Doctors: Say no to drugs!

The United States of America is addicted to narcotics.  I do not mean the millions of individuals who are hooked.  I mean the whole nation is jonesing for the stuff.  I also do not mean the junk that slips into our nation in coffee cans or across midnight borders.  I mean the billions of pills pouring off assembly lines.  I could blame pharma or the FDA, but the truth is closer to home.  The villains are those men and women who write prescriptions.  It is time for doctors to say no to drugs!

Now let me be clear.  I know pain.  More exactly, I know the treatment for pain.  I have fought with my cancer patients against an oppressive ocean of agony for 30 years.  I know which drugs work, when to use them and when they will fail.  I believe that pain for a cancer patient cuts deep to the soul and is a constant reminder of sickness and death.  Every patient needs access to an aggressive array of pain medications, which must include appropriate narcotics.  But, come on now, things are completely out of control.

In order to treat serious pain very well takes only a few narcotics. You need a short acting pill or liquid, a long acting pill, a topically absorbed medicine, and an IV medicine.  It is a good idea to have one or two extras for allergies or reactions.  Almost all pain can be treated with some form of morphine and perhaps a little fentanyl.  High quality pain control can be achieved with less then 10 medicines.  Nevertheless, the pharmaceutical plants shower a rainbow of me-too drugs, flooding the market with deadly compounds.  Physicians fall right in line and write prescriptions for every new shiny tablet.

Here is a partial list: Actiq, Anexsia, Avinza, Bicodone, Buprenorphine, Butorphanol, Codeine, Damason-P, Darvocet, Darvon, Demerol, Di-Gesic, Dilaudid, Duodin, Duragesic, Duramorph, Embeda, Exalgo, Fentanyl, Fioricet, Fiorinal, Hycodan, Hydrococet, Hydrocodone, Hydromorphone, Kadian, Kapanol, Lorcet, MS Contin, MSIR, Meperidine,Methadone, morphine, Norco,  Nucynta ER, Opana ER, Oramorph, Orlaam, Oxycontin, Oxycodone, Percocet, Roxanol, Roxicodone, Ryzolt, Tramadol, Tramal, Tylox, Ultram, Vicodin, Vicoprofen, Xodol, Zydone,  and the newest and perhaps most controversial narcotic pain medication yet, sold in an easily abused capsule, Zohydro.  You may notice that sometimes I list both the brand name and generic … because they are both available just to add to the confusion and abuse potential.

I could blame the FDA for approving over 50 prescription narcotics when we only need a few.  However, the mandate of the agency does not allow it to consider the health of the nation as a whole.  Rather, hampered by politics, poor funding and a belief that it is just a tunnel to the consumer, the FDA views only narrow safety and efficacy concerns of individual products and takes little consideration for their affect in the real world.

I would love to blame pharma.  Why not, they are getting rich on the chaos?  However, the drug industry is burdened with the bizarre philosophy that market forces and competition is the best path to a quality care, even if it leaves a few hundred thousand bodies lying around.  Despite the blatant failure of US brand capitalism to produce a healthy society, we still act as if profit and sales success equals quality.

In addition, I cannot blame patients. They are the ones in fear.  They are the ones who suffer.  We cannot say to millions of cancer patients and others who experience levels of pain beyond the wildest Kafkaesque nightmare, that they should push back and refuse the “best and newest” pain-relieving solution. That would suggests a coldness and cruelty, which I do not feel, and our society fortunately does not share.

Therefore, I blame doctors.  They should know better. They continue a humiliating history of responding to marketing instead of medical data.  Rather than use research and scientific principals to conservatively choose basic drugs and techniques that work, they caw-tow to biased analysis, the easiest, the most expensive, and the latest Madison Avenue craze.  In doing so they encourage the expensive manufacturing of unnecessary products and flood our society with so many different chemicals and compounds that no one can understand the affects and our society’s health is undermined.

Doctors have always had the power of the medical order.  Nothing happens in healthcare unless somewhere, directly or indirectly, a doctor orders it.  Their failure to take a stand, to force medicine to be data driven and view not only the patient on the table in front of them, but society as a whole, continues to lead us to disaster.  The misuse of narcotics threatens not only those addicted and overdosed, but the rebound deprives suffering patients of desperately needed help.  It is time for doctors to insist on the strictest standards for our patients and nation; the manufacture of medicines we truly need and outcomes based care.  It is time for doctors to say, “No.”


  • Liz
    Yeah except when the patient has problems with your choice and then you need more options. Any form of morphine or related meds makes me extremely sleepy and causes me to throw up. Actually that is how I knew a drug addict nurse didn't give me the prescribed morphine for pain control in the recovery room… Yes I can take drugs for the nausea, but I'd rather find a drug that doesn't require a second drug for side effect control. As a result I think that more drugs are useful - especially if they have fewer side effects or address a kind of pain that current meds don't help much, or a group of patients with allergies, whatever, who aren't helped much by what is out there… I do agree that doctors need to not write the Rx's for drugs that are not needed.
  • As usual, Doctor, I salute your courage and your ability to get our attention. And as usual, I couldn't resist posting in my blog about your brave post. Sincerely, Margaret Fleming
    • James Salwitz, MD
      Thank you very much, I am honored. jcs
  • Bridget
    One area that needs more attention regarding pain, drugs, and level of administration of medication is the patient's perception of need for pain relief. My own experience, which is only one experience in the field of oncology, made me realize how rarely I could count on being heard. Surgeries for breast and the later endometrial cancer involved talking with the surgeon and two oncologists, and no one believed me when I said I anticipated needing minimal pain relief in recovery based on previous experience. I feel pain, and relief to me is taking the top edge of the pain away so that I can function. I went home from both procedures with a prescription for Percocet, 30 or 33 pills each time. I used 1.5 pills for the first recovery period and a total of 4 pills for the hysterectomy. Ibuprofen worked for my needs for both recoveries I returned the pills to my oncologists for their offices to dispose. By halving the tablets, I found that Percocet enabled me to sleep at night and kept my pain within a tolerable range during the day. Patients with some life experience (I am 61) can often communicate their needs in a meaningful way. Is anyone listening? I am in the school of 'less is more' and yet, others require more pain relief to manage their healing or transition. Listening to what a patient is communicating, watching for the wince, seeing the edge pull back, and responding to the specific needs are key skills in pain management. If I had needed more help with pain, I would have called the office to request more assistance, but as I predicted, the prescription was over-supplied and the drugs were wasted.
  • pam956
    The source of the problem is "drug money". As long as the drug companies are making money manufacturing and developing drugs, the doctors will write the prescriptions and the pharmacists will fill them. We have all those beautifully filmed and artfully animated commercials to keep us informed on what drugs to ask our doctors for. And the names are so lyrical, they just roll of our tongues. The US Govt funded drugs for soldiers serving too many tours of duty in the Middle East who are now coming back addicts and psychiatric cases suffering from PTSD. And now the US Govt is funding the VA hospitals with millions to treat the drug addicts and psychiatric cases they created. So I can't really blame the doctors. I wish it were that simple.
  • meyati
    I have surfer's ear-diagnosed by Navy specialists. This means that I'm allergic to acetaminophen. With Surfer or Diver's Ear the reactions mimic a severe inner ear infection. I don't get any respect for that. I learned that i have to take an aggressive family member into the exam room to get any codeine. I go into the ER for accidents. They used to give me Darvon or some codeine. I've told them to go to hell and I don't bother picking up a prescription--When I hurt so much, why do they want to make me sick too?
  • D Someya Reed
    So, if you find it difficult to blame anyone but doctors for the prescription drug problem, how do you suppose things would be different (with doctors) if the profit or profiteering (unreasonable profit) motives were removed? Placing blame solely on doctors somewhat mirrors what some other countries do, as well. They do not legally punish those who manufacture defective or questionable products (in this case certain drugs). Instead, they hold those who sell these products directly to the public, legally liable. The legally liable “retailer” would then become the doctor who would have the ultimate responsibility of testing the product before dispensing it to the public. They claim the "retailer" should have known better pretty much as you are saying about doctors. Do you suppose this is the answer and the medical community would embrace it? I don’t disagree with you that doctors play a huge role in this but I think that others who place their own demands on doctors cannot be discounted or excluded. However, I doubt that either of the scenarios I mentioned above would ever come to exist in our society. Even if they did, two things certainly would remain and as they, too, revolve around the doctor you do have a very valid point. These are (and do happen though I’m making no claims upon statistical frequency): 1. Pressure from the patient (whether appropriate or especially when not) to “give me something” and, of course, the doctors who cave to this pressure. 2. Those doctors who feel they are not doing their job (or will be perceived as not doing their job) unless they give the patient something which in most cases would be a (fast & easy) pill. This happens most often in cases of an unknown diagnosis but drugs are given to deal with the verbally expressed symptoms. A dangerous practice if you don’t really know what is being treated. I realize, because of your background and personal leanings, you neither like nor agree with me saying this but hospices are ripe for both of these circumstances. Patients (but mostly family members) feel the hospice staff have done nothing unless they medicate the dying patient. Hospices perpetuate this by their repeated focus on pain relief through medication, their claim of expertise in it and their denial that there are some patients who simply aren’t in pain or have already titrated their medication to allow an acceptable balance between alertness, functionality and pain control. They even discuss it internally as part of “hospice arrogance.” If you disagree then perhaps you (or someone you know within the hospice industry) can explain to me why a hospice with medical records in their possession for a semi-paralyzed patient (which included detailed notations of further and “imminent internal spinal rupture and cord compression resulting in full paralysis”) would insist to the point of threats of discharge to be allowed to medicate said patient to unconsciousness (so as to be without pain at the onset) at each and every visit merely to roll the patient fully on her side though they claimed “We are not going to do anything but look” and expressed no concern for any later pain after the meds wore off. This was the hospice nurse’s demand and would be no different than knowingly causing pain in order to provide for its relief. The nurse’s actions were fully supported by the nursing supervisor, nursing director, executive director (though of non-medical background) and medical director of the hospice. The fact that the medical records also detailed the extent of tumor infiltration in both lungs was ignored and discounted when brought up with regards to the safety of placing and holding the patient in such a position. Not one of the hospice management staff actually came to the house or even attempted to call to discuss these concerns. The nurse’s assessment stood unquestioned by anyone at the hospice. This is irrefutably, unless you can explain different, an example of the attitude that (from paraphrased comments in conversations with the hospice): We are hospice, experts in pain control. It’s what we do best. If you say you don’t have pain, we won’t believe you. We know better because we’ve been highly trained for this and you haven’t. We know from experience that your cancer and your dying will both run a predictable course. If you say your pain is acceptable, we will watch for the slightest indication of discomfort. When we see it, and we will, we will medicate you because pain control is our primary function. It doesn’t matter to us whether you want to be medicated or not. Our goal and our purpose are to ensure that every one of our patients dies pain-free. That is a good death. This is not as much of an aberration as you might like to believe. I have had almost as many hospices express support for the actions of this hospice as were appalled by them over the years.
  • Always great to see someone write the truth about difficult medical problems.
    • James Salwitz, MD
      Thank you very much. Given the source I am particularly honored by your support. jcs
  • Kris
    I am not so sure who can be blamed. Although we are "ordinary" people, I believe that it's up to us, the patients, to know our body, learn what we want/need and decide what benefits us. It's our life after all.

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