All of which brings us to now.
We are once again experiencing an epidemic of drug-induced death and injury in our communities. Deaths from opioid overdoses have nearly doubled in just the past few years, as have the number of people addicted to various forms of narcotics, all of which has strained the limited resources available to prevent this scourge beyond the breaking point. Lawmakers have responded by creating new regulations aimed directly at doctors, pharmacies and hospitals in an attempt to address the epidemic. As a result of both governmental intervention, and the effects of recent hurricanes on production facilities, we are also facing a severe and potentially long-term shortage of many forms of narcotics.
Which brings us to the point of this article: You can make a difference!
Please help us help you and your patients deal with these shortages, regulations, and the epidemic of drug abuse. Following are a few suggestions:
- Rethink your use of narcotics. Narcotics impair recovery from surgery. They expose patients to risks of long-term dependence. They disrupt patients’ normal physiology. Please use parenteral narcotics only when absolutely necessary, and even then use as little as possible. Use oral narcotics for as short a time as possible, or not at all. Switch patients as quickly as possible to non-narcotic alternatives – NSAIDs, aspirin, Tylenol, and long-acting nerve blocks like Marcain. Best of all, consider non-medicinal forms of pain control like heat, ice, pressure, music, and old-fashioned encouragement.
- Please be aware of and comply with the requirements of HB21. Go to the FMA website (flmedical.inreachce.com) and take the two-hour required CME ($75 for non-members). Register with E-FORCSE (florida.pmpaware.net) so that you can check the database for any patient for whom you prescribe narcotics. Learn the requirements for verbiage on narcotic prescriptions, such as “Acute Pain Exception” for prescriptions exceeding the three-day limit, and exceptions to the acute pain requirements (pain due to cancer, terminal conditions, palliative care, and a trauma with an “Injury Severity Score” of nine or greater).
- Educate your patients regarding pain, non-narcotic treatments, expectations regarding pain control (i.e., that complete pain control is not necessarily the goal), how to avoid the risks of ongoing dependence, and what resources are available should they become dependent on narcotics.
- Work with your legislators to help create legislation that better fits the needs of our patients and our physician colleagues to deal with pain.
Ultimately, our patients are depending on us to do what we’ve always done – treat them using the best science possible, and advocate for them and their families in the process.