Narcotic Painkiller Use Increased in the Elderly

An investigative newspaper article published in the May 30, 2012 issue of the Milwaukee Journal Sentinel, in cooperation with online periodical MedPage Today, chronicles the increased use of narcotics for chronic pain relief in the elderly. The article highlights how in 2009 the American Geriatrics Society put together a panel of geriatric pain specialists who published geriatric narcotic pain relief guidelines that have led to the dramatic increase in use of narcotics in the elderly. There is apparently no outstanding or solid evidence that Opioids or narcotics actually work better than non-narcotic pain medications in relieving the chronic pain of senior citizens.  It is the Milwaukee Journal’s opinion that the members of the blue ribbon panel who made this decision received financial benefits from the pharmaceutical manufacturers who produce narcotic pain pills and were biased in their recommendations.  Individual members of the panel received financial rewards from the companies making the narcotic pain pills and the sponsoring organization, the American Geriatric Society, reportedly received $344,000 from Opioid manufacturers.

A study in the 2010 Annals of Internal Medicine looked at over 10,000 people who had received 3 or more Opioid prescriptions over a 90 day period. The researchers found that 51 had suffered an overdose including six deaths.  Of the 40 most serious overdoses, 15 occurred in those aged 65 or older.  A 2010 research paper in the Archives of Internal Medicine looked at 12,840 Medicare patients with an average age of 80 who had used Opioids, traditional anti-inflammatory drugs, or a class of non narcotic   prescription painkillers like Celebrex. Their findings included:

  • Opioid users were more than four times more likely to suffer a fall with a fracture than non-Opioid users
  • Deaths from any cause were 87% more likely in Opioid users.
  • Cardiovascular complications including heart attacks, strokes, and cardiac death were 77% higher in Opioid users than in users of NSAIDS.

In part, as a result of the American Geriatrics Society guidelines, Opioid use for pain relief has increased by over 32% since 2007.   Locally, we have seen the proliferation of pain clinics. These clinics, often owned by non-physicians, bear some responsibility for the proliferation of narcotic pain pills on the streets of America being used illegally.   Poorly conceived state legislation and the lack of surveillance and monitoring led out-of-state drug pushers to drive into Florida, hire individuals to doctor shop from pain clinic to pain clinic where they accumulate thousands of pills that are sold out of state on the streets illegally.  Ultimately this led to a law enforcement and statewide crackdown which drove illegal and legitimate pain specialists out of the state of Florida. It is almost impossible to find a certified pain physician in Palm Beach or Broward County who will take on a new patient under the age of 65 years old due to the legal hurdles recently imposed on them to crack down on the illegal dispensing of drugs.

George Lundberg, MD and Maria Sullivan, MD of Columbia University presented a sane and reasonable approach to pain pill management in MedPage Today in the June 11th issue.  They suggested that non narcotic pain products be tried initially. They encouraged doctors and nurses to discuss the side effects of narcotics with patients including constipation, sedation, addiction, and overdose and with long term use the risk of hyperalgesia and sexual dysfunction.

They noted the high abuse potential of short acting Opioids such as Dilaudid (hydromorphone) and Vicodin (Hydrocodone/acetaminophen) and pointed out that these drugs may be good for short term initial pain relief but not chronic use.  They reviewed the pharmacology of methadone and pointed out that it is responsible for far too many overdoses due to its basic metabolism and mechanism of action. They suggested never using it in patients who have not taken Opioid narcotics regularly.

They discussed the need for patients to keep controlled substances in a secure and locked place to prevent theft of the medication.

For those practitioners who prescribe Opioids for chronic pain they suggested having a chronic pain narcotic protocol including a medication contract with the patient that outlines its correct use. Psychological evaluation for abuse potential should be considered in all chronic pain patients prescribed narcotics. Urine toxicology screening periodically should be performed to look for abuse.  There are clinical interview screening materials such as the SOAPP (Screening and Opioid Assessment for Patients with Pain) form which helps identify individuals with a high risk of abuse.  Stratifying your pain patients into low, medium, and high risk individuals may help distinguish the level of surveillance necessary to safely treat the patients.

It would make great sense for the state of Florida and the Florida Medical Association to develop a common sense pain management course for practicing providers to take prior to renewing their state medical licenses.  The course would cover the newer pain protocols and medicines and review the safe and monitored use of Opioid narcotics.  We must treat and eliminate or reduce pain. We just need to do this in a safer manner.

