Search for tag: "prescribing"

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Interviewer: So, when it comes to opioids and being prescribed opioid painkillers, do most doctors at this point in time all operate from a similar paradigm when it comes to whether they should prescribe them, whether they should not prescribe them to a particular patient? Or do patients still need to kind of have a working knowledge of opioid pain pills? Because they scare me. I hear some of these stories and they sound a little frightening.

Dr. Miller: Well, as you know, the news is out that opioids are very addictive. The statistic is something like 80% of current heroin abusers had started out on prescription opioids. And so we have a track record in this country now over the last 30 years of overprescribing opioid narcotics for the treatment of pain, and that has led unfortunately to an increase in deaths from opioids and heroin use and other bad things.

So, in answer to your question, there is not a policy about prescribing opioids that applies to all physicians. And, more importantly, we're not yet all completely on the same page about how to use and treat people with opioid painkillers.

Interviewer: Yeah. So, to some extent, the consumer, the healthcare consumer should have a working knowledge. And as somebody that might find myself in the healthcare system, how would I know whether or not it's appropriate for me if all doctors aren't operating from the same paradigm as of yet? And why is that? Why aren't they? Is it just because the information hasn't caught up to everybody yet?

Dr. Miller: I think that's part of it. They're individual prescribing practices, and some physicians don't prescribe opioids very commonly while others do. And presumably, the ones that are now prescribing opioid for pain and do quite a bit of that are well versed in how to use that, setting up contracts with their patients on how to take opioids and when to report in and when to get their refills and so forth.

So there is a spectrum of understanding of how to prescribe opioids. It starts back with medical student training and then residency training. We have not had what I would consider to be top-of-the-mark training in opioid use throughout our medical training, and that's changing over time.

Interviewer: Gotcha. Just takes a little time for that to kind of roll out, yeah.

Dr. Miller: It takes time.

Interviewer: So, back to my original question. I asked somebody who might find themselves in the healthcare system and now I'm trying to determine, "Is this really the right course of action for me or not?" how would I make that informed decision?

Dr. Miller: That's a great question. It starts with a question. So asking your physician how your pain can be best controlled is the way to start. What is the best way that you, meaning the physician, think that your pain should be treated? How do we do that?

In general, it depends on the type of procedure you're having or the pain you're experiencing. And the plan is really to start slow and use non-opioid substances or drugs, like non-steroidal anti-inflammatories like aspirin or ibuprofen or Tylenol, or other modalities, like massage or other physical therapy efforts.

Interviewer: Which I've read, and people might find this hard to believe actually can be just as effective if not more effective than opioids for chronic pain, those types of things.

Dr. Miller: That's true. Yeah, I think we were under the misassumption that opioids treated all types of pain pretty easily as a public, and that's not true. There are many other ways to treat pain. Acupuncture is another way that works well for some patients.

But again, you have to assess the severity of the problem, the potential severity of the pain. So if you have an open abdominal procedure where the muscles of the wall of the abdomen are cut, you're very likely going to have some pretty intense pain for a while.

And then you work with the physician to decide how much pain medicine you need and for how long. So, in general, shorter courses are preferred. And you don't want to be taking large amounts of opioids for a long period of time for a problem that is healing itself.

So, again, you start with questions. You start with, "What is the best way to treat the pain you might anticipate that I will have? What is your standard of practice?" or "I have this particular pain. What do you think the best way for me to have it treated is?" And then listen carefully to what they tell you.

If it starts off with a conversation that seems unclear or moves very quickly to opioid narcotics, then you might want to ask more questions about why are we starting with that particular medication rather than something that's potentially less addictive.

Interviewer: If we were to try to draw a visual path, I have the feeling that opioids might be prescribed for chronic pain, which is long, ongoing pain, like severe back pain that you're suffering from, or it could be pain that you might experience during a surgical procedure. Those would be the two different paths possibly?

Dr. Miller: Right. So there's chronic pain, pain that you can expect to have for weeks and months and perhaps years.

Interviewer: Yeah. And those are the types of things that some of these other modalities, as you said, massage, acupuncture, physical therapy, exercise could possibly mitigate and would be a better option.

Dr. Miller: Correct. At least trying that initially or working through that without using opioids initially would be a good point.

Some of the illnesses that we've gotten away from prescribing opioids would be things like migraine headaches, fibromyalgia, types of pain that are chronic, that don't really have a well-understood initiating cause or a cause that we think is going to heal over time, or pain that is episodic. If you treat that with opioids, sometimes that leads to a higher rate of addiction.

Interviewer: Gotcha. And in a surgical procedure, say I'm going to go into a surgical procedure and my physician says, "Yeah, this is going to be pretty intense for a couple of days. I'm going to recommend opioids." They're saying it right away, but they're also saying it's only going to be for a couple of days possibly. Should I be frightened of that?

