The Beginning of an Epidemic

August 20, 2017

I am conservative when it comes to prescribing medication as a rule. I believe in using the least amount of medication necessary for the shortest amount of time to achieve the desired outcome. I favor non-pharmacological treatments over medicine whenever possible. As a result I am a sleep physician that does not prescribe "sleep medicines". This may seem odd but the reason is that traditional "sleep" medicines are really sedatives. There is a difference between sedation and sleep as described by this article from the New England Journal of Medicine. These sedatives are associated with several adverse outcomes including motor vehicle accidents, dementia and death. Sedatives are very effective at what they are designed to do which is make people unconscious. I used them routinely when I worked in the intensive care unit. Interestingly they are also associated with adverse events in the ICU as well. Patient's who have sleep disorders like sedatives because sedatives makes them unconscious quickly and prevent awareness of poor quality sleep. Sedatives actually hurt your quality of sleep by suppressing REM sleep and making sleep disordered breathing worse. Sedatives cause physiologic addiction so people who use them experience withdrawl if they stop abruptly. Long term use of sedatives will cause tolerance so that a dose that used to work no longer works and the poor sleep quality returns. The options are to go up on the dose or go through withdrawl. That is why the FDA has only approved sedatives for short term use - weeks to months in most cases. Why would anyone prescribe these drugs long term?

The press is full of stories about the opioid epidemic in America right now. Prescribed opioids are the number one cause of drug overdose death in the country. Prescribed opioids kill more people than heroin and cocaine. Why are opioids being over-prescribed by physicians? I recently read this concise review of the opioid epidemic in Medical Economics. The opioid epidemic started in the mid 1990's when The American Pain Society concluded pain was under-treated. This lead to pain scales being incorporated into vital signs. Then a private company called The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) decided that hospitals should not be paid by medicare unless they do a better job treating pain. When hospitals get threatened with non-payment from medicare what do they do? They put together committees and care plans to address that issue. In this case hospitals made a conscious effort to address pain which resulted in physicians writing more prescriptions for opioids. In the US there were about 80 million opioid prescriptions written in 1991 and in 2011 that grew to 220 million. Over 15,000 Americans are dying annually from prescribed opioids. This epidemic demonstrates a major failure in JCAHO and our federally funded healthcare programs. If a physician is responsible for one death due to incompetence we get sued and can lose our license. JCAHO promoted a practice which has influenced hundreds of thousands of deaths and still has a major influence on our healthcare system. Why aren't regulatory bodies held to the same standard?

One more interesting fact. The incidence of narcotic overdose is higher in patient's taking sedatives. Don't worry - I am not going to be pressured into prescribing sedative medications.