We Still Have a Chance to Stop Kratom Prohibition – And the DEA Actually Wants to Hear Your Thoughts
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Study indicates high rate of ‘intentional’ drug-related deaths among nurses
Posted on November 21, 2016 by Pharmaciststeve
Study indicates high rate of ‘intentional’ drug-related deaths among nurses
More nurses die from deliberate drug overdose than any other health care professionals, according to a landmark new study.
Researchers from the Department of Forensic Medicine at Monash University examined more than 400 drug-related deaths of Australian healthcare workers between 2003 and 2013.
It included medical practitioners, paramedics, nurses, dentists, psychologists, pharmacists and vets.
Lead author Jennifer Pilgrim found the highest number of deaths was among nurses — 62 per cent of the deaths — followed by medical practitioners, at 18 per cent.
Most of the nurses were women, and the doctors male.
“Drug-caused deaths among healthcare professionals in Australia commonly involve females in their mid-40s, with a diagnosis of mental illness, personal and professional stress and the intent to self-harm,” the study found.
Intentional self-harm was the main cause of death, and mental illness was common, with depression diagnosed in almost half of those who died.
But taking into account the number of people employed in different parts of the health sector, veterinarians were most at risk of a fatal overdose.
“Most of these vets involved intentional self-harm where they took an overdose of barbiturates,” she said.
“Until this study, we didn’t know if drug-related overdoses were a problem in Australia.
“Professional and personal stresses were also very common, along with financial problems, relationship problems and workplace stress.”
Drugs obtained illegally through workplace
On average, 37 health care workers died each year from drug overdoses.
Most of the drugs were obtained illegally through the workplace by theft or self prescription.
Dr Pilgrim said the findings raised real concerns about whether enough is being done to monitor health workers for mental health problems and drug use.
“Many healthcare professionals treat themselves or don’t seek treatment at all,” she said.
“It highlights the need for better detection of these problems to provide them with the support they need.”
She said, alarmingly, almost all the healthcare professionals were still licensed to practice at the time of their deaths, despite probable work place impairment.
“How are these potentially preventable deaths not considered workplace incidents?” she asked.
Better oversight needed to prevent more deaths
Researchers say the findings suggest a need to “consider improving the detection and management of drug-addicted and impaired healthcare providers” in Australia to prevent future deaths.
Dr Pilgrim said though overall numbers were small, there was a high death rate among anaesthetists.
“Most of these involved taking the drugs they used for work,” she said.
International research shows many healthcare professionals were afraid to speak up about mental health and substance abuse issues for fear of stigma and losing their jobs.
Healthcare workers face additional risk factors such as stress, long working hours, self-medicating and ready access to controlled drugs.
Listen to the story on The Health Report on ABC RN at 5:30pm today, and 5:30am on Tuesday. Or anytime online at www.abc.net.au/radionational/healthreport.
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Amazing how they “PLAY WITH NUMBERS” to make their point
Posted on November 20, 2016 by Pharmaciststeve
New course on addiction
http://thetimes-tribune.com/opinion/new-course-on-addiction-1.2120057
While it is TRUE that abt 78 people die every day from a DRUG OVERDOSE… only abt 50% are from opiates.. they never filter out the drugs that the other 50% die from … 50% – 100% when you are trying to make a point… is that just splitting hairs ?
Then there is the definition of “illegal drugs”… if you don’t have a legal prescription for a prescription opiate… it is an ILLEGAL DRUG… and the term “misuse prescription drugs” is defined anyone taking any prescription medication that they don’t have a legal prescription for it… even if it is a SINGLE DOSE.
Please note that it is overlooked how many people die from the use/abuse of the drug ALCOHOL.. .that would be abt 85,000 or 232/day… put don’t look for any bureaucrat to mention that THREE TIMES the people die from ALCOHOL than any number of ways they can come up with the use/abuse of all medications.
Also note that there is no mention of the DRUG NICOTINE and the 440,000 that die every year from its use/abuse… or 1200/day…
And this DOCTOR doesn’t go near the number of 200,000+… (abt 600/day) that is the number of people that die from medical errors from DOCTORS – like him – and other healthcare professionals.
2000 people dying daily… but .. we must focus on the estimated 40 that die from opiate overdoses… which we don’t know how many were unintentional/accidental OD’s and suicides.. because our system doesn’t bother to segregate those stats… would just muddy the waters about the real number of opiate deaths.
By the Editorial Board / Published: November 20, 2016
A new report by surgeon general Dr. Vivek Murthy calls for a major cultural shift in the way Americans view drug and alcohol addiction. The report, “Facing Addiction in America,” details the toll addiction takes on the nation and explains how brain science offers hope for recovery. (Associated Press File)
With the nation in the grip of an unprecedented opioid addiction epidemic, U.S. Surgeon General Dr. Vivek Murthy has issued a valuable new report that should serve as a guide to a national recovery effort.
“Facing Addiction in America” grimly details the toll but points to a sound strategy to fight it.
According to the report, 78 Americans die every day due to an opioid overdose and 20 million people use illegal drugs or misuse prescription drugs. And more than 66 million Americans admit binge drinking in a given month.
The report estimated the annual economic cost of addiction at $249 billion for alcohol and $193 billion for drugs.
Dr. Murthy emphasized that research has proved addiction to be a disease. “Addiction to alcohol or drugs is a chronic but treatable brain disease that requires medical intervention, not moral judgment,” the report declares.
He applauded an ongoing shift in that direction of an array of public policies that emphasize public health rather than law enforcement.
And Dr. Murthy offered hope, noting advances in brain science and related fields that could result in effective treatments.
The report should prompt Congress to maintain access to treatment under the Affordable Care Act. Without it, the epidemic is certain to escalate.
And lawmakers should increase funding for addiction research through the National Institutes of Health because Dr. Murthy’s report demonstrates that medicine-based treatments are far more effective than counseling alone.
The epidemic is so vast that it must be fought at every level of society and government. Dr. Murthy’s report is a timely, valuable guide.
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Rep Chuck Isenhart (D) – CANCER is just a “regular ailment” no need for opiates to treat pain
Posted on November 19, 2016 by Pharmaciststeve
Lawmakers seeking change to help stop pain killer abuse in Iowa
DUBUQUE, Iowa (KCRG TV-9) — A group of Iowa lawmakers say something needs to change to stop the heroin epidemic in Iowa. They say change might need to start with better regulation of prescription pain killers.
On Wednesday, Senator Rob Hogg from Cedar Rapids and Representative Chuck Isenhart from Dubuque hosted a pain killer abuse forum.
2016 has been a deadly year for heroin overdoses in Dubuque. So far this year, rescue crews have saved 26 people who were over-dosing on heroin. Another 9 people died after they overdosed on the drug.
Law-makers say heroin addiction often starts when people abuse prescription pain killers. The Centers for Disease Control and Prevention say people who get addicted to prescription pain killers are 40 times more likely to become addicted to heroin.
The law-makers organized Wednesday’s forum to gather input from doctors, law-enforcement and substance abuse counselors. They say they want to evaluate the amount of pain medication that doctors prescribe in Iowa.
While overall heroin use has increased, experts at Wednesday’s meeting say the number of heroin overdose deaths has dropped slightly this year. They say that could be a result of recent change in Iowa law.
In April, Governor Branstad signed a bill into law that makes it legal for first-responders and family members of addicts to have and administer Narcan. The drug can prevent overdoses from becoming fatal.
Now law-makers say they’re working to gather information on what law could change to better regulate prescription pain killers.
“We’ve become dependent really on using strong pain killers for treatment of regular aliments, such as cancer and inadvertently many people have become addicted to those pain killers,” said Isenhart.
Experts say one thing that does seem to be working well are the state’s prescription drug take back events. Those events allow people to drop off old prescription medicine to law enforcement officers.
In the past 6 years, the state has collected 39 tons of left over prescription drugs through those events.
In Dubuque, people can drop off those medications any time at Hartig Drug on University Avenue and at the Dubuque County Sheriff’s Office.
