There were 240 million opioid prescriptions in the U.S. in 2016, a number that accounts for about 30 percent of the world’s opioid prescriptions, and is enough for one opioid prescription for every adult American.
Experts believe the overprescribing of opioids is at least somewhat responsible for the current opioid crisis. This led to a national discussion around prescribing stewardship, as well as the development of policy and regulation with regard to opioid prescribing. Included among this have been limits on the duration of therapy, partial fills, and requirements that providers access their state’s prescription monitoring program before prescribing. These policies have had some success and there has been a decline in the number of opioid prescriptions in the last several years.
This should be good news, but unfortunately, opioids aren’t the only thing filling America’s medicine cabinets. Looking again at 2016, there were more than 190,000 kilos of amphetamines, drugs like Adderall and Ritalin, produced for consumption in the United States. The estimates are that about 16 million adults and more than 3.5 million children are taking these stimulants.
Americans filled more than 16 million prescriptions for benzodiazepines including Ativan, Klonopin and Xanax in the same time frame. Selective serotonin re-uptake inhibitors (SSRI) account for more than 49 million prescriptions per year.
Taken together, that is one psychoactive prescription for every person in the United States, from the youngest neonate to our oldest citizen. This is an astronomical figure and is a clear signal that in the United States, mental health is treated with pharmaceuticals.
This has been coupled with some devastating results. There has been a four-fold increase in benzodiazepine related deaths since 2002. Benzodiazepine deaths involving opioids have nearly doubled. Overdose deaths from prescription amphetamines aren’t specifically tracked, but there are known cardiovascular risks to use of these drugs. These statistics are alarming, but they don’t tell the whole story. As healthcare providers, we are truly missing out on the opportunity to help, to comfort and console, when our answer is to always pull out the pen and the prescription pad.
I will cite one example from my own personal experience. When my grandfather died, my grandmother, his wife of close to sixty years, was grieving. She was deeply saddened that the man, a U.S. soldier who rescued her, a Jewish woman, from Paris in World War II, had died. Her geriatricians response; an SSRI. I was disappointed by this. I am sure my grandmother’s geriatrician wanted to help. He wanted her to feel better. But a drug wasn’t going to help. This was grieving and it took time and family support to help her through that difficult time. But I fear that far too often, it is just easier to write a script. This is simpler to do than listening, talking, caring, holding a hand, reassuring and healing. It replaces compassion and empathy and it helps to keep that appointment, that visit, that encounter to a minimum. This is not how to practice medicine.
“This pain is killing me”
“Can she have something to help calm her nerves”
“I need something to sleep”
These are complaints that can often be alleviated with a therapeutic conversation, delineation of expectations and non-pharmacological intervention. But as the statistics clearly show, prescribers have had a hard time saying no. Explaining why we shouldn’t do something, like writing a prescription when one isn’t necessary, is often more cumbersome than just doing it. All providers enter medicine or nursing to help, but their training relies heavily on the pharmacologic management of disease. And it goes beyond training. There are concerns about cost containment, patient volume, and of course, patient satisfaction scores. As a result, the prescription pad is pulled out at the end of many healthcare provider visits.
As a result, patients have been flooded with opioids, benzodiazepines, amphetamines and SSRIs. This has been a harm to society and a harm to the profession of medicine and nursing. The result has been an alarming increase in addiction and overdose deaths in the last several years and not just from opioids. But we can make amends.
It is time to admit that our medical system has become far too reliant on pharmaceuticals. Admitting fault after medical error has been found to actually strengthen the physician-patient relationship. Medical error is often a system issue and admitting fault can help to correct the underlying issues that lead to that error. This is not to say that these medications don’t have a place in care. They do, but certainly not to the extent that they have currently been deployed.
For budding healthcare providers, there is a need to integrate curriculum centered around patient communications that focuses on setting therapeutic expectations, exploring non-pharmaceutical pathways of care and encouraging communication. Discussions around pharmaceutical treatment need to be coupled with discussion around empathy and compassion. For those already in practice, there is an urgent need to allow providers to spend time with patients, allowing them to develop therapeutic relationships rather than a dependence on pharmaceuticals; patient and provider alike. There is a message here for researchers here as well. The answers aren’t always in biomarkers and drugs.
Taking a more cautioned approach to treatment, to all psychoactive drugs, is an important first step to ending the over-prescribing epidemic. This must be coupled with healthcare policy that is less focused on throughput and more on engaging in therapeutic patient-provider relationships and developing longitudinal care for individuals and families. The pen is mighty and as with the sword, must be wielded carefully and cautiously. This has never been more evident when those pen strokes are writing a prescription.