A new lawsuit against the New England Compounding Center, brought on by their patients who were injured by tainted steroid injections, has introduced an important conversation in the pain management community. The meningitis-infected shots have tragically taken 32 lives and sickened over 400 more. Paralysis and hospitalizing headaches are some of the symptoms these patients have suffered. Many are wondering if this incident could have been prevented.
Many of the patients who received these steroid injections did not have the conditions that the treatment was purported to address. Steroid injections are greatly overused. This invasive back-pain therapy has not proven useful to many of the patients who receive it due to misuse. Since back pain is debilitating for most patients, many doctors address the ailment with a quick-fix shot. Unfortunately, shortcutting the body’s healing process is almost always not healthy, more costly, and sometimes dangerous. The New York Times accurately states that the shots should not be used until other treatments have been tried:
Though doctors are still arguing, most academic researchers say there is no evidence that steroid injections are useful in easing straightforward chronic low back pain. Professional guidelines say such shots should generally not be used for back pain that is less than four to six weeks old, which studies show almost always gets better with noninvasive treatments. Although many Medicare patients get spinal injections to treat a condition called spinal stenosis, a narrowing of spaces between bones of the spine, Dr. Friedly said, shots are not used for that condition in many European countries.
Shockingly, the amount of spine injections given are more correlated with the number of specialists in the area than the incidence of back pain in an area.
The shots — which may include a steroid and an anesthetic — are often dispensed at for-profit pain clinics owned by the physicians holding the needle. “There’s a lot of concern about perverse financial incentive,” Dr. Friedly added. Mr. Kinnard’s clients got their injections at the St. Thomas Outpatient Neurosurgery Clinic, a limited-liability corporation half owned by doctors, which occupied a floor of one of Nashville’s major hospitals. It gave 5,000 injections a year, or about 20 each business day, and epidural steroid injections are listed on its web site as its “top procedure.”
It’s always important to read procedures and medical specialists before visiting them. Due to their prevalent use, I recommend anyone experiencing back pain to read How Back Pain Turned Deadly on NYTimes.com.
Read the Label: Medication Mistakes Could Cause Harm
Last week, we discussed how medication mistakes can be made by anyone—but also how they can be prevented by anyone. This week we’re back with more tips:
Many people think that more is better – if one dose of pain relieving medication doesn’t help enough, two will do the trick. This can result in an overdose of medicine.
How to prevent: “Medication should be taken in accordance with the instructions the physician intended,” warns Dr. Lewis. “Doubling medication or taking medications in excess can lead to serious consequences. Don’t assume that because you don’t feel an expected physical feeling from a medication that the medication is not working. Ask your doctor if you have any questions about the proper dosing of your medication.”
We’ve all seen the ad: A severely allergic (depressed, asthmatic, constipated) person, previously rendered housebound (immobile, in pain) due to symptoms, now leaping through a field of flowers (cavorting on the beach) – freed by a certain prescription medication. Typically, the side effects of the medication are minimized by being read or flashed on the screen very rapidly. Such direct-to-consumer (DTC) advertising of prescription drugs, legal only in the United States and New Zealand, has been controversial, to say the least. Pharmaceutical companies contend that the ads, broadcast on TV and radio, seen in magazines and newspapers, the Internet and on billboards – educate consumers and encourage them to see their doctor for diagnosis and treatment. Congressional leaders, worried about increased health care costs, would like to regulate these ads and impose laws to stop them because they think that it’s too much information for consumers and too much pressure on doctors to prescribe the meds being advertised. And some doctors say that DTC advertising is dangerous, because it involves only the newest medications, sometimes found to have serious safety concerns only after consumers have knowledge of – and ask for – the medication.
Opinions aside, there’s no doubt that most people are woefully illiterate when it comes to medications. And it doesn’t hurt to learn more about them, says Thomas Giannulli, MS, MD, chief medical information officer at Epocrates, a drug reference application used by many physicians. “The more informed, the better,” says Dr. Giannulli. “I think it’s okay that people come in to the doctor with an idea of what they want. If you’re more informed, you feel free to have a conversation with your doctor, and you’ll have a better outcome. It’s a win-win situation.”
There are many consumer-oriented drug reference guides in print or online. One good choice is Medline Plus, a service of the U.S. National Library of Medicine and the National Institutes of Health, accessed at nlm.nih.gov/medlineplus/druginformation.html.
And Epocrates is an application that can be downloaded to your phone for free, says Dr. Giannulli. “It’s intended for medical professionals, but it’s a useful tool for looking up medications and learning more,” he adds.
Medications are removed from your body by your liver and your kidneys, which is the reason you should be aware of how well these organs are working, says Robert Gold, PhD, MBA, hospital pharmacist and instructor of clinical pharmacy at Purdue University, who wrote consumer health book, Are Your Meds Making You Sick?, out of concern for consumer safety (the book is available at Amazon.com). “When these filtration systems do not work as they should, drugs remain in the body for a longer period of time, which then increases the likelihood of problematic reactions,” says Dr. Gold.
Simple lab tests can determine whether your kidneys and liver are working well, he adds. Ask your doctor about this testing, especially if you have a chromic condition that may affect the function of these organs, such as diabetes, hypertension, or liver disease.
Read the Label: Medication Mistakes Could Cause Harm
Last week, we discussed how medication mistakes can be made by anyone—but also how they can be prevented by anyone. This week we’re back with more tips:
“Many pills are ingenious drug delivery systems in disguise, covered in layers of coatings to ensure that medication is released slowly and in strategic locations in your digestive tract,” says Dr. Lewis. “All of that ingenuity is completely foiled if you chew or crush the pill. Instead of sweet therapeutic relief, you’ll get an immediate and potentially fatal release of medication into the body."
How to prevent: Swallow your pills whole, unless your doctor tells you otherwise (for example, if you’re tapering down a medication and your doctor says you can break the pill for a half dosage). If you have trouble swallowing pills, ask your doctor or pharmacist if the medication comes in a liquid form.
This is a very common mistake among athletes who are being treated for an injury, says Ruth M. Parker, MD, Professor of Medicine and Pediatrics at the Emory University School of Medicine and Professor of Epidemiology in the School of Public Health. “People will see the doctor for pain and they’re often prescribed a narcotic that contains acetaminophen (a common pain reliever). Then if they still have pain after taking the narcotic, they’ll add an over-the-counter medication that contains acetaminophen, too. Taking too much acetaminophen can cause liver damage.”
A similar problem exists with non-steroidal anti-inflammatory medications, used for pain and inflammation, such as aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Midol extended relief). “Using more than one non-steroidal medication can predispose you to kidney injury,” says Dr. Parker.
How to prevent: Read the fine print on the label of any medication you buy so that you know what is in it and can avoid duplication. Also, recognize that many products, both prescription and over-the-counter, contain acetaminophen, including pain products, cold and flu medicines and certain sleep aids. You should never exceed the daily recommended maximum of acetaminophen, which is 3,000 mg. Everyone needs to know what they’re taking,” says Dr. Parker. “Then they need to do the math.”
Stay tuned for more suggestions!
Read the Label: Medication Mistakes Could Cause Harm
Sally Fraleigh, a former registered nurse living in Maple City, Michigan, prided herself on being independent. At 82, with severe diabetes, disc degeneration, and macular degeneration that caused some visual impairment, she was still able to live alone. But she was having increasing trouble seeing the small print on her insulin (injectable diabetes medication) bottles. One day, distracted by her dog’s barking, she mistakenly gave herself a large dose of her “short-acting” medication instead of the intended large dose of “long-acting” medication. Within minutes, the mix- up had plummeted her blood sugar to a seriously low level. “Fortunately, I realized my mistake right away,” says Sally. “I drank some juice with sugar and called the ambulance, and I was treated in the emergency room.” Sally is not alone in her experience. According to the Agency for Healthcare Research and Quality (AHRQ), 1.9 million people become ill or injured from medication errors (with both over-the-counter and prescription medications) each year. And this figure represents only those people who are hospitalized or who are treated in the emergency department as a result of the error. While many of these medication mistakes are made by healthcare professionals, consumers also play a part in making errors – and they can play an important role in preventing them, too. Here are some common medication mistakes and tips for how to prevent them:
There are many reasons for taking the wrong medication, from being distracted to getting up in the dark and reaching for the wrong pill bottle. Medication mix-ups can happen at the pharmacy level, too, when a pharmacist misinterprets an illegibly written doctor’s order, especially because there are many medications with names that are very similar. Also, some medication mix-ups aren’t always entirely accidental – many people share their prescribed medications with other people, which may result in an injury.