UPDATE 11/19/2016 from bureaucrat
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Side Effects: Drug companies’ influence felt in Washington
Posted on November 19, 2016 by Pharmaciststeve
Side Effects: Drug companies’ influence felt in Washington
TAMPA – Why can’t someone do something about skyrocketing prescription drug prices?
That is the question we’ve been asking all week – and trying to get you answers.
As 10Investigates found, a major part of the problem is political. The pharmaceutical industry spends a lot of money trying to make sure lawmakers are on their side.
Each year, patients consume millions of prescription drugs to stay healthy or simply stay alive. And the rising prices are taking a serious toll on America.
62-year-old Janet Snyder is a transplant patient and she says of the price increase, “It kills us, it literally kills us.”
The dramatic cost increase in the drugs Snyder needs every day forced her and her husband to alter their retirement dreams. She blames the drug manufacturers and Congress.
“It’s really hard to have faith in Washington when you think that drug companies have them in their back pocket,” Snyder says.
And Snyder isn’t exaggerating about the influence that pharmaceutical industry has on Washington. In addition to turning out millions of pills each year, Big Pharma turns out millions of dollars to support the campaigns of elected officials who, they hope, will pass legislation to help the industry maximize profits.
“(It’s) the most political powerful lobby in Washington,” U.S. Rep. Kathy Castor (D-Fla.) of Tampa tells us. “Pharmaceutical corporations have maximized their profits at the expense of the American taxpayers.”
Castor is talking about the $26 million the pharmaceutical industry spends on campaign contributions to members of Congress and $186 million a year on lobbyists. Castor received less than $4,000 of contribution money from the industry.
We asked Castor if she has felt pressure from the industry and she told us, “Yes. They want to operate like it is the wild west.”
Castor says part of the problem is the 2003 bill Congress passed prohibiting Medicare from negotiating drug prices with pharmaceutical companies.
Senator Marco Rubio, who was just reelected, says of the prohibition on Medicare negotiating prices, “That is something that needs to be reexamined, but there is conflicting evidence that it would lead to lower prices or not.”
Rubio, who received $221,000 in campaign contributions from the pharmaceutical industry, says Medicare isn’t the answer. He says the issue is the Federal Drug Administration needs to approve drugs quicker, leading to more competition and lower prices.
We asked Rubio how much he is influenced by the contributions from the industry, which put him in the top 10 in the Senate and he said. ”None, because people buy into my agenda. I don’t buy into theirs.”
In terms of Medicare and drug prices, Rubio also points to a 2007 letter from the Congressional Budget Office claiming that negotiating with the drug companies would not necessarily lower prices.
Rubio contends you have to look at it from the drug companies’ point of view.
“You need to have companies invest in risk money in order to innovate those new medicines, and they expect to make their money back with a profit. These are profit-making ventures.”
However, Castor, who is aware drug companies have to make a profit, has introduced legislation she says will prohibit excessive profits.
She said, “To negotiate fair prices as they do in the (Veterans Administration), that would save taxpayers billions of dollars.
Still, many patients feel like Janet Snyder does – the problem is compounded by the mixture of politics and money.
Snyder says, “I feel like the way things go in Congress and the Senate, it’s controlled by who’s giving them the most money.”
The top three local House members in terms of political contributions are Patrick Murphy, who was just defeated in his Senate bid, Palm Harbor’s Gus Bilirakis, who said was too busy running for reelection to do an interview, and Sarasota’s Vern Buchanan.
Florida’s other Senator, Bill Nelson, was on the low end of contributions receiving $10,000 from pharmaceutical operatives.
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What Impact Do Medication Errors Have On Nursing Home Residents?
