How Is Prescribing Opioids Like Coaching Football?


September 10, 2014

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Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

Thank god -- small "g" -- it is finally football season again. Oh, I know, it is violent, and a lot of people get hurt, some really badly; but it is a voluntary activity, and the participants do give some sort of informed consent. I have loved it, especially at the college level, since about 1944. New rules are making it somewhat safer.

When Darrell Royal coached the Texas Longhorns to three national championships in the 1960s, he used a wishbone formation and almost always ran the ball. He said that "three things can happen when you throw the ball...and two of them are bad": You may complete the pass, it may be incomplete, or it may be intercepted.

A quick segue to American medicine in 2014. Doctor, when you prescribe an opioid drug for a patient with pain, three things can happen, and two of them are bad: The patient may have successful short-term pain relief, the patient may become addicted, and/or the patient may overdose.

The United States is experiencing new waves of drug trouble. This time, the trouble was hatched by the "law of unintended consequences." The Joint Commission and others succeeded in making pain the fifth vital sign, which seemed like a good idea.

Not so good, it turns out. Americans have a lot of pain. US physicians are now especially striving for high patient satisfaction scores. Ergo, mucho prescriptions for pain-relieving substances. However, oral opioids can addict and can kill by overdose. And they not only can, but do -- a lot.

Unless you, doctor, are really careful about your prescriptions for opioids, if your patient gets into trouble, you may find your practice ass in a wringer. The Drug Enforcement Administration, the local fuzz, your state licensing agency, myriad plaintiff attorneys -- they will all want a piece of you.

Bad Odds in Some States, Reason for Hope in Others

According to recent data[1] on the number of prescriptions written for opioids (260 million per year nationally, and tallied by state), you physicians and your patients in the football-crazy states of Alabama, Oklahoma, West Virginia, and Kentucky stand most at risk. Your prescription numbers of >128 per 100 people per year are far greater than in, say, California, Hawaii, New York, and Minnesota, with fewer than 63 prescriptions for opioid pain relievers per 100 people per year.[1]

Bad odds, not good medical practice. There are lots of ways to do better. The recent rescheduling of some opioids will help. Substituting cannabis for opioids, if it is effective, could be a giant positive step, because the cannabis safety cushion for lethality is so huge.

There is hope. The Gator (Florida) and Volunteer (Tennessee) states have made recent dramatic improvements.

Please do not prescribe opioid pain relievers for chronic pain unless you simply must, and then only in a very limited way. Protect your patients and yourselves. And for those docs and patients in the most football-loving and opioid-prescribing states, a biased, positive note in this grand season: Roll Tide!

That's my opinion. I am Dr George Lundberg, at large for Medscape.


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