Dr. Miller: No, you should not. I think most surgeons now are very well aware of the amount of narcotics that they're going to need for the particular duration of healing that you're going to experience.

If you're getting a month's worth of narcotics for a procedure that you might expect to be out of the hospital for in several days, then that is probably too much, and you could just say, "How many days do you think I'll be needing to take these medicines?" And then you might ask to say, "Look, why don't you just give me a week or two weeks or whatever you think is best for this particular healing period?"

Interviewer: Read an interesting article. The surgical department here actually did a study that found out that, as of right now, prescribing of opioid-based painkillers after a procedure is . . . they don't take the individual into consideration. Everybody would get them whereas they felt that they should talk to each patient to try to figure out what would be appropriate for that patient.

Dr. Miller: Correct. So what that study or that . . . it's not a study, but what that approach shows is just what you and I are talking about, that every patient has an individual need for the way their pain is treated and that depends on the procedure. So it depends on the type of the procedure, the length of the incision, the area of the procedure, and then the assumed time of healing.

So laparoscopic procedures, where they make very small incisions, are likely to heal quite a bit faster and would need less pain control and possibly could be managed without narcotics. Larger procedures, possibly longer periods of time, a week to two weeks, where they might need opioids. Again, it's quite individual.

And this is another thing. The science is not well worked out in terms of why one person's pain requires more and different types of analgesics than others. It's not known yet. So everybody is a little bit different.

Interviewer: And I think that brings up an important point too, that another way that people get into trouble is they are prescribed to take a certain amount over a certain time and they're like, "Well, I know my body and I don't normally react, so I'm going to take two instead of one." And with Tylenol, it's probably not a good idea, but with opioids, it's a really bad idea to start changing that dosage.

Dr. Miller: Yes. Again, we're not entirely clear why some people start on a path and then become rapidly addicted to opioids and seek opioids for the pain relief. It's not quite clear. Some people can be on opioids for some time and stop and it's not a problem. We don't really understand that completely.

Interviewer: But maybe not a gamble worth taking if you think you could . . .

Dr. Miller: Well, yeah. What we know now, given the evidence of the '90s and the last decade, is there was too much opioid prescribing, and it did lead to higher rates of addiction. So, obviously, the more opioids that are out there that people are taking for longer periods of time or perhaps in higher doses leads to higher rates of addiction.

Interviewer: So the important takeaway from this, it sounds like, is if you're finding yourself in position where that is a recommended way to deal with your pain from a physician, to start having a conversation. Because not having that conversation and just perhaps taking those pills could lead to a place you don't want to be.

Dr. Miller: That's correct, or it could lead you to have excess opioids at home, whatever type or form you have, and somebody else could maybe use that and that would lead to some problems down the road for them.

Interviewer: What about a resource if somebody wants to read a little bit more? The CDC? Is that a good place to go to learn more? Or National Institutes of Health?

Dr. Miller: CDC has guidelines, and we've actually repurposed the guidelines in our community clinic group as a training tool and an education tool for physicians in our community clinic group to read and learn from. So the CDC would be a good place to start.

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Dr. Gellner: As a parent, I completely understand that when a child is sick, you want any medicine you can have to make them feel better and fast. However, antibiotics are not always a good choice. I'll discuss myths and facts about when antibiotics are really needed on today's Scope. I'm Dr. Cindy Gellner.

Announcer: Remember that one thing that one person told you that one time about what you should or shouldn't do with raising your kids? Find out if it's true or not. This is Debunking Old Wives Tales with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Ask any pediatrician and the number one question when a parent brings a sick child to the doctor is, "Are you going to give them antibiotics? Often parents will bring in their children for fevers, coughs, or sore throats. So giving them antibiotics will make them better more quickly right? Not true. Most of these symptoms are caused by viruses, not bacteria. And so antibiotics will do nothing to make them feel better and may make them feel worse, especially since one of the big side effects of antibiotics is diarrhea.

When antibiotics are used, they kill all the bacteria in the body, good and bad, that are sensitive to that antibiotic. Too much antibiotic use means that the stronger antibiotic resistant bacteria take over and then the problem is sometimes, we see these new bacteria require heavy duty antibiotics that can only be given by IV, or sometimes we don't even have a good antibiotic to treat these resistant bacteria.

So if your child is given an antibiotic, it must be taken for 10 days to kill all the bad bacteria, right? Well, no, some antibiotics only need to be taken for five to seven days for treatment. The bottom line is be sure you give the antibiotic exactly as your doctor prescribes.

But what about if your child's snot is thick and green? This means antibiotics are needed, right? No again. Studies have shown that mucus color results from white blood cells and proteins fighting inflammation in the mucus and not any harmful bacteria. In fact, the longer mucus is produced, the greener and thicker it becomes. That's why a common cold lasting more than three to four days produces green mucus. Now, if the drainage has been going for an extended period of time and your child is getting worse, then your child's doctor will help you decide if antibiotics are needed at that point.

I've often heard from parents that this or that antibiotic doesn't work for my child. They're immune to it or it's not strong enough. Well, the fact is people don't develop immunity to antibiotics. If the antibiotic didn't work for your child in the past, maybe they were being treated for a viral illness and not a bacterial one, or the bacteria had developed resistance. The only time a child shouldn't be prescribed a particular antibiotic is if they have a true documented allergy to it.

Finally, some parents worry that if their child takes too many antibiotics, it will lower their immunity. False. Antibiotics have no adverse effects on the immune system. What too many antibiotics will do is cause all the good bacteria in your child's body to be killed and put them at risk for issues like chronic diarrhea and resistant bacteria.

So remember, when it comes to prescribing antibiotics for your sick child, trust your pediatrician. They have the training to determine when an antibiotic is needed and when it's not. And don't be afraid to ask about our decisions. We want parents to be involved in their child's health care decisions.

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Interviewer: What are emergency rooms doing about opioids? That's next on The Scope.

Announcer: This is From the Frontlines with emergency room physician, Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. And of course, by this point, most of us know that opioids are a major problem and it seems like taking that first one is what really lead you down that path. And for many people, they might have gotten them in the ER at one point. So I'm curious, Dr. Madsen, is that the case? Did you use to give out opioids for pain and has that changed?

Dr. Madsen: So I've absolutely given out opioids and we still do. I mean, there are cases where people need some kind of pain medication and, often, that's the only thing that's going to help them in the short term. But we've definitely seen the pendulum swing in the last few years. It used to be, in the ER we always talked about, "We're not treating pain adequately. We're not giving enough medication." And I think the response to that, 15, 20 years ago was to say, "Let's get more opioids. Let's prescribe more, let's give more IV medications."

Now, we've seen what's resulted from that. And it's not just the ER, it's primary care physicians, it's pain clinics, it's specialists. It's all across the spectrum of health care in the United States.

Interviewer: In the ER, was the opioid generally in pill form, or did you give it through IVs?

Dr. Madsen: We have often . . . and again, to say we don't do this, we do it because there is a role for opioids, and I think there's something we need to make sure we understand too is that there's a role for these medications people that have severe injury, long bone fractures, things like this, that's the only thing that's going to treat their pain adequately.

And so we do give at IV. There are IV forms of opioid medications like Morphine or Hydromorphone. And then there are pill forms as well that we can prescribe, hydrocodone, oxycodone, things like that. You've heard of Lortab, Norco, Percocet, all these sorts of brand names. So there are those two options that we use in the ER and that people use elsewhere as well.

Interviewer: So if I'm a patient, I find myself in the emergency department, and I'm told that my pain is such that you would recommend that I should have an opioid-based painkiller. Should I be nervous that I could possibly get addicted to it?

Dr. Madsen: I think the big issues with addiction come when we're taking medication not to treat the pain but often for the way it makes us feel. And if this is a new injury, if it's a serious injury, or if it's a serious issue like severe abdominal pain and that's the only thing that's going to control it, I think you need it. And I think you have to make sure you have some balance there and not just think, "Opioids are bad. I'm going to get addicted if I even have a touch of this medication." That's not the case.

So when people take it long term, they're taking it more for the way it makes them feel rather than, say, coming in for severe pain and I'm taking this because I need this pain in my abdomen treated right now because I've got a ruptured appendicitis or something like that going on.

Interviewer: So how have things changed in the ER?

Dr. Madsen: Yeah, so I think one of the biggest changes I've seen, so a couple of areas. Number one, we have a statewide database we can use and it's very useful. I can look up, if someone comes in and I can see have they gotten multiple prescriptions for opioids?

If they have and it's come from lots of different physicians, particularly lots of different ERs, I'll talk to that person and I'll express my concern, say, "We're seeing lots of different prescriptions from lots of different places. I'm concerned about the possibility of, maybe, addiction here. You need to go to one person, get this from one doctor so they can monitor what you're getting and make sure you're staying safe with these medications."

The second thing we've seen are just, like I talked about, decreased prescriptions for opioids for a lot of stuff that maybe we used to prescribe it for, for bumps and bruises and back pain because we wanted to make sure people's pain was taken care of. Now, I think it's more like saying, "Hey, try Ibuprofen. Ibuprofen, it's a great medication. Avoid opioids if at all possible."

Again, still there are cases where opioids are necessary. It's the only thing that's going to really adequately control someone's pain, but a lot of those kinds of gray zone areas. I think a lot more physicians are moving away from opioids altogether or are really limiting the number of opioids they're prescribing to those patients.

Interviewer: So this is a good first step, I would imagine. What else needs to be done?

Dr. Madsen: Well, I think we need to know a lot more about how we can better address pain and if there are other factors. Does anxiety really play into this, is something we studied in our ER. Patients who come in who are feeling very anxious, how much does that amplify the pain? If I address that anxiety, is that going to help with the treatment of pain?

Something else we're doing really new in our ER and one of the few places doing this is we have a physical therapist in our ER as well. So we're using our physical therapist to come in and see a lot of these people with back pain, work with them right there, get them set up with physical therapy to hopefully avoid the opioid prescription, to get them some treatment and say, "Hey, you don't need just to take pills for this. Here's some exercises, some strengthening, some stretching. It's going to give you a whole lot more relief than taking some sort of opioid."

Interviewer: So just like anything else, it's a useful tool. It's just that maybe we haven't been using it the best that we should up until this point?

Dr. Madsen: That's exactly right. I think the pendulum swung too far one direction and it's going back the other way. Hopefully, we can have some nice balance here and address this, what it really is, a nationwide epidemic.

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Interviewer: Olympians are some of the strongest, fastest, hardest-working athletes in the world, pushing their bodies to the limit. But what's it like for a doctor who takes care of them? That's coming up next, on The Scope.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: I'm here with Dr. Willick, and he is a sports medicine physician at the U. He's worked with the international Olympic and Paralympic medical communities and has worked with some athletes himself. When you're working with an athlete, what kind of considerations do you have to take in when compared to, you know, just someone that hurt their leg when they're hiking, or something like that?

Dr. Willick: One special consideration with any athlete who might get tested for doping is that we have to make absolutely, 100% certain we don't make any mistakes when prescribing medications. So for every single medication that we prescribe with an athlete, we always check, double check, and triple check whether or not it is on the prohibited list to make sure the athlete doesn't inadvertently get into trouble. It turns out that a lot of anti-doping violations are actually mistakes made by healthcare providers unknowingly prescribing a prohibited substance to an athlete when they shouldn't.

Another important consideration when you're taking care of elite athletes is, what is their training and competition and travel schedules. We often have Olympic and Paralympic athletes come to clinic who may only be in town for three days. They may be in between one World Cup event and the world championships, for example. Sometimes you have to prearrange things to get a lot done in a short period of time. You have to know when their next major competition is, because that's going to affect your workup and your rehabilitation protocols. For a recreational athlete, for example a hiker, we often have more time for the workup and rehabilitation.

Interviewer: So, with these extraordinarily driven athletes and things like that, what is it like when, you know, maybe they're injured, or, do you ever come up to a situation where they want to compete, and they're going to compete, and it's against what you want, what's best for them? You're saying, "Hey, I'm your doctor, no, you shouldn't be doing this"? Do you ever run into those types of things, or, how do you deal with those?

Dr. Willick: The short answer to your question is yes, of course. We run into that with recreational athletes as well as the world's best athletes. People want to do their sport, they want to continue being active, they want to compete. Every case is taken individually. There are times when it might be okay for an athlete to compete with a particular injury, knowing that maybe it'll give them a setback, but if they have one chance to compete in the Olympics, sometimes they just have to go for it.

And that's very different than if you have one chance to compete in the next 5K that's being run in town, knowing that there's going to be another 5K a week later and another 5K a week after that or a month after that. But often, there's only one opportunity to actually compete in the Olympic or Paralympic Games and the fact of the matter is, that can be reflected in the medical decision-making. However, if it is truly unsafe or unwise for the athlete to compete, we absolutely have that discussion with the athlete, along with their coach, sometimes with their family and other members of the team.

Interviewer: So coming up, we have all these people sitting down, watching the athletes, right, and cheering for their country, their favorite athletes, watching their favorite sports and stuff like that. What is something you would want the viewers, our American listeners who are sitting and supporting their country, to know about these athletes? What is something that they should appreciate and know about these athletes?

Dr. Willick: The viewer should appreciate the thousands of hours of hard work the athletes have put in to be on TV at the Olympic or Paralympic Games for a few seconds, or a few minutes, or maybe an hour. Thousands of hours of strength training, and flexibility training, and motor skills training, and meeting with a sports nutritionist, trying to regulate their sleep, meeting with a sports psychologist, and the dozens or hundreds of support staff behind every athlete. From all the specialists, to the coaches, to the coaches they had in their earlier days, and yes, even the medical staff supporting that athlete.

Interviewer: So you'll be watching?

Dr. Willick: I will be watching, yes.

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