Posted on November 19, 2016 by Pharmaciststeve
What Impact Do Medication Errors Have On Nursing Home Residents?
http://www.ladailypost.com/content/what-impact-do-medication-errors-have-nursing-home-residents
The last 5-6 yrs of my career was spent working as a temp in the two largest nursing home pharmacies in the country. From what I saw from my vantage point was that there was a lot of meds that were just not given to the pt. I can’t count the times that I would get a call about needing a medication sent out STAT… and when I looked at the pt’s records… the pt got a 14 days supply 3-4 weeks ago… or longer… Depending on the medication… I would often refuse to send it out STAT/special delivery.. it can go on out on the next run.. since most facilities got TWO DELIVERIES EVERY DAY. I did not have access to the MAR’s (Medication Administration Record) forms, but obviously the staff member passing out the medications… just marked that it was given…even if there was no medication available to be given and never followed up to see that it was reordered. Reordering medications in a nursing home setting is simply pealing off part of the label and sticking it to a reorder sheet and faxing in the sheet when done giving out the medications to pts. In all too many nursing homes, the staff was too forgetful or too lazy to perform this simple task.
A new analysis points to surprisingly low rates of serious impacts from medication errors affecting nursing home residents, despite the fact that these errors remain fairly common.
The investigators noted that it’s unclear whether medication errors resulting in serious outcomes are truly infrequent or are under-reported due to the difficulty in ascertaining them. The findings are published in the Journal of the American Geriatrics Society.
Medication errors can cause considerable harm, and older adults in nursing homes may be especially vulnerable. To assess the prevalence of medication errors leading to hospitalizations and deaths in nursing home residents, and to determine the factors associated with these errors, Joseph Ibrahim, MBBS, FRACP, PhD, an academic physician in geriatric medicine at Monash University in Australia, and his colleagues conducted a literature search of relevant studies published between 2000 and 2015.
After identifying 11 studies, the researchers examined three types of medication errors: all medication errors, transfer-related medication errors, and potentially inappropriate medications.
Medication errors were common, involving 16 percent to 27 percent of residents in studies examining all types of medication errors. Transfer-related medication errors occurred in 13 percent to 31 percent of residents, while 75 percent of residents were prescribed at least one potentially inappropriate medication.
The team found that serious impacts of medication errors were surprisingly low, however, and they were reported in only zero to one percent of medication errors, with death being a rare event.
“This is an important step to addressing the global issue for improving the quality and safety of medications for older people,” Prof. Ibrahim said. “Nursing homes should review their systems of care from prescribing to administration. Good practice requires using a team-based approach involving the resident, care and nursing staff, pharmacists, and medical practitioners.”
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DEA can’t even notice “drug dealers” on their own PAYROLL ?
Posted on November 19, 2016 by Pharmaciststeve
Father-son informants trafficked drugs while on US payroll
NEW YORK (AP) — Informants with dirty pasts are a fixture at drug trials, but even by those standards, the father-son team that played a central role in the cocaine trafficking prosecution of the nephews of Venezuela’s first lady stands out.
Over several years, the U.S. government and other law enforcement agencies paid about $1 million to Jose Santos-Pena, 55, and hundreds of thousands of dollars more to his son, Jose Santos-Hernandez, 34, for information about drug dealers.
The pair traveled to multiple countries, including some where Drug Enforcement Administration agents aren’t welcome, to make secret recordings of people believed to be involved in drug trafficking. That included Venezuela, where Santos-Pena recorded two nephews of Cilia Flores, the wife of Venezuelan President Nicolas Maduro, handling a block of cocaine.
Then, in April, prosecutors learned that while working for the DEA, Santos-Pena and Santos-Hernandez were also hard at work smuggling drugs themselves.
In late summer, just as the case against Flores’ nephews was getting ready to go to trial in New York, Santos-Pena and Santos-Hernandez pleaded guilty to trafficking charges, admitting dealing drugs for at least four years, including while they were building the Venezuelan case last fall under the direction of the DEA.
Prosecutors went ahead anyway with their case against Venezuelans Francisco Flores, 31, and his cousin, Efrain Campo, 30, who were accused of conspiring to ship over 1,700 pounds of cocaine into the U.S. They were arrested in Haiti last year and flown to the U.S. for trial.
The government, though, did not know that more surprises lay ahead for its star witness, Santos-Pena. His son did not testify at the trial.
At a court hearing in September, Santos-Pena confessed to prosecutors during a lunch break that he had used a prostitute twice during a trip in Caracas, Venezuela, last year. He had also allowed his son’s friend to sit in on some of the DEA-orchestrated meetings with their Venezuelan targets. And he admitted that he’d been using cocaine regularly while working for the DEA.
And as the trial against Campo and Flores neared its conclusion this month, defense attorney Randall Jackson revealed that he had jailhouse tapes that proved Santos-Pena continued to communicate about drug deals in recent weeks.
After the tapes were played for jurors, a prosecutor notified Santos-Pena that his continued lies, including that he had not communicated with his son while in prison, meant the government was ripping up a cooperation agreement that he was counting on to win leniency. Without it, he faces a minimum of 10 years in prison and a maximum of life. Santos-Pena seemed surprised.
Prosecutors overcame the humiliation of their star witness when the jury returned a guilty verdict Friday against the nephews.
“He was slime,” juror Robert Lewis, a 69-year-old architect, said of Santos-Pena. He said other evidence, including transcripts of conversations involving the nephews and text messages, were enough to prove guilt.
“We had to rely on those things,” Lewis said.
“It’s the nature of the business to have cooperators with really unseemly pasts,” said Daniel C. Richman, a law professor at Columbia Law School. “Making deals with bad guys are par for the course in a whole range of cases. I don’t think it’s the nature of the business to have the cooperators breaking the law while purporting to have agreements with the government.”
Prosecutors knew going in that Santos-Pena had a shady past. Before he began cooperating with U.S. authorities in 2007, he testified that he had been a member of the Mexico-based Sinaloa drug trafficking cartel for a decade. He moved to the U.S. in 2003. He said he was involved in deals this year in Los Angeles and Pomona, California, involving about 7 kilograms of cocaine.
In court papers praising the two informants earlier this year, federal prosecutors wrote that Santos-Pena and Santos-Hernandez had “participated in multiple significant international drug trafficking investigations, including cases focusing on some of the most violent places in the world targeting extremely violent criminals.”
Lawyers for Campo and Flores said in their closing statements to jurors Thursday that the informants are simply liars who shouldn’t be believed.
“You saw a rare thing, a government cooperator get ripped up in court,” attorney David Rody said.
For all the dirt revealed about the informants in the Venezuelan case, they will never rival the notorious history of Salvatore “Sammy the Bull” Gravano, who admitted his role in 19 murders in a sweetheart deal that resulted in a five-year prison sentence in exchange for his testimony against the late Gambino boss John Gotti.
Still, Richman noted, the issue for jurors is the credibility of the witness.
As for Gravano, Richman said: “He was just a murderer, not a liar.”
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Your opportunity to be heard in the next battle in the war on drugs ?
Posted on November 18, 2016 by Pharmaciststeve
President elect Trump has chosen potentially the next Attorney General
Senator JEFF SESSIONS https://en.wikipedia.org/wiki/Jeff_Sessions
Of course, all of Trump’s choices for various position will have to be approved by a majority of the 100 Senators…
The current Surgeon General Vivek Murthy announced last week that:
Surgeon General: Addiction Is A Chronic Brain Disease, Not A Moral Failing
So has the Surgeon General claimed that the 1917 court ruling that opiate addiction is a crime and not a disease has started the process that … that ruling should be overturned ?
Since about 98% of the incumbents running for reelection in the House and Senate got reelected… the chronic pain community apparently voted their political beliefs rather than making a political statement of wanting a change. So now we MAY have an additional opportunity to cause change. Apparently it takes a SUPER MAJORITY of the Senate – 60 votes – for any nominee to get approved. Communicating with your Senator about your approval or objection for a particular nominee is the only way to make a impact on the new administration over the next FOUR to EIGHT YEARS.
IF DAMN FEW chronic pain pts contact their Senators… NO ONE is going to believe that there are some 100 + million chronic pain pts….and/or those in the chronic pain community are not having any problems and/or most/all are ADDICTS and don’t want to SPEAK UP.
We are seeing a dramatic increase in SUICIDES… we don’t know how many suicides that we don’t hear about and/or they are being classified as “opiate related death”. It would appear that even when a death is – without a doubt – a suicide.. at best it might get local media coverage. It would seem that the national/local media doesn’t want to address the epidemic of suicides and denial of adequate therapy for all those pts suffering from various subjective diseases ( pain, anxiety, depression, ADD/ADHD, mental health).