How to prevent: Prevent medication errors at the pharmacy level by questioning the pharmacist, advises Richard Kelley, MD, co-founder of Physician’s Way, a weight loss center in Austin, Texas. “Always take the time to review any medication you receive from a pharmacy with the pharmacist on duty. You may have to wait on occasion, but it is in your best interest that you or your family member receives the medication that was intended to treat the problem at hand. Ask the pharmacist if the prescription is reasonable for the medical issue being treated,” he says. When taking your pills, make sure that you read the name and the instructions before taking, even if you’ve taken them many times before. Never take your pills in the dark. And never, ever share your prescribed medications with others or take anyone else’s prescriptions! Your doctor writes a prescription with consideration for your specific health issues, not those of your friends or your spouse.
How many people, often celebrities, do you hear about in the news who have died because of mixing their prescription meds? Actor Heath Ledger’s autopsy report says that he died of acute intoxication brought on by the combined effects of several prescription medications, including oxycodone (a narcotic pain medication) and diazepam (a sedative).
How to prevent: Prevent a tragedy by asking your doctor or pharmacist whether two medications or substances can be taken together, recommends Moshe Lewis, MD, Chief of Physical Medicine at California Pacific Medical Center. “Learn about a medication’s potential interactions with alcohol, other prescription medicines and over-the-counter medicines,” he says. “You can and should ask your doctor, even if you decide to take a new non-prescription remedy. Over-the-counter medications, herbs and supplements are particularly misleading because we think of them as less harmful than their prescription counterparts. Yet every year, patients have to undergo emergency organ transplants due to haphazard combinations of seemingly harmless herbals.”
A similar problem exists with non-steroidal anti-inflammatory medications, used for pain and inflammation, such as aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve, Midol extended relief). “Using more than one non-steroidal medication can predispose you to kidney injury,” says Dr. Parker.
Stay tuned for more suggestions! This article was originally written by Linda Hepler at Max Muscle Magazine.
Learn about a medication’s potential interactions with alcohol, prescription medicines, and over-the-counter medicines. You never want to add something new to your body until you know whether its ying will knock your yang out of flow and off balance. In the second part of my two-part series on physicians, patients, and pills I cover five specific tasks patients should engage in with their doctor regarding prescription drugs. Tweet this to your friends and discuss these points with your doctor at your next visit.
You can and should ask your doctor about any new non-prescription remedy. Over-the-counter medications, herbs and supplements are particularly misleading because we think of them as less harmful than their prescription counterparts. Yet every year patients have to undergo emergency organ transplants due to haphazard combinations of seemingly harmless herbals. Only your doctor can tell you which combinations are hazardous or even lethal before it’s too late.
Tell your your doctor about any history of substance abuse. It isn’t your doctor’s job to judge you. It is your doctor’s job to make sure your medications don’t put you in danger, and your doctor can’t do that if you withhold information about your medical history. This necessarily includes your substance abuse history, past or present. If you have a history of substance abuse, you don’t need to worry that you will be left to agonize without pain medication. Telling your doctor your full and complete medical picture only lets her do her job, customizing your pain therapy to your needs.
Never, never and let me say it again… never share prescription medications. By now you know that it can pose unexpected risks. Furthermore, it’s actually illegal! And it can create legal liability if an adverse reaction happens. If you share your prescription, you expose yourself to charges of engaging in the practice of medicine without a license. If someone you care about needs a pill or a prescription, do the responsible thing for them—tell them to see their own physician, not raid your drug cabinet. Please do not pretend to be a pharmacist. You could kill someone.
Don’t doctor shop or fill prescriptions at multiple pharmacies. Doctor shopping is the practice of going to multiple doctors simultaneously to scam prescriptions. It is illegal, and prosecutors are cracking down. Filling prescriptions at multiple pharmacies is a red flag—to your physician, to state drug authorities who monitor your prescription filling actives, and to your insurance carrier. In instances when you have a legitimate need to fill medication at more than one pharmacy, simply discuss this with your physician in advance. If he or she knows why you need to break routine, they can incorporate the appropriate documentation into your chart. Keeping your doctor in the loop by planning your pharmacy changes ahead of time helps him to trust you just as you trust him.
Be willing to submit a urine or blood sample or information needed to monitor your use of painkillers. Don’t be insulted when you’re asked to pee in a cup. If you want to continue to receive easily misused drugs, it’s in your best interest. Doctors are constantly faced with patients who are addicts, either through using illicit drugs or doctor shopping. When a doctor asks for a urine sample, she wants assurance that there is no potentially lethal misinformation that could affect his or her prescription strategy for you.
By complying with requests for fluid samples, you are making life easier on yourself in another way. You’re helping your doctor to weed out abusers from his/her practice so that he/she can focus on practicing medicine with their bona fide patients.
Pills don’t always work the way we think they do. Half a pill doesn’t always mean half the strength, and twice the medication can quadruple dangerous side effects. Well-chosen medications soothe our pain, but a rowdy mix will use our body as a battleground. Trusting your doctor, and allowing your doctor to trust you are absolutely essential elements of quality health care.
As prescription painkiller abuse has risen, the doctor-patient relationship has become more difficult. Doctors must now constantly worry that they are being misled. It’s important to remember that they’re doing this to make sure they’re serving you correctly. Here are five ways to protect the integrity of your prescription.
1. Always follow prescription medication directions carefully. When it comes to medication management, there is no substitute for a medical degree. That’s why only your physician can write prescriptions. You should think of your doctor as your personal health expert, who took four years to earn their wings in medical school and then at least three years in residency to perfect their work under an expert’s watchful eye. If you have questions and suggestions, discuss them with your doctor before trying them out. Ask your personal expert, they will have your back.
2. Don’t increase or decrease doses without talking with your doctor. Why risk ending up in the hospital, or worse, when a simple heart-to-heart discussion with your doctor can give you an answer that keeps you safe? A sudden or unplanned change in medication can have bad side effects that you did not bargain for. This is the very reason you see a doctor—he or she can use their expertise to design a medication plan that will protect your health.
Openness, candor, and direct communication are key ingredients for a mutually beneficial physician-patient relationship. Nowhere is this truer than in the risky and emotionally fraught field of pain management. When your pain is at its worst, remember that you should rely on your doctor. If the medication (e.g. pain pills) is not cutting it, tell your doctor. Trusting your doctor will keep you safe, and calling him or her before changing plans will help them to trust you, as well. If you can’t discuss your medication and health openly with a doctor, then perhaps it is time to find a new keeper to entrust with your medical care.
3. Don’t stop taking medication on your own. By now you’ve noticed a theme—if you want your medication to help and not harm, you have to follow your doctor’s instructions. Ending a treatment routine is as complex as starting a new one, so don’t quit your prescriptions cold turkey before their time.
Some medications need to be continued well after the symptoms have disappeared. Antibiotics are an obvious example—if you stop taking them before their time, your infection might bounce back with a brand new resistance to drugs. Other medications, such as antidepressants and prescription painkillers, often need to be gradually and expertly titrated downward before you wean yourself off of them entirely. Let your doctor escort you off of a course of medication rather than taking matters into your own hands.
4. Don’t crush, chew, or break pills. Let’s be real here. If your doctor wanted you to find new uses for the pill, she would have told you that in the office. Don’t mistake your adult medication for a children’s chewable vitamin. Many pills are ingenious drug delivery systems in disguise, covered in layers of coatings to ensure that medication is released slowly and in strategic locations in your digestive tract. Pills are meant to be swallowed whole, so pull out a glass of water and swallow.
