By Josh Bloom — September 22, 2019 My mother is one of the “lucky ones.” She has a devoted family and caretaker, is able to live in her own home, and doesn’t have to worry about choosing between food and prescription medications. But she is also 92 and recently her chronic back pain has gotten severe enough that it can sometimes prevent her from walking.
She also has a good primary care doctor. He’s likable, concerned, and also sharp.
But here’s what concerns me and should really concern you.
Following her exam, I spoke to him by phone. His plan to address her pain was to increase her Tylenol dose from four to eight per day. Of course, doing this was not going to help one bit, but I can understand his reasoning.
“In her case, there are only three choices, Tylenol is one. NSAIDs are unsafe for the elderly, especially for their stomachs and kidneys. So we’re left with opioids, which we don’t want to use.”
He was technically correct but was speaking from a safety perspective, which has no doubt has been shaped (distorted, really) by the wrong-headed demonization of pain medications.
For most people, even an elderly woman, a daily dose of 2,600 mg of Tylenol – a bit less than the daily recommended maximum – will be safer than long-term use of Advil or Aleve. Barring liver toxicity, it will also be safer than Vicodin or Percocet. But that’s not the whole story. Safe isn’t all that safe.
Tylenol won’t hurt her or help her, but her pain is already harming her, so it is the choice of Tylenol, not the drug itself, that will hurt her, albeit indirectly. And if the pain is not relieved she will certainly spend more and more time in bed. That will hurt her too – worse than any drug.
It is this pernicious shift in the mindset of medicine – consideration only of risk, not benefit – that is most troubling. And since the callous zealots, who I so often write about, have so spectacularly succeeded in equating the terms “opioids”, “risk,” and “addiction,” it has now become essential for most physicians to protect patients (and themselves) from risk, regardless of whether the benefits clearly outweigh the risks. If they are lucky enough not to be harassed by the DEA/DOJ and a patient using opioids dies, look out – lawyers will be circling.
This is the worst kind of defensive medicine and its practice is now far too often standard practice. The CDC’s mea culpa this past summer was far too little and far too late. The medicine cabinet door was closed after the pills escaped and it won’t be reopening anytime soon.
My mother is probably a little luckier than yours will be. Although her physician was probably aware that Tylenol is no more effective than placebo for back pain (See Tylenol Isn’t So Safe, But At Least It Works, Right?) and that tramadol (1,2) does not even belong in the same sentence, let alone classification with hydrocodone or oxycodone; it is far weaker, I wasn’t getting off the phone until he agreed to let her try it. I shouldn’t have had to even mention it.
What is going to happen when your arthritic, elderly mother leaves her doctor’s office with a big bottle of Tylenol? What is going to happen if she needs something stronger?
We already know the answer. Pain patients have been living it for years. Let’s call it “risk-free suffering” – a term that might have made it into 1984 had it been written 70 years earlier.
It is now two days since my mother tried tramadol. Her pain level has decreased substantially; today she was able to go out for brunch with friends, something that would have been impossible two days ago. She has experienced no side effects (3).
What is going to happen to your mother?
NOTES:
(1) Tramadol (also called Ultram) is a quirky and imperfect drug, but this does not mean it should be automatically shunned; it’s not like there are such great alternatives. Some people do very well with it while others suffer nasty side effects. Its metabolism varies greatly from one person to the next and it can also interfere with the metabolism of other drugs. It is (rightly) considered to be a “messy” drug. It doesn’t fit neatly into any class of drugs even though it’s now lumped in with opioids. In fact, when it first came out in 1995 tramadol wasn’t even considered to be an opioid and was treated like any other prescription drug. This changed in 2014 when it became a Schedule IV controlled substance because some people were abusing it. It is classified as an atypical opioid analgesic.
(2) David Juurlink, who is Canada’s doppelganger of Andew Kolodny, absolutely hates the drug. I wonder what he would give to his 92-year old mother if she had trouble getting out of bed.
(3) My mother’s physician was primarily concerned about constipation, which is a known side effect. But he agreed that there wasn’t any reason that she couldn’t try it, especially at a low dose.
By Josh Bloom
Dr. Josh Bloom, the Director of Chemical and Pharmaceutical Science, comes from the world of drug discovery, where he did research for more than 20 years. The field of drug discovery involves chemistry, biochemistry, toxicology, and pharmacology – skills that he has used to write on a wide variety of topics since he joined ACSH in 2010. One of the topics he has tackled is the so-called “opioid crisis.” He is now recognized as an expert in this area and was the first journalist to write a nationally published opinion piece about the unintended consequences of a governmental crackdown on prescription pain medications (New York Post, 2013). Since that time he has published more than 20 op-eds in regional and national newspapers on different aspects of the crisis. In that same year, he testified at an FDA hearing, where he noted that fentanyl was the real danger, something that would be proven years later. At that time almost no one had heard of the drug.
He was also the first writer (2016) to study, dissect and ultimately debunk the manipulated statistics used by the CDC to justify its recommendations for opioid prescribing, which have resulted in Draconian requirements for prescribing pain medications as well as government-mandated, involuntary tapering of patients receiving opioid treatment, both of which have caused great harm and needless suffering to chronic pain patients. His 2016 article, “Six Charts Designed to Confuse You,” is the seminal work on CDC deception and has been adopted by patient advocacy groups and individuals and has been sent to governors and state legislatures.
Dr. Bloom earned his Ph.D. in organic chemistry from the University of Virginia, followed by postdoctoral training at the University of Pennsylvania. His career in drug discovery research began at Lederle Laboratories, which was acquired by Wyeth in 1994, which itself was acquired by Pfizer in 2009. During this time he participated in research in a number of therapeutic areas, including diabetes and obesity, antibiotics, HIV/AIDS, hepatitis C, and oncology. His group discovered the novel antibiotic Tygacil®, which was approved by the FDA for use against resistant bacterial infections in 2005. He is the author of 25 patents, and 35 academic papers, including a chapter on new therapies for hepatitis C in Burger’s Medicinal Chemistry, Drug Discovery and Development, 7th Edition (Wiley, 2010), and has given numerous invited lectures about how the pharmaceutical industry really works.
Dr. Bloom joined the American Council on Science and Health in 2010 as ACSH’s Director of Chemical and Pharmaceutical Sciences, and has since published more than 60 op-eds in numerous periodicals, including The Wall Street Journal, Forbes, New Scientist, The New York Post, National Review Online, The Boston Herald, and The Chicago Tribune, and given numerous radio and television interview on topics related to drugs and chemicals. In 2014, Dr. Bloom was invited to become a featured writer for the site Science 2.0, where he wrote more 75 pieces on a broad range of topics.