IMO… the chronic pain community has come to a CROSS ROAD… it is well documented what has happened to those in the chronic pain community over the last 8+ yrs… Remaining silent, whining, bitching and moaning to each other on closed Face Book pages… will not cause any positive changes.
A fair number of my readers send me links to various new articles about things happening to/with the chronic pain community… and I reposts them… but.. how many of my readers take those articles demonstrating how badly those in the chronic pain community is being treated and/or abused … and share it with the Facebook page of their local TV station, newspaper, Twitter feeds for reporters of local TV and newspaper… and send them to your state and Federal Representatives and Senators… ?
Politicians/bureaucrats/legislators work with NUMBERS… if they are contacted by few constituents… they will presume that there is NO ISSUES…
Feel free to use my blog as a “clearing house” … I never use a chronic painer’s name when they send me stuff that I re-post…use it as a start for a daisy chain to “spread the word” thru other channels…
Continue to whine … bitch… moan… to each other … and do nothing… and the last EIGHT YEARS will just be a PRELUDE to what is going to be coming your way over the next FOUR to EIGHT YEARS.
I am just an OBSERVER…. a MESSENGER….
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The fuzzy line between medication use and abuse
Posted on November 17, 2016 by Pharmaciststeve
The fuzzy line between medication use and abuse
www.kevinmd.com/blog/2016/11/fuzzy-line-medication-use-abuse.html
Opioid painkillers, such as Vicodin (hydrocodone) and OxyContin (oxycodone), are crucial medical tools that are addictive and widely abused. Tranquilizers and sleeping pills of the benzodiazepine class, like Xanax (alprazolam), Ativan (lorazepam) and Klonopin (clonazepam), are safe and effective in limited, short-term use, but are often taken too freely, leading to drug tolerance and withdrawal risks. Stimulants such as Ritalin (methylphenidate) and Adderall (amphetamine) ease the burden of ADHD but are also widely used as college study aids as well as recreationally. All of these medications are available only by prescription. This means prescribers serve as
gatekeepers, permitting access for medical needs and denying it otherwise.
This gatekeeping can be difficult. Doctors are imperfect lie detectors and can be fooled with a plausible story. Pain, anxiety, insomnia and inattention are mostly invisible. The internet offers quick lessons in how to fake a medical history. Beyond the initial assessment, every physician has patients who repeatedly “lose” bottles of painkillers or tranquilizers and request more. Secretly seeing multiple doctors to obtain the same drug remains fairly easy. While a few doctors run illegal “pill mills” and flout the gatekeeper role, many more are simply too overworked to be vigilant with every patient.
None of us became physicians to fight the war on drugs. On the contrary, most of us are uncomfortable doubting our patients’ honesty. It’s stressful to worry about being too suspicious or too gullible, and it’s a waste of valuable time.
The possibility of tranquilizer abuse arose with a new patient of mine recently. My concern led to multiple phone calls to pharmacies and to consulting California’s CURES database online. I was convinced enough that something was amiss that I confronted my patient, who responded by calling me names, making vague threats and leaving in a huff without paying for the appointment (and, of course, never coming back). Although the reaction seemed confirmatory, in truth I’m still not certain my suspicions were correct. Why did I put my patient and myself through such grief? Because I wanted to “do no harm.” Accepting the gatekeeper role requires scrutinizing and sometimes confronting the patient at the gate.
Let’s consider other drugs that are used both medically and recreationally — but unlike those mentioned above, do not involve a physician gatekeeper.
The best candidate may be cannabis. Currently legal in 25 states, medical marijuana requires a doctor’s authorization but not a prescription that specifies dosage, frequency and duration of treatment or route of administration. By definition, a Schedule 1 drug, like marijuana, is not “FDA approved” for any medical use. Yet cannabis is very much like the Schedule 2 drug Adderall: it has a few solid medical uses, a much larger set of dubious or controversial ones and a sea of mostly illegal recreational use. A lot of medical marijuana is used for relaxation or sleep, blurring the medical-recreational distinction in much the way Adderall does when used for studying. Purely recreational use is legal in four states as of this writing. Legalization is on the ballot this November in five additional states, including California where I practice.
I have never authorized medical marijuana, although several of my patients were approved by other physicians and use it regularly. Once a patient tells me he or she uses marijuana, whether doctor-approved or (for now) illegally, I can act in my preferred role as advisor. We can discuss risks and benefits, sativa vs indica, THC and CBD, all without me having to second-guess my patient’s story, make a paternalistic decision about whether to authorize access or even cast judgment on the decision to use it.
In states where recreational cannabis is newly legal, it joins the three drugs already native to our cultural landscape. Adults consume alcohol, caffeine and nicotine with nary a prescription, gatekeeper or hoop to jump through. And although we rarely think about it, all three have medicinal effects. Alcohol can reduce stress, aid sleep and may promote health in a number of other ways. Caffeine treats fatigue, migraine headaches and possibly obesity. Nicotine eases Parkinson’s disease and perhaps schizophrenia and helps with weight loss. While smoking rates are declining in the U.S., most Americans continue to use alcohol and caffeine often for a complex mixture of reasons: taste, psychoactive effects, social custom and sometimes for plainly medicinal purposes. Widespread use also leads to addiction in a significant subset of the population: caffeine becomes necessary and not just optional, and we go to extraordinary efforts to manage alcoholism. As tragic as this is, nearly everyone agrees that Prohibition was the greater evil.
I like that I’m an advisor, not a gatekeeper, for marijuana and the (other) legal vices. I also reject the gatekeeper role for stimulants by telling callers I don’t treat ADHD. This is trickier, my refusal to treat a legitimate psychiatric disorder is arguably too finicky. It can be hard for an earnest sufferer to obtain a thorough evaluation and treatment, even if, paradoxically, it is all too easy for a drug abuser to tell a sob story and score a prescription. Nonetheless, with stimulants, as with medical marijuana, I’m uncomfortable making Solomonic distinctions where medical and non-medical uses lie so closely on a continuum.
In any event, I draw the line there. I continue to prescribe tranquilizers and sleeping pills for my patients who seem to need them. I may unwittingly abet substance abuse in some cases, but the alternative is to not prescribe any abusable medication, a stance that feels far too finicky. After all, medication gatekeeping is the norm for many physicians. Oncologists, surgeons and ER doctors can’t tell patients they don’t treat pain. Surgeon General Vivek Murthy sent a letter to every U.S. physician in August urging us to help fight the “opioid epidemic” by limiting dosages and durations of opioid prescriptions and by substituting non-narcotic alternatives — in essence, by being better gatekeepers.
The only way to avoid doctor-as-gatekeeper entirely is to make all drugs available without a prescription. The prospect of narcotics and amphetamines on the open market strikes most of us as extremely foolish, even though Prohibition and the failed war on drugs should give us pause. Another strategy is to embrace gatekeeping even more seriously, as Dr. Murthy advises. Careful comprehensive evaluation, “start low and go slow” prescribing, close monitoring using a system like CURES and strictly limiting refills should drive down prescription drug abuse. Unfortunately, this takes more clinical time, one thing most physicians can’t spare, and trades away doctor-patient collaboration for something more wary and legalistic. As usual, physicians are asked to erode the traditional doctor-patient relationship and do more work to keep the system afloat. Meanwhile, patients suffer further small indignities and colder encounters.
Alternatively, we could wait it out. The line between medical treatment and personal enhancement or optimization gets fuzzier all the time. Society may soon fail to distinguish treating an anxiety disorder and taking something to relax in the evening or treating ADHD and simply maximizing one’s mental sharpness. The medical-recreational divide already looks more like a continuum for marijuana and stimulants, and it is essentially gone with respect to alcohol, caffeine, and nicotine. If this trend continues, physicians may no longer be called upon to distinguish legitimate from illegitimate drug use. Our focus as medication gatekeepers may shift from the purpose of the prescription to its safety, making us more like pharmacists than judges.
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