5. Be clear about the drug’s effects on driving and other daily tasks. There’s a reason that you need a photo ID to buy alcohol, but a doctor’s legally binding signature for strong painkillers. Prescription pain medications can affect our cognition just the same as alcohol, and sometimes more.
“I will always love you” icon Whitney Houston died Saturday, her body reportedly submerged in the bathtub of a Beverly Hills hotel. Whether substance abuse issues played a role in her death remains to be seen pending autopsy and toxicology results. The death of Whitney Houston comes as the latest in a growing and alarming trend of celebrity deaths—from King of Pop Michael Jackson to singer Amy Winehouse. “All too painfully we are seeing an increasing trend of untimely celebrity deaths following a long history of substance abuse issues,” says San Francisco pain management specialist Moshe Lewis, MD. A fan of Whitney Houston’s since the age of 16, Dr. Lewis is devastated by her passing adding that he “grew up with her music on a daily basis.” Unfortunately, as a physician with sub-specialty training in public health he is identifying drastically diminished life spans amongst celebrities whose “lives seem to be cut short almost exponentially with fame” notes Dr. Lewis.
To Dr. Lewis it seems like just yesterday he was giving interviews on King of Pop Michael Jackson’s death from the anesthetic propofol. Sadly less than three years later following Michael Jackson’s death in the midst of a massive comeback tour we are overwhelmed by the loss of the Queen of Pop in the midst of promoting a new movie as part of her comeback campaign.
Whitney, “we will always love you” and can only hope that your life provides a valuable lesson for the public at large to hear. When we address the demons of low self esteem, depression, and anxiety with therapy instead of substances, we can live long enough to appreciate that we are not perfect, but a work in progress. We do not need to be the richest, the prettiest, the smartest, the most athletic or the most famous person all the time.
According to the Drug Enforcement Administration (DEA), “doctor shopping” and frequent early refill request are one of the primary ways that addicts obtain prescription drugs for non-medical use. “Doctor shopping” refers to when an individual visits several different doctors to obtain prescriptions for the same medications, and then has the prescriptions filled at different pharmacies. This allows the individual to obtain more of the prescribed substance than any one physician or pharmacist would allow. Legally, doctor shopping is not a minor matter; it is prosecuted as a felony and is punishable by up to five years in prison.
At a 2006 hearing, a high-ranking official from the DEA testified before the House Government Reform Committee Subcommittee on Criminal Justice, Drug Policy, and Human Resources regarding current efforts to address prescription drug abuse in the United States. According to Mr. Rannazzisi’s testimony, doctor shopping is a growing problem in this country and is a primary means for addicts to obtain prescription medication for illicit use. Mr. Rannazzisi referred to prescription drug abuse as an “epidemic.”
Other illegal activities associated with doctor shopping may include the forgery of prescriptions or the sale or transfer of the drug to others. To address this situation, PDMPs (prescription drug monitoring programs) are being introduced in many states. These programs are designed to allow physicians and pharmacists to cross-check prescriptions with each other and identify individuals who may be doctor shopping.
Abuse of prescribed medicines often begins with legitimate use. Because of this, individuals who otherwise would not abuse substances find themselves addicted when it is already too late. They begin doctor shopping to feed their addiction, but rationalize this behavior as being necessary to manage the pain and maintain the façade of being in control. Pain medication, prescribed for a variety of common reasons, including back pain or surgery, caesarian sections, or even dental procedures, carries the highest risk for dependence.
One Ohio mom recently posted her story on a public message board. She related having had three back surgeries and a herniated disk in her neck. She started on pain medication after her daughter was born by C-section. Soon, the medication from her pain management physician wasn’t enough. She went to see another physician, and then another.
She was finally caught when a doctor’s office, where she had called to schedule an appointment, asked for her social security number. Apparently, the office participated in a PDMP and had access to a list of all the physicians and pharmacies she had used. The office contacted her husband and provided him with a copy of the list. Now she is enrolled in a treatment program.
This story is typical of many pain medication abusers - middle- and upper-class individuals who lead otherwise respectable lives.
In 2006, one of the most famous doctor shopping and prescription drug abuse stories came to light. Conservative talk show host Rush Limbaugh turned himself in to Palm Beach authorities for doctor shopping. From 1998 to 2006, Limbaugh obtained massive amounts of the painkiller OxyContin, both through multiple prescriptions from different health care providers and through illegal channels. Limbaugh began taking painkillers in the late 1990s after an unsuccessful back surgery. By the time he turned himself in to police, he was rumored to be taking up to 30 pills per day. His drug abuse was severe enough to damage his hearing. According to a 2004 statement from the White House’s Drug Czar John Walter, “The non-medical use of prescription drugs has become an increasingly widespread and serious problem in this country; one that calls for immediate action. The Federal government is embarking on a comprehensive effort to ensure that potentially addictive medications are dispensed and used safely and effectively.”
A study completed by the Boston University School of Medicine in 2006 reported that more than 10 million Americans are taking opioid medications to treat pain, and more than 40% of those use potent painkillers on a regular basis. The study consisted of random telephone surveys of 19,000 adults from 1998 through 2006. With such a jump in use and abuse of pain medication by Americans, it’s no surprise that associated behaviors such as doctor shopping and prescription fraud are also on the rise.
Since a lot of my patients use potentially addictive drugs, I always have important discussions on how to avoid substance abuse. This NYTimes article is a great summary of why we get addicted and how dangerous it is. On the 3rd page, the article discusses how medical doctors are not trained to manage chronic pain so they simply prescribe more dangerous and addictive drugs.
The toll from soaring rates of prescription drug abuse, including both psychiatric medications and drugs for pain, has begun to dwarf that of the usual illegal culprits. Hospitalizations related to prescription drugs are up fivefold in the last decade, and overdose deaths up fourfold. More high school seniors report recreational use of tranquilizers or prescription narcotics, like OxyContin and Vicodin, than heroin and cocaine combined.
The numbers have alarmed drug policy experts, their foreboding heightened by the realization that the usual regulatory tools may be relatively unhelpful in this new crisis.
As Dr. Volkow said to a group of drug experts convened by the surgeon general last month to discuss the problem, “In the past, when we have addressed the issue of controlled substances, illicit or licit, we have been addressing drugs that we could remove from the earth and no one would suffer.” But prescription drugs, she continued, have a double life: They are lifesaving yet every bit as dangerous as banned substances. “The challenges we face are much more complex,” Dr. Volkow said, “because we need to address the needs of patients in pain, while protecting those at risk for substance use disorders.”
The San Francisco Chronicle recently interviewed one of my patients and myself to gain a perspective on how many doctors are "scared to death to prescribe [medicine] stronger than ibuprofen 800mg", given concerns about drug misuse. The article discusses the balancing act between the lack of access to pain physicians and the way most patients can be functional despite pain medication. Here is an excerpt of one of my quotes:
"I have colleagues who are board certified in pain who will not write significant pain medication for treatment. Many of them are feeling overwhelmed and scared," said Dr. Moshe Lewis, a pain management specialist with California Pacific Medical Center who has treated Reia. "Most of the patients I see, probably 90 percent, have legitimate pain. The challenge is figuring out who's who."
The U.S. Food and Drug Administration (FDA) is asking drug manufacturers to limit the strength of acetaminophen in prescription drug products, which are predominantly combinations of acetaminophen and opioids. This action will limit the amount of acetaminophen in these products to 325 mg per tablet, capsule, or other dosage unit, making these products safer for patients.
In addition, a Boxed Warning highlighting the potential for severe liver injury and a Warning highlighting the potential for allergic reactions (e.g., swelling of the face, mouth, and throat, difficulty breathing, itching, or rash) are being added to the label of all prescription drug products that contain acetaminophen.
These actions will help to reduce the risk of severe liver injury and allergic reactions associated with acetaminophen.
Acetaminophen is widely and effectively used in both prescription and over-the-counter (OTC) products to reduce pain and fever. It is one of the most commonly-used drugs in the United States. Examples of prescription products that contain acetaminophen include hydrocodone with acetaminophen (Vicodin, Lortab), and oxycodone with acetaminophen (Tylox, Percocet). OTC products containing acetaminophen (e.g., Tylenol) are not affected by this action.