Opioids over-dose deaths

Overall, opioid related deaths have been trending upwards since 2010.  In 2016, there were more than 63,600 drug overdose deaths in the United States. The CDC further estimates that 42,249 of those deaths involved some opioid. More importantly synthetic opioids continue to contribute larger proportion of opioid overdoses and related deaths ( top graph) . The synthetic opioid, the very potent fentanyl, illicit fentanyl, has overtaken prescription opioids in causing overdose dose deaths in the U.S.A. Synthetic opioid overdoses alone were 19,413, or 22.7% of overall overdose deaths. In a research letter published in JAMA, of opioid overdose related deaths in 2016, illicit fentanyl was involved in 19,413 deaths surpassing deaths from prescription opioid overdose, 17,087. About 15,469 deaths involved heroin. The easily manufactured, available and highly potent synthetic opioid seems to find its way into many other recreational drugs of abuse. The implication of which is that the unsuspecting drug user who sets out to use ends up consuming a substance significantly more potent and easier to overdose on, with fatal consequences.

Role of the Primary Care Physician

There are clear implications of this trend for primary care providers among many of which is continued adherence to the Prescription Monitoring Program. In addition there is need for renewed effort on education of patients and the public on the dangers of drug use particularly highlighting the fact that the recreational drug they are about to consume maybe "cut" with highly potent and dangerous synthetic opioid. Prevention and treatment plans to double current efforts to address this public health epidemic with greater emphasis on addiction treatment and rehabilitation remain a priority. Many would agree that the ROI for addiction treatment and its comorbidities is higher than any other known disease state in the USA.

The synthetic opioids bypass opioid production “from farm to street " - process time (inherent in cultivating and harvesting the natural product), making the 100 times more potent, dangerous and deadly synthetic product readily available.

References:

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

https://jamanetwork.com/journals/jama/article-abstract/2679931

https://www.cdc.gov/nchs/products/databriefs/db294.htm

IT IS NOT PREGNANCY

A young female notices increasing fatigue, weight gain and general feeling of unwell, other changes characterized by a disruption in what use to be regular menstrual cycle that is now delayed, and milk discharge from the breasts. Sounds like pregnancy right?  She may not be necessarily pregnant. Thyroid disease, particularly low functioning thyroid will cause these clinical symptoms. In this condition, pregnancy test is usually negative and additional tests may reveal a low thyroid level. Not only can thryoid disease mimick pregnancy, thyroid disease especially low functioning thyroid hypothyroidism, in a reproductive age female can be the cause of infertility among married couples. A treatable and reversible cause of infertility. Early identification or exclusion of thyroid disease as a contributor to infertlity can help avert the sometimes tortous and expensive search for the cause of childlessness in a couple starting a family.

Targeting hypertension - patient conversation:

Patients can be resistant to taking anti-hypertensive treatment. Patients can cite side-effects that in many instances they have never experienced, and may only have  heard from others or read about, as reason for avoiding treatment with anti-hypertensives. And a good many of such reasons can be myths. Nonetheless, real fears about duration of treatment and side-effects of treatment must be addressed in the patient who is planning on starting treatment. Failure to educate and address what and how patients feel about antihypertensive management and treatment is an invitation for non-compliance with treatment. First, I encourage my patients to get a home BP monitoring kit and then we agree on what are normal levels. I define our targets going forward. It is good practice when possible to have patients demonstrate the correct use of their home unit in the office. We at the same time get an opportunity to compare, adjust and correct for readings with our in-office equipments.

Often one encounters the patient whose sole reason maybe that s/he dislikes the idea that s/he might have to take blood pressure medication "forever". As a Provider, be prepared to welcome the "forever" conversation. Patients like to present the "forever" argument making sure to strip the "forever" of all its qualifications and metrics except the infinite duration of therapy implied. It is a very convenient and simple argument, afterall, who in his/her right mind would want to be swallowing pills "forever" , indefinitely, when there are more fun things to be doing? But "forever" can really mean for how long each person lives with and without treatment. I begin by trying to quantify and examine how long is "forever" with my patients. Simply put, "forever" may mean five years more or less before a cardiovascular event like a fatal or non-fatal stroke in a patient who is not taking medication to treat her/his hypertension. "Forever" may also mean years, in multiples of five, in a patient who takes h/her daily antihypertensive pill before any adverse cardiovascular event occurs and maybe never will have an event because her/his hypertension is controlled. In other words, I tell patients that every patient's forever is unique to that patient and is capable of being shortened or extended by what the patient chooses to do. Daily pill to keep blood pressure at a safe level can extend one's "forever". Given a choice, most patients would like to extend their "forever" with the daily pill.  A good number of people come around to accepting that "forever" without BP pill can significantly be less than "forever" with BP the pill, and the choice begins to get clearer when presented in these terms.

The next thing is that some patients suggest cutting back treatment doses when blood pressure approaches 100 -120 mmHg systolic, even when they deny any symptoms indicative of a low blood pressure, believing that their pressure is getting very low. It is almost as if you did not have the all important conversation about targets. So we go over targets as many times as needed. I'd like to explain that it makes sense to get the benefit and the full benefit, when possible, of taking medications that one already has started taking in the first place, especially in treatment of hypertension. Studies show that keeping blood pressure below a systolic pressure reading of less than 120 mmHg is superior to target of less than 140 mmHg in preventing fatal and non-fatal cardiovascular events and death from any cause. This observation is particularly true in persons who do not have diabetes and those with type 2 diabetes who do not have any evidence of established cardiovascular disease. Click here to go to the Study. Even though side effects are slightly more with targets of less than 120 mmHg in some studies, they do not include injurious falls. Even among adults 75 years and older, treating to target below 120 mmHg is not associated with any more side effects than treating to targets below 140mmHg. READ MORE

References:  http://annals.org/aim/fullarticle/2598413/pharmacologic-treatment-hypertension-adults-aged-60-years-older-higher-versus

https://www.ncbi.nlm.nih.gov/m/pubmed/24352797/