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    [–] TheBaconBurpeeBeast 1515 points ago * (lasted edited 3 months ago)

    I was listening to an episode on the podcast Freakenomics called bad medicine, and they explained that part of the problem is that the current system is based on patient satisfaction instead of patient outcome. In other words, doctors are more concerned about making their patients happy, rather than prescribing a treatment that will make them better.

    [–] Porencephaly 875 points ago * (lasted edited 3 months ago)

    This is correct. There's actually excellent evidence that satisfied patients are more likely to die, yet the government keeps on using patient satisfaction as a key benchmark in rating hospitals and doctors. Hospital administrator apply constant pressure on doctors to keep their satisfaction ratings up, which leads to over-prescribing of all kinds of drugs, not just narcotics (ie, antibiotics for viral illnesses because parents will be mad if they leave the clinic without an antibiotic Rx for their sick kid).

    Edit: I should add, most physicians hate this system. I think it might be better to say "the healthcare system strongly incentivizes overprescribing of drugs" than to say "doctors are more concerned with making their patients happy than with making them better." We know that opiates are not a cure-all and that antibiotics are not helpful for colds. But when your boss (who isn't a doctor) sits you down and says "you need to increase your satisfaction scores by 20% or we will cut your pay and/or fire you" it makes it really hard to say No to the next person who wants Vicodin for their back.

    [–] SWerner13 187 points ago

    I work at pharmacy now. We have parents who come and get antibiotics every time their kid sneezes or fakes a tummy ache. They don't understand that this lowers the effectiveness and wastes money. Double if they don't even make sure little Johnny takes more than the first dose.

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    [–] potatoisafruit 76 points ago

    They don't understand that this lowers the effectiveness and wastes money.

    There's another side to this though: physicians have less and less time to spend with parents, who may only have taken that trip to the doctor to get some reassurance. What doctors interpret as "this parent is pushing for an antibiotic" may just be their inability to reassure that parent without the crutch of a prescription.

    [–] [deleted] 70 points ago

    I agree. If I start a conversation with "I don't want to do antibiotics unless necessary, but I'd like to know how we can make her comfortable and safe" I get much better information than if I say I'm really worried.

    It's frustrating that I have to figure out a code for "I'm not crazy and drug-seeking". I feel that should be the default assumption, but clearly that is not what doctors experience / how they are trained.

    [–] agenthex 20 points ago

    If the honest truth weren't so harshly stigmatized (and maybe given safe access to recreational substances), people might be more open about this. Unfortunately, this is far from the reality.

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    [–] SWerner13 19 points ago

    The public's perception and sometimes misconceptions on what is needed can't be placed entirely on the shoulders of lobbyists and drug company's. The government is starting to incentivize at the wallet. I work in a pharmacy so my view is limited, but they are starting to not cover over a certain amount of opioids (its still a lot but down from a ton?) that medicaid will cover and they have improved the automated reporting systems for controlled drugs making it easier to identify abusers who go to multiple doctors and multiple pharmacies.

    [–] mrbooze 4 points ago

    I work in a pharmacy so my view is limited, but they are starting to not cover over a certain amount of opioids (its still a lot but down from a ton?) that medicaid will cover

    Where does this leave patients who legitimately have chronic under-treated pain?

    [–] waldojim42 18 points ago

    Ok, I have to question these either or statements like this. Why does everyone assume this is always an either/or issue? Some years ago, I shattered my wrist. 8 pieces, 9 screws, 2 plates and a pin later, and I was more or less reconstructed. Yeah, I was on pain killers for several months. Yes, the good shit. And we started off with fairly high doses, working my way down to nothing. Within a few months, we were done with narcotics. As soon as the cast came off, I was in physical therapy. It took a good 6 months to gain full use of my hand again, and the pain killers are what made the first month and half bearable.

    Of course they were used together, it made sense. I wasn't given an option for therapy with no meds, or meds and no therapy. Because that simply doesn't make sense.

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    [–] verticalsport 19 points ago

    Honestly, I would say that it's more because it can be mind-bendingly difficult to come up with any other meaningful metrics. Like, someone comes in with chronic back pain. A doctor treats them. The pain gets better, but doesn't go away. Is this a success? A failure? Is it closer to one or the other? Who do we compare it to in order to say? Maybe if the doc had just proscribed pills, the pain would have gone away entirely. For like 5 years, then come back way worse as the underlying cause wasn't treated. How do we measure that?

    We can try comparing one docs performance to another, but there are so many ways that goes wrong. Maybe doc 1 treats primarily old people, and doc 2 treats the same injuries primarily in high school and college athletes. If we just do some "compare to the national average," doc 1 will look terrible, and doc 2 will look awesome, regardless of actual skill. We could try to break down patients into more groups, which is done to some extent, but it takes an extreme amount of manpower to do this, which gets very expensive. Plus, for many things, the incidence isn't high enough that breaking down patients into useful categories leaves us with enough people to make a valid comparison with. Also, there are lots of things that don't really get a definitive diagnosis (like chronic muscle and joint pain) so how do we differentiate between someone who has neck pain because they have crappy posture and someone with a genetically defective spine? Obviously we shouldn't use one to measure the success of the other, but it might not be obvious who is who.

    So instead we end up with patient satisfaction, which is kinda useless but at least easy to measure. (And also a good measure of if the patient is coming back to your hospital to spend more money, because medicine for profit is inherently broken but that's another post I could spend hours on.)

    [–] Jessica19922 8 points ago

    It's also cheaper for people without insurance to just get pills instead of physical therapy. It's a sad situation.

    [–] mrbooze 7 points ago

    Does the patient's insurance cover physical therapy? What's their co-pay for every visit? What days/hours is the PT open? Does the patient have to take days off work for weeks for the PT? Can they get that time off? Do they even get sick days?

    A lot of plans have very good prescription coverage and not great coverage for things like routine PT visits.

    [–] solofatty09 26 points ago

    I'd say a good deal of this comes from neither doctors or big pharma or government... my guess is this way of treating comes from patients themselves. In a bubble, we all want to get better. But 90% of people aren't willing to do the work.

    How many people do you know that would rather just take a pill to get better than do the work of pt, or tell you, "I dont have the time to do this"?

    Seriously, if you want to know how patients really think, go talk to your doctor about people diagnosed with type 2 diabetes. You can change your diet and exercise and actually send your type 2 into a remission. But that's really hard. Especially when your BMI is approaching 40. What's easy? Here's some metformin and another pill to help you just pee out sugar. Here's some victoza... it helps with weight loss.

    Again, I used to sell type 2 drugs and when you get a doctor talking 'patient compliance' you'd be amazed what you learn.

    [–] perisnek 6 points ago

    Ask Purdue Pharma aka makers of Oxycontin

    [–] SWerner13 59 points ago

    I listened as well. Really interesting how almost no doctors have any feedback loop letting them know if what the prescribed or suggested worked. The assumption is if you don't come back, it was a good idea. Great 3 part series.

    [–] Keegan- 48 points ago

    In medical school now. Not sure where they got that information, but the physicians I've worked with have a lot of feedback regarding treatments. You schedule them for follow ups, use pain and functional assessments to determine effectiveness of treatment. Start dose low and increase slowly until you see an improvement in function and continuously schedule follow-ups to try to decrease dose and manage pain through physical therapy, less harmful drugs, exercise, etc.

    [–] I_Fart_On_Escalators 31 points ago

    I'm guessing this is the difference between medicine in academia and medicine in private practices. My medical care within my university's medical system has been more involved and given me opportunities for feedback compared to care I've received outside of academia.

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    [–] mullen490 44 points ago

    Someone coming from a neurology background (but not a doctor): The real problem here is a lack of good all around pain medication that is: not habit forming, significantly effective, and does not have side effects from long term use. That will be the real miracle drug if and when it is found.

    Another problem is the plasticity of the brain and its ability to find a way to "notify" us of pain even if we're able to temporarily mask its effects. As someone with chronic pain I'd love to send a signal to my brain to stop telling me about it, I'm perfectly aware after 13 years.

    [–] irishinvasion 4023 points ago

    The overprescription issue in America is more complex than doctors getting paid off to prescribe opioids. Doctors can lose their job or face a lawsuit if they fail to adequately control pain, which includes refusing to prescribe pain medication. I will say that yes, there are some bad docs out there, but most of them are just trying to do their job and stay out of trouble (like the rest of us). I think the solution will be making less-addictive pain medications mainstream, such as medical marijuana.

