Tuesday, 26 February 2019

Better parenting, or more smartphones?

You may have heard of the phrase “primum non nocere” — the Latin phrase that doctors are supposed to follow that instructs them to “first, do no harm.” Doctors also have an important ethical obligation to alleviate pain. But what happens when these two mandates collide? That, unfortunately, is the case with opioid pain relievers: powerful medicines like oxycodone, hydrocodone, and hydromorphone. These medications are potent pain relievers, but this relief comes at a serious, and sometimes deadly, cost.

The United States is now in the era of an “opioid epidemic” in which deaths from opioid overdose have reached alarming numbers. In 2015, it was the most common cause of accidental deaths among adults. Nearly 30,000 Americans died from opioid-related overdoses — more than from motor vehicle accidents or gun violence. We now know that this epidemic was likely caused by the large increases in the number of opioids prescribed by clinicians to their patients, which increased at least four-fold between 2000 and 2010.
It’s not just about how many opioids are prescribed…

Now, recent literature is further refining how we think about the opioid problem, which is not just about how many opioids are prescribed. A study by Dr. Michael Barnett and colleagues from Brigham and Women’s Hospital in Boston published in the New England Journal of Medicine in February 2017 had a surprising finding: becoming dependent on opioids is not just about patients, it’s also about the physicians that prescribe opioids. If a physician was more likely to prescribe opioids than his or her peers, then a patient under their care was more likely to be on opioids long-term.

This research focused on over 200,000 elderly patients covered by Medicare. The researchers wanted to determine the extent to which individual doctors vary in their prescribing of opioids, and if that had implications for long-term use of opioids by patients. The study looked at patients who had not been prescribed opioids in the prior six months who then were prescribed an opioid after a visit to an emergency department (ED). The ED was chosen because patients don’t choose their doctor when they go there.

The emergency department doctors were divided into “high intensity” and “low intensity” prescribers, based on how frequently they prescribed opioids compared with their peers in each hospital. Then, study investigators looked at patients who were still on opioids in the 12 months after the ED visit. Low-intensity prescribers prescribed opioids to about one out of every 13 patients, while high-intensity prescribers prescribed opioids for about one of every four patients. Patients treated by doctors who were more likely to prescribe opioids (or to consistently prescribe higher doses of opioids) were more likely to still be on them long-term.
The study’s limitations and lessons

The study had some limitations. The authors couldn’t say for sure that all the opioids these patients ended up taking were actually prescribed by the emergency department doctor. They also didn’t take into account the types of patients some emergency physicians see. For example, some days I see lots of patients with painful fractures and other days I don’t. There is a component of randomness, in which physicians in the ED don’t choose their patients or the problems they have. Also, some physicians are more frequently assigned to “fast track” areas of the ED where injuries are treated more frequently, and those doctors more commonly prescribe opioids for reasons that would justify a patient being on long-term therapy. Finally, the data are from 2008-2011, now several years old. We know that opioid prescribing has started to taper off in the past few years. In my own department, for example, we found that our prescribing of opioids decreased by half between June, 2015 and December, 2016.

Still, the study provides an important lesson for patients. Whether it’s a visit to the ED, dentist, orthopedic surgeon, or even primary care physician, some doctors are more likely to prescribe opioids. Patients need to know about the potential harms of these medications and that for some people, a small initial prescription will lead to long-term use. Patients should be encouraged to try every non-opioid method to cope with pain first before taking opioids. This includes trying medications like acetaminophen and ibuprofen (if appropriate), heat/ice packs, lidocaine patches, physical therapy, etc. If a person ends up taking an opioid, she or he should use the smallest dose needed to feel comfortