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Drug Wars in the Exam Room

As physicians, we have all been faced with patients inappropriately looking for prescriptions for controlled substances. Some are looking to abuse them and some to divert them for profit. It is often hard to distinguish when a patient truly needs these medications or when they are just “drug-seeking.” More experienced doctors have a better sense of which patients are which. Drug-seeking patients often play on our emotions because they know we generally care about patients and may have difficulty turning down a request for opioids from someone in supposed pain. For years, patients have used many ruses to access these medications. Many of them “doctor shop,” use several pharmacies, or frequent various emergency rooms, making it difficult to track their prescriptions. And it’s much harder for a doctor to turn down a request from a new patient in acute pain than from one the doctor knows well and doubts. Having so many controlled substances available and sold on the streets has led to an increase in prescription drug dependency. These patients have a hard time breaking these addictions and often can only stop with help from special rehab programs. It has led to a further resurgence of IV heroin addiction and opioid deaths in many areas. As the states have tightened controlled substance prescriptions, they have become less available for diversion and are now a gateway drug to heroin—which is cheaper than prescribed medications. I am seeing teens in my practice addicted to IV heroin, a habit that started by raiding parents’ or relatives’ medicine cabinets. It has never been more imperative for doctors to step up and do...
NSAIDs: Striving for Judicious Use

NSAIDs: Striving for Judicious Use

Every winter when cold and flu season hits, millions of people take non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen to ease the aches and pains associated with being sick. In addition, about 23 million Americans use over-the-counter NSAIDs every day. There were also close to 98 million prescriptions for NSAIDs filled last year, making them one of the most commonly prescribed medication classes in the United States. Addressing AEs Like all medications, NSAIDs can cause adverse events (AEs), particularly when they are used inappropriately. Both selective and nonselective NSAIDs can cause significant and even life-threatening events, including gastrointestinal, renal, and cardiovascular AEs. It’s important to counsel patients about appropriate use of NSAIDs. The FDA recommends using NSAIDs at the lowest effective dose for the shortest period of time required to provide therapeutic effect. The incidence of NSAID-related AEs increases significantly with concurrent use of multiple NSAID products and higher doses and longer duration of use. Many patients knowingly use prescription and OTC NSAIDs at the same time, increasing their risk of AEs. However, many more likely do so unknowingly because they’re unfamiliar with the term NSAID and don’t know which products are NSAIDs. Many patients are also unaware that some cold and pain medications contain NSAIDs that are combined with antihistamines, decongestants, or other analgesics, which can lead to using multiple NSAID products at the same time. A lack of patient awareness about NSAIDs—combined with the availability of OTC NSAID products—complicates their appropriate use. Ensuring Proper Use There are several steps physicians can take to ensure appropriate NSAID use. A thorough medication review at each patient visit, including...
Examining Physician Rx Drug Abuse

Examining Physician Rx Drug Abuse

Substance use is one of the most frequent causes of impairment among physicians, and some reports estimate that 10% to 15% of doctors will have a substance use disorder in their lifetime. “Substance-related impairment among physicians is a serious problem, with significant consequences for patient safety and public health,” says Lisa J. Merlo, PhD, MPE. “The rate of physician substance use is similar to that of the general population, but physicians are more likely to misuse prescription drugs. Understanding the reasons for prescription drug misuse may help us more successfully identify, treat, and monitor addicted physicians.” A key challenge to treating substance use disorders is that most physicians do not refer themselves for treatment, making it difficult to collect data on this issue. One strategy is to partner with physician health programs (PHPs) to recruit study participants. PHPs were established to ensure that distressed or impaired physicians are treated and monitored for the long term so that they can safely return to practice. “Studies have shown that nearly 80% of physicians who participate in PHPs remain substance free—with no relapse—at 5 years follow-up,” Dr. Merlo says. “Unfortunately, many doctors with substance use disorders have these problems for years before they seek help or are referred to a PHP.” Exploring the Issue Despite the impact of substance use among physicians, few analyses have looked at prescription drug misuse in this population. Studies have suggested that access to prescription medications may increase the risk of substance abuse among physicians. However, Dr. Merlo says that more information is needed to understand the reasons for prescription drug misuse among physicians and to develop...
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