51暗网

By The Exchange

For Dr. Gary Sobelson聽who practices family medicine in Concord a recent suggesting that people with mental illness consume a disproportionate share of prescription painkillers was concerning but not necessarily surprising.

“The mentally ill are high consumers of all medical services, are in fact more consciously aware of many physical symptoms that often lead to prescribing in many areas — not the least of which is pain management and opioids,”聽Sobelson said on

Primary care doctors are聽increasingly prescribing drugs for such mental health conditions as聽depression and anxiety, as well as for聽pain. And they must assess these聽complex situations 鈥� including the potential for substance abuse — with little time to interview patients, given the聽demands of the health care system, according to Peter Evers, CEO of 51暗网 Mental Health.

鈥淭here are so many co-occurring medical disorders with people who struggle with mental illness that are not adequately treated,鈥� he said. 鈥淭here鈥檚 a close association of psychic pain and physical pain.鈥�

The chronic illness of depression, Evers said, is associated with chronic physical聽illnesses such as diabetes, which can cause severe pain.

鈥淪edentary lifestyles, smoking, a diet that that isn鈥檛 paid attention to — all contribute to those chronic diseases that are ongoing, so you鈥檙e likely to find somebody who鈥檚 going to present with all of those factors as well,鈥� Evers said.

The solution to some extent lies in integrating medical services, Evers said 鈥撀� an approach Riverbend has been promoting through its Integrated Center for Health. In this way, mental health and聽primary care doctors can help each other聽better assess聽patients’ backgrounds and risks. 鈥淚f we don鈥檛 get to the point where we have proper integration of mental health and physical health we鈥檙e going to still struggle with some of these things,鈥� he said.

Some theories behind the numbers.

Brian Sites, an anesthesiologist at Dartmouth Hitchcock and co-author of the study, says that he and fellow researchers were surprised by their findings: Although people with mental illness make up only 16% of the U.S. population, they receive about 50% of the opioid prescriptions.

鈥淭here was actually some concern that patients suffering from these disorders may not be getting their fair share of opioids, because physicians may be more conservative with their prescribing, based on the recognition that these patients may have a higher likelihood of opioid abuse, overdose, addiction and long term use. So it was not clear at that time what we鈥檇 find. And then we got the complete opposite of some of our assumptions. We found this very large, disproportional prescribing to this vulnerable group.鈥�

Sites said although he can’t fully explain what’s behind the numbers, the association between mental illness and opioid use is on firm mathematical ground. 鈥淲e took into account age, sex, race, health conditions, various levels of pain, and even when we did that we still demonstrated a strong association between the presence of mental health disorders and the likelihood of getting a prescription from your physician, about two-fold.鈥�

He does have some theories, though, about why this might be the case: 鈥淚t could be that a family physician on the front lines with a patient in their office is overcompensating for somebody who has advanced anxiety and the possibility of little coping mechanisms. It could be overcompensation on behalf of the physician in an empathetic way.聽 Patients with various mental health disorders may express their symptoms in a way that is different than someone without those disorders,鈥� he said.

Dr. Quentin Turnbull, psychiatrist with the Mental Health Center of Greater Manchester, says people who seek psychiatric treatment have higher rates of pain complaints. 鈥淪o if you look at illnesses like major depression, 45% of those folks present with pain complaints; people with PTSD, about 30 % present with pain complaints. I鈥檓 not saying that those are all imagined, but there are definitely higher complaints. So those get taken seriously by family practitioners who want to do the best they can for those folks in a short of amount of time.鈥�

Pondering Pain

鈥淭he definition of pain is a subjective phenomena of actual injury to the tissue. There is no biological measure for it,鈥� Sites said. 鈥淪o this is all subjective, so the mind-body interactions here are very, very strong.鈥�

As Sobelson sees it, psychiatry also grapples with the issue of subjectivity, perhaps adding to the challenge of diagnosis and treatment.聽 鈥淚t鈥檚 based on what people say and how they present themselves, unlike a lot of other areas of medical science. Now, great efforts have been made to standardize those subjective measures. But in the end there鈥檚 no blood test for depression or anxiety either.鈥�

A physician’s first instinct is to ameliorate pain, Evers said. “So to be confronted with this idea of, you shouldn鈥檛 prescribe to this person because they might have problems down the road when you don鈥檛 have much time and you鈥檙e looking at someone in pain鈥� I think that鈥檚 a huge piece of this,鈥� he said. 鈥淎nd on top of that you have huge drug companies that frankly have been pushing medications not only to physicians but to people in the community in a way that聽has not happened (elsewhere in the world).鈥�

Although the U.S. makes up only 5 % of the world鈥檚 population, it consumes more than 80 % of the world鈥檚 opioids, Sites said. Despite this, Americans鈥� experience with pain, as a population, has not improved.

There are some good alternatives to opioids 鈥� such as nonopioid pharmaceuticals, cognitive behavioral therapy, medication, acupuncture, acupressure, massage therapy, Sites said. 鈥淏ut you need an infrastructure to support and deliver these,鈥� he said. And that infrastructure, including insurance coverage for alternative methods, is not yet in place.

Another roadblock: patients themselves.

Sites says that patients often link satisfaction with what amounts to over-prescribing or over-treatment, which, it turns out, is linked to a 20 to 23 % increase in the likelihood of death. 鈥淧atients like to get things: drugs, procedures, imaging, especially when their deductible is met,鈥� he said.聽Another reason why denying an opioid prescription to a patient in pain is no easy matter.

People want immediate satisfaction,Turnbull said, which puts them at risk for addiction. 鈥淚f there鈥檚 any delayed gratification鈥攊f you went down to Mohegan Sun, and you pulled the One-Armed Bandit lever, and they got back to you three months from now to let you know if you鈥檇 won something, you wouldn鈥檛 spend all night pulling the lever. 鈥� And people do want the best results with the least amount of effort.鈥�

In fact, Turnbull said, actively treating psychiatric conditions such as mood and anxiety issues can lead to remission of the problems. That leads to a聽marked reduction in pain complaints. 鈥淧eople鈥檚 ability to function improves markedly. Depression by itself is one of the world鈥檚 leading causes of disability and lack of physical functioning鈥�. Some of our most effective treatments in psychiatry are actually not medication, are actually therapy-based.鈥�

Possible improvements in New Hampshire but the crisis remains.

Sobelson said it鈥檚 important to consider the timing of the Dartmouth-Hitchcock research, which precedes some of the more heightened attention to the opioid聽crisis. New Hampshire, he said, now has several new laws requiring doctors to assess risks before prescribing opioids, for instance.

鈥淧reliminary data is very encouraging. I鈥檓 not saying that means we鈥檙e going to eradicate opioid abuse or opioid over-prescribing even, but I do think it鈥檚 had a big impact.鈥�

One impacts was perhaps unintended: 鈥淭here is a judgment going on now. And there are physicians who are saying, Sorry, I won鈥檛 take a patient who鈥檚 on opioids,” Sobelson said. 聽“I know physicians 鈥� and this is more the norm than not 鈥� who will review patients records and if they are on chronic opioids, they will not accept them into their practices.鈥�

Sites said even if New Hampshire has made some progress, the national picture remains grim. 鈥淲e are in the midst of a crisis; it鈥檚 growing,鈥� he said.聽 鈥淥ur data is an underestimate. CDC numbers for 2015 are through the roof with prescription opioids. I鈥檓 not as optimistic that we have figured out a strategy to solve this. The major mechanism driving the opioid epidemic isn鈥檛 heroin, it is the opioid prescriptions. They are in essence a gateway drug.鈥