Proper Disposal of Medications- South Palm Beach County

Self disposal of prescription medications is becoming a major problem. Water is being contaminated with prescription drugs.  Recently, researchers found traces of Prozac in fresh water fish and shell fish.

The City of Delray Beach and the Delray Beach Police Department will be providing a public service by disposing of your unwanted medications. They have placed a “Med Return“ receptacle in their lobby at 300 W. Atlantic Avenue.

You can phone 561.241.7888 for more information.

A Physician’s Call for Help – Rewarded by the Best Payment of All

My wife and I were sitting down to an uncharacteristically late dinner for us Friday at a local eatery when my cell phone rang. Caller ID identified it as Dr David Rosenberg, a family physician practicing concierge medicine about one hour north of my home in Jupiter, Florida.  We had not spoken in months and after some pleasantries and catching up he said, “Steve I just saw a story on the TV News that there is a back to school community fair in Pearl City in your community tomorrow morning and the doctor they had counted on to perform the required school exams for new students had cancelled due to a personal crisis.

Dr. Rosenberg wanted to know if I would join him for a few hours at the Wayne Barton Learning and Community Center and perform the physicals. He told me he had phoned fifty physicians and no one had yet agreed to come. He was prepared to do them himself.  I gave my wife that “duty calls” look and she nodded back approvingly and I told him it would be my pleasure. I agreed to meet him at 10 a.m. at the center.

Wayne Barton is a former City of Boca Raton police officer who is now a community leader and activist. He created a nonprofit agency and, with generous philanthropic support, has built an educational and community center for students from poor homes. He provides year-round learning and tutoring for students and has an annual “Back to School Jam” where new students receive the required school physical plus receive backpacks filled with school supplies that their working parents have great difficulty affording.

Mr. Barton greeted me at the entrance as I walked in and thanked me for coming on short notice. The regular physician who cancelled due to a family crisis has been volunteering for years and is my personal friend, mentor and is my patient. Trying to fill in for him is a tall order and made the experience even more special for me. Dr. Rosenberg, who organized this last minute physician participation, was there as well and with him were two other concierge physicians and a wonderfully warm physician’s assistant.

For the next several hours, with the help of a large dedicated volunteer staff, we saw numerous lovely children with their families. A mother and her high school age daughter and son, who had escaped the ravages of the earthquake in Haiti, were among the first.

A young woman and her two children who had escaped Communism and Castro’s Cuba nine months ago came through my station.  I saw a young man with lead poisoning requiring treatment and follow-up and another lad who wanted permission to play football despite the jaundice in his eyes tipping me off to his history of sickle cell anemia that he had conveniently left off his form.  I was able to stay for three of the four hours and I received the best payment of all – beautiful smiles, blessings from several and a thank you from all.

The degree of appreciation coupled with the level of need leads me to believe it’s time to discuss with Mr. Barton a regular free clinic at the center.

Once last thought, I couldn’t help but notice that the physicians who responded to the call for help were all practicing in a concierge medicine model.

Smoking Increases the Risk of Breast Cancer, Lung Cancer and Colon Cancer in Women

The Surgeon General of the United States issued another report on the dangers of smoking and its addictive potential last year.  At the time of release I was quite skeptical about the cost of the report and the need to remind Americans again that smoking is dangerous for you.  Then along comes a detailed review of the National Surgical Adjuvant Breast and Bowel Project. According to Stephanie Land, PhD, of the University of Pittsburgh, long-time smokers had a 59% increase in the risk of invasive breast cancer compared with nonsmokers.  The study looked at the links between four types of malignancy: breast, lung, colon, and endometrial cancer with smoking, alcohol use and leisure time activity.  The findings suggested that:

1.       Women who had smoked between 15 and 35 years had a 35% increase in the risk of breast cancer compared to non smokers. In that same group, if a woman smoked more than a pack a day she had a five – fold higher risk than non smokers.

2.       Women who had smoked 35 years or more had a 59% increase in the risk of breast cancer. These long-term smokers had a 30 times higher risk of lung cancer than non smokers.

3.       The risk of colon cancer among long–term smokers was five times higher than among non smokers.  A drink of alcohol a day reduced the risk of colon cancer by 65% compared to non drinkers.

4.       Inactive women had a 72% increased risk of uterine endometrial cancer compared to active participants in the study.

The study of almost 14,000 women highlighted the benefits of improving life style choices.  While researchers search for drugs and medication to prevent these life threatening illnesses, the study pointed out the benefits of altering the life style choices of women to prevent the development of cancer.

It is clear that smoking prevention and smoking cessation programs can do far more to prevent these cancers than pharmaceuticals. With cutbacks on funding for public health and the elimination of most health and hygiene classes in middle schools and high schools due to financial constraints, I wonder if we are being penny wise and pound foolish.

Dutch Diet Drink Reduces Hunger

Obesity is an epidemic negatively impacting our health in America and around the world.  According to the National Center for Health Statistics, over 68% of American adults are overweight or obese.  As we move away from a hard working agrarian society to a society which consumes fast food while getting less activity due, in part, to our technological advances, we are always looking for aids to keep our weight down.

In recent years the pharmacological approach has fallen on hard times due to the many significant side effects associated with diet medications.  Expensive surgery to reduce the stomach size and re-route the intestines has met with mixed success, high costs and adverse effects as well.

Last month, Harry Peters, a research manager of Unilever Research and Development in the Netherlands announced preliminary successful results of a prototype diet beverage. He and his staff concocted a chocolate flavored brew that stayed liquid and palatable when you drank it but firmed up into a thick gel when exposed to the acidic and digestive juices in the stomach.  The gel distended the stomach and produced a sense of satiety and fullness with a resultant decrease in appetite in the vast majority of the study participants. The research is quite preliminary but again presents hope to those of us fighting the battle of the bulge.

“Although the self-reported decreases in hunger are robustly reported in this study, further studies are needed to establish its implications for food intake, compliance to weight loss programs and long-term effects on weight loss or weight maintenance,” Peters and colleagues concluded.

Free Health Screening – A Service to our Community’s Health

Last weekend I had the privilege of supervising University of Miami Miller School of Medicine students at a free public health screening in Pompano Beach, Florida.  The screening was sponsored by the medical school, with the assistance of community leaders, and held in a local public school. The program organization, recruitment of student and faculty volunteers and management of the program was undertaken and implemented by the students. It is one of several programs of this nature undertaken by these students in Dade, Broward and Palm Beach County Florida.

Stations were set up to screen for vital signs, weight, body mass index, glucose and cholesterol. A women’s center with breast exam, cervical pap smears and dexa heel bone density tests was available. There was an ophthalmology station with physicians from Bascom Palmer Eye Institute. A dermatology section was available with fellows from the world class dermatology program at the University of Miami. Pediatric and neurology sections were available as well as mental health screening. The program was enhanced by the participation of the Broward County Health Department and numerous other community organizations.

After the patients rotated through each station they exited at a checkout area manned by students and faculty. The students organized all the data for the patient participants, explained what their exam findings meant and established mechanisms for the patients to receive follow-up care in the Public Health setting.

This was the fifth year I have participated as a voluntary faculty member. I noticed the patients were younger, sicker and presenting with more social and health problems than in previous years. Several times during the screenings, the fire rescue squad was called to transport individuals to the hospital because their initial entry into the health system detected a serious enough condition to require immediate hospitalization. The patients were proud, hard working American citizens of all races, colors and creeds who were devastated by the recession with loss of jobs and health insurance benefits.  For many, this screening was their first trip to the doctor in years. Although well received, this screening was the most rudimentary of safety nets available for this community from the health care field.

Some 225 patients were examined in an eight hour period. I was proud of the students for a job well done. After it was over I went home and took time to read the local newspaper. There was a front page article about how our new governor had just proposed a budget which cuts all funding for primary medical care at Public Health Facilities. I wondered how many of those patients we referred for follow-up to Public Health facilities would now have to wait until next year’s screening program to obtain it?

I wish those Tea Party and righteous cost cutting conservative politicians and our governor had spent the day interviewing, examining and counseling the patients I saw today. I wonder how they would react to a frightened fifteen year old hoping to get a pregnancy test and too poor to afford a store bought test?  I wonder what they would say to a 5th grade teacher who had lost her home to foreclosure and couldn’t afford to pay an ophthalmologist in the private setting to check her glaucoma. I wonder what Governor Scott and the Tea Party would say to a 50 year old former triathlon performer who lost his construction and landscape business during the recession, lost his health insurance, gained forty pounds due to the stress of life and was now unemployed, diabetic and hypertensive with no access to health care?

It’s easy to pontificate about the flaws of health care reform until you sit down with the sickest and most vulnerable and realize they are no different than you and I.