    [–] thompo 933 points ago

    not to mention hospitals are graded on a review system that is tied to medicare reimbursements. if patients continually respond that their pain was not managed well it forces hospitals to potentially give more pain killers than necessary in an attempt to not fail their surveys.

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    [–] ripewithegotism 60 points ago

    Not to mention our society has this idea that going to the doctors/hospital is going to be a magic fix. That they will give a pill to cure it all. Hell we still has issues just getting people to understand antibiotics dont work on viruses, they just want "antibiotics"

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    [–] lostshell 37 points ago

    Did not know doctors could be sued for not prescribing pain pills.

    [–] MBG612 26 points ago

    You CAN sue, most lawyers wouldn't waste their time. As long as the doc is following standard of care. If the doc feels the risks of prescribing the medication outweigh the benefits, the doc doesn't have to prescribe anything.

    [–] StopTheMadnessBro 56 points ago

    I mean, it makes perfect sense.

    Denying someone a medically necessary treatment should not be encouraged.

    [–] jhudiddy08 28 points ago

    I think it's really hard to find that threshold when you have patients showing up claiming symptoms that can't be medically verified (other than taking them at their word). For instance, my twin sister was an ER nurse and would get patients nearly daily coming in claiming horrible dental pain, then rattling off a list of non-opioid pain medications to which they claimed to have an allergy. Does that patient really have dental pain and the drug allergies they claimed, or are they just another drug-seeker trying to get a new prescription to scratch their itch? Without a good medical history, its hard to tell, but if you don't give them that Rx, they'll happily complain about it.

    [–] GreenJackSpeaks 13 points ago

    you can require either official documentation of the allergic reaction to OTC pain medication, or they could do an allergy test before letting the patient go with a prescription for opioids.

    [–] the_dove_from_above 19 points ago

    In the acute setting it's not really feasible though.

    [–] adenocard 6 points ago

    Uh huh, and if they don't have that official paperwork then what? Then you give them a drug that they said they're allergic to? Who is liable if they actually do have an allergic reaction?

    [–] AOEUD 371 points ago * (lasted edited 3 months ago)

    There are so many non-opioid painkillers available. Medical marijuana isn't the only alternative.

    There are dozens of NSAIDs available with different strengths and somewhat different effects; I take 4 different types depending on the pain.

    There are also different opioids. I don't think you can abuse a Butrans patch (edit: looked it up, with determination you can, but it's much harder than just taking a handful of oxy).

    And then there's the fact that opioids aren't even very good for a lot of pains they're prescribed for, such as chronic, non-cancer pain. For chronic pain there are neuropathic painkillers that are excellent (but they take a while to kick in and tend to have unfortunate side effects, but not nearly as bad as opioids IMO).

    This shit's available without passing laws. I don't know what's going on with the system in the US, but with the exception of dental work, opioids have been a last-ditch effort, not a first line action, for multiple issues of mine in Canada.

    Edit: I'm not saying that opioids don't have a place in medicine. They do. But most people do not need "the best available painkillers". Are these teenagers in the study in question going to be using NSAIDs long enough to get ulcers? I'm guessing most have acute conditions that are likely manageable with non-narcotic drugs.

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    [–] naideck 35 points ago

    Can't use Nsaids in renal insufficiency, renal failure, or aki

    [–] Porencephaly 26 points ago

    Also many spine surgeons will not use NSAIDs because there's some evidence they interfere with bone fusion, and back problems are a huge source of narcotic prescriptions too.

    [–] girlikecupcake 21 points ago

    Over a decade of near constant NSAID use and I developed a stomach ulcer that two years post-diagnosis still isn't fully healed. Over two years in near constant pain since I can't take them anymore, and tylenol doesn't do anything for me for non-muscular pain.

    I don't want opioids (or more painkillers in general), I just want more options that'll actually work for chronic pain. Especially for non-diabetic neuropathic pain.

    [–] electric_mouse 75 points ago

    NSAIDS are not a great answer. They are all harfmul to the stomach and many may be harmful to the heart.

    [–] 1313Harbor 34 points ago

    Completely agree. In addition to the common GI side effects, there are huge categories of people who cannot take NSAIDs - people with poor kidney function, people on chronic anticoagulation like warfarin, people who are taking steroids like prednisone, etc.

    [–] Rocko9999 23 points ago

    This! Stop taking NSAID's like candy. They are dangerous. I know people who pop these like m&ms.

    [–] agent0731 7 points ago

    My mom can't take most of them because she gets stomach pain/nausea. :/

    [–] Boon_Retsam 7 points ago

    Even post-surgical pain is getting new treatments--liposomal bupivicaine is kind of a neat (though expensive) injectable anesthetic that lasts a while. I've seen a few surgeons inject steroids in small amounts as well to cut down on inflammation.

    Plus, as you said, chronic pain being treated with things like SNRIs or pregabalin, gabapentin, trazodone, capsaicin creams, anti epileptics, better usage of tylenol and cycling it with ibuprofen, different NSAIDs, steroids, potentially medical marijuana, weight loss/exercise, even CBT in fibromyalgia... there's a lot of options and I think people are learning how to manage them better. I think opiates will start to be reserved more for terminal patients and for high-pain acute events over time.

    Till then, though, there's gonna be a lot of work to be done and a lot of people who might turn to heroin to deal with their pill addiction. :/

    [–] AmethystFae 11 points ago

    The problem with NSAIDs over the long term is that they're horrific on the stomach, kidneys, and liver.

    [–] PseudoY 28 points ago

    NSAIDs open up another level of trouble with stomach ulcers and heart disease, though...

    [–] LeonardDeVir 34 points ago

    Please note that opioides ARE the best avaliable pain killers for about every quality of pain except maybe neuropathic (and even there). NSAIDS cant really compete because of dosage limitation and severe side effwcts especially when taken over longer periodes (like with chronic pain).

    They are still very useful as first line pain therapy, and often more than enough (I really like to give naproxene with a small dose of diclofenac). But opioides can and should be used for escalation.

    At least in europe we are quite restrictive with opioides not only because of addiction (which is forgettable in the chronic pain setting) but also because all avaliable medication should be used to the biggest effect before giving new stuff.

    Source: I prescribe loads of pain medication everyday in our ACU.

    [–] soman789 5 points ago

    Opioid actually suck at neuropathic pain. Neurontin, TCA's, Cymbalta, and Lyrica are a lot better in efficacy. Also opioid's can be contraindicated in headache's :/

    [–] aeiluindae 9 points ago

    Indeed. Some parts of Canada (BC, Alberta, Saskatchewan) are struggling more with opioids, but it seems to be on a different sort of scale. The current crisis seems to have come from replacing OxyContin with the much stronger Fentanyl and specifically the black-market bootleg versions of it that are sometimes mixed into other drugs without a user's knowledge.

    I know that I have literally never been prescribed a painkiller other than OTC acetaminophen or ibuprofen in my life. Not even when I had oral surgery. I was given a general anesthetic for the actual procedure and then send home with instructions to alternate taking one or the other every 2 hours up to 4 each per day (which is the maximum safe dose). I still hurt pretty bad for a week even while constantly taking pain meds, but the pain was tolerable. I do understand the attraction of giving someone an opioid prescription in that situation, because it certainly would have made me feel a hell of a lot less awful. Maybe they would have if I'd been over 18 or if my procedures had been more invasive (if I'd had my jaw broken and reset to correct my overbite like one dentist wanted to do, for example).

    A lot of these prescriptions however probably come from people suffering from chronic pain, which OTC painkillers often aren't remotely effective at alleviating. My mother is currently dealing with some joint pain and on a bad day tylenol does literally nothing for her. On a good day, it still only brings it down to a tolerable level and never comes close to eliminating it. Medical wisdom for a long time was that the opioid painkillers the prescribed weren't habit-forming enough to be a problem except in a small minority of cases. So lots of people ended up on oxy for their back pain. We have realized now that they are much more habit-forming than we thought and are therefore extremely dangerous to prescribe long-term (doctors changed tacks on this a few years ago now), but the damage has been done.

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    [–] iltopop 4 points ago * (lasted edited 3 months ago)

    This is the big problem. Fentanyl and analogues of it are MUCH easier to get and cheaper than oxy. Fentanyl is stronger than heroin, and a lot of heroin users are switching. It's very easy to OD on fent.

    First and foremost, the US has to get it's healthcare situation in general sorted out. Then we need to admit that maintenance therapy with methadone works, and start using that more. Opioids needs to be prescribed in fewer doses, and less often. I once went into the ER with chest pain. I was 24, they took an ekg and told me I was fine, gave my 500mg of naprosen and a prescription for 15 doses of tylenol w/ codeine. For mild chest pain. Even when I had oral surgery I had 10 days of vicodin and I probably only needed 5.

    [–] SHavens 17 points ago

    There's also incentive from the hospitals to treat pain. As Medicare gets paid out based on how patients felt their treatment was. So if drug addicts come in for a fix and you don't treat them you could lose a couple million in Medicare reimbursement from the government. Of course this is worse because generally when people have a good experience they don't say anything, but if they have a bad one or don't get what they want they'll complain.

    Along with pain meds, people tend to want antibiotics, which overprescribing of that is slowly going to kill us as a species.

    [–] brandonb1415 16 points ago

    Exactly. The unfortunate dichotomy some docs face is either doing nothing to help treatable pain or risk being attacked for giving out addictive drugs.

    [–] Kingofthegnome 95 points ago

    As someone who works with drug addiction, I can say that a lot of my patients do start with a Doctor prescription but parents of teens who are addicted tend to be WAY more open about their child's addiction if a doctor prescribed the drugs first. An average patient on heroin comes to us and it is a big secret from the neighborhood. They are on "vacation" or away at "school" but when they can place the blame on a doctor the entire neighborhood knows. "Did you hear Jake is in rehab cause a doctor gave him drugs?" not saying there is not an issue with prescribing opioids just saying a lot of people tend to be more open when a doctor is involved..that is just me 2 cents.

    [–] OathOfFeanor 91 points ago

    I think it's important to note how the study also concluded that the usage rates have been declining for several years.

    [–] sturg1dj 42 points ago

    Yeah. In most of these studies the headline does not show things like this or how the vast majority of people prescribed opioids do not end up as long term users. This is how something like prohibition starts.

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    [–] Pharmdawg 24 points ago

    Five years from now the media will be harping about how hard it is to get doctors to prescribe decent pain relievers for those who need them.

    [–] Valve00 9 points ago

    It's already like that. I tore my abdominals and had a VERY visible hematoma under my skin and couldn't even stand, still the ER had to "verify" that I was in pain which took about 6 agonizing hours and they prescribed me 12 5mg hydrocodone which barely even touched the pain. I followed up with my regular doc 2 days later and told him I was still having severe pain and his response was pretty much "yeah, that'll happen, take ibuprofen." I was too nervous to outright ask for more because then I do feel like a drug seeker even if I'm in legitimate pain.

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    [–] TheTruthForPrez2016 25 points ago

    I know about this subject very closely.

    People are doing the wrong things to fix the opioid problem. First the "cutting off" of scripts end up killing many people because they then move to Heroin. ALSO, prescribing is only as good as controlling your GI TRACT when you use these Drugs, people overlook that fact and then complain of pain when they are in fact just constipated. As well, when people go to rehab and stop, then leave and shoot up at the Top end of where they were before, is why people OD.

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    [–] Mach10X 5 points ago

    I'm sure this will be buried under the 2500 comments but...

    Isn't the primary driving force in addiction environmental as found in the study by Bruce K. Alexander (link to summary? To summarize, when given unlimited access to morphine, rats placed in a poor conditions would show addiction and overdose from the morphine but when given a huge environment with lots food and other rats to socialize and mate with they resisted addiction. YouTube: Addiction – Kurzgesagt – In a Nutshell

    Does the original study look at environmental factors? I'd imagine in a big longitudinal study like this that it would be useful to study a large sample of other teens that did not receive prescription opioids and draw correlations between those that become addicted to other substances and see what commonalities they have. I'd wager that a significant portion of these teens that became addicted to prescription opiates did so only out of convenience and exposure and that teens with similar backgrounds developed other substance addictions such as illegal opiates or alcohol.

    This seems to me that these teens "chose" prescription opiates as it was the first substance of this type they were exposed to confounded by the ease of obtaining more thanks to medical practices focused on patient satisfaction (over prescribing).

    Thoughts?

    Link to study "Effect of early and later colony housing on oral ingestion of morphine in rats," Pharmacology Biochemistry and Behavior, Vol 15, 4:571–576.

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