At Last . . . I Hope!

At last! No, I’m not thinking of Etta James’ version of the song that became de rigueur at weddings, reflecting the consummation of a romantic longing. Nor am I thinking about Stanley Kubrick’s A Clockwork Orange, when the prison governor sarcastically tells the newly imprisoned Alex about the ideas just put in place for reforming violent criminals using aversive conditioning, which he feels confident are misguided and certain to be ineffective.

What I’m thinking about is the “AT LAST!” that’s spoken emphatically and with tremendous relief when something too long in gestation has happened. As in FINALLY!

[[{"type":"media","view_mode":"media_crop","fid":"48695","attributes":{"alt":"© VLADIMIR BOROZENETS/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_5255619266088","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5845","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"139","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"© VLADIMIR BOROZENETS/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]What has happened at last? The CDC and FDA have finally recognized that there might be something of a problem in the way opiates are prescribed (like . . . well . . . like antibiotics). I mean prescribed casually, with little thought for the undesirable but totally predictable adverse effects on individuals and populations.¹

Who could possibly have imagined that lots of people would become addicted to opiates? And never could anyone have thought that such addictions would lead multitudes in every part of the country and from every socio-economic group to become heroin addicts. Just because heroin is much cheaper and arguably easier to come by than prescription opiates, who in their right mind would want to use heroin? Or did they just not realize the clawing craving that opiate addiction induces?

Did it not occur to anyone at the FDA to stop and think about the fact the opiates were revealed last year to be the most widely prescribed drug category to Medicare patients? Was there no concern when prescription opiates were recently approved for use in children?

Yes, I know that many, many patients have severe chronic pain, and I know how important opiates can be in end-of-life palliative care for cancer or in hospice care. I’m not really a puritan, but I am greatly relieved after years of exasperation that at last there is recognition that the widespread personally and societally debilitating heroin epidemic is at least in part iatrogenic. I don’t believe any physician wanted to addict his or her patients to opiates. I know only too well the conundrum for physicians when confronted with an addicted patient who didn’t intend to become one, but who is hooked and who wants us to continue prescribing an addicting medication that may not be clinically indicated.

It is reassuring that opiates are not the first treatment of choice in chronic pain recommendations. If used, they must be part of a multifocal plan that includes non-pharmacological treatments. Extended-release and long-acting formulations are not recommended for acute pain. Someone should have shown these guidelines to the surgeon who recently did laparoscopic surgery on one of my kids and then gave a prescription for 50 oxycodone tablets.

For a complete description of the CDC recommendations,² see the report on the CDC website-my aim here is not to review the comprehensive report. While psychiatrists are often called upon to deal with the addictions the overprescribing of opiates produces, we are rarely the ones who wrote or suggested that someone else write the initial prescription. I think our role in the prescription opiate addiction problem and its subsequent heroin addiction epidemic is more cleaning up a mess for a problem someone else created.

As psychiatrists begin to read the CDC guidelines for use of prescription opiates, there is, I hope, an aspect of what has occurred with those medications that serves as a cautionary tale for us. I’m referring to the explosion of stimulant and sedative prescriptions for our patients.

When it became known with more certainty that ADHD persists into adulthood, we began seeing 2 increasingly large groups of patients. One group had been prescribed stimulants starting in childhood; now complaining of adverse arousal effects, they are being prescribed benzodiazepines-often in large doses and for many years. (I won’t belabor the fact that 2 to 3 times as many patients are prescribed stimulants as epidemiological data about ADHD prevalence would suggest should receive them, and I know that most of the prescriptions for children are written by pediatricians.) Adults presenting with complaints that they have unrecognized ADHD for whom stimulants were prescribed based on their stated symptoms make up the second group. Most college students know what to say to get this longtime study aid. Patients presenting with mixed depression and anxiety make up another group.

For decades, benzodiazepines have been among the most widely prescribed medications-most often by non-psychiatrists. But what has happened in recent years seems to reflect a shift in our own prescribing patterns. And it’s not only for ADHD patients, many of whom have never been formally evaluated neuropsychologically, either as adults or children. As the mixed depression/anxiety symptomatology of many patients became a subject of greater awareness within psychiatry, benzodiazepine use grew.

We know that for many patients with mixed anxiety/depression, effective treatment with antidepressants relieves anxiety symptoms as well. But benzodiazepines, prescribed as short-term adjunctive treatment while waiting for the antidepressant to take effect, somehow became long-term therapy. And too rapid dosage tapers produce rebound symptoms so aversive that patients wind up resisting even the most judiciously slow taper.

Today, I saw a patient with a history of depression who had first come to our clinic only a few months ago who has been taking benzodiazepines for over 30 years. Think about how the conversation went when I suggested it might be important to him to reduce or eventually discontinue that medication.

But last week I saw a patient whose primary diagnosis was depression. She had been prescribed a high dose of a benzodiazepine at the start of treatment to address mixed anxiety/depression symptoms. When her depression resolved, her physician continued the benzodiazepine. At her request, the dosage had been slowly tapered by half. When I asked if she had noticed anything different, she offered that she had noticed her thinking had become much clearer in recent weeks.

I’ve also been thinking about the many patients who come to our clinic addicted to amphetamine-type stimulants and/or benzodiazepines. Few of these patients are looking to get high. They are merely looking for treatment, just like the vast majority of chronic pain patients. Few will consider trying to stop these medications.

Stimulant and sedative addiction is a much more insidious epidemic than prescription opiates or heroin. I’m not sure anyone has a good sense of how large this problem really is. These patients are not turning in droves to heroin, and they almost certainly never will. But for a good proportion of them, their problems are likely at least in part to be iatrogenic-just like those who turned to heroin after becoming addicted to prescription opiates.

Now that the CDC has stimulated the FDA to take action about prescription opiates, it’s clear that something must be done to bring these other groups of unfortunately and inadvertently addicted patients to the forefront of clinical guidelines discussions . . .  at last, I hope.

Disclosures:

1. Fox CR, Linder JA, Doctor JN. How to stop overprescribing antibiotics. New York Times. March 25, 2016. http://www.nytimes.com/2016/03/27/opinion/sunday/how-to-stop-overprescribing-antibiotics.html. Accessed April 14, 2016.

2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. 2016;65:1-49. http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed April 14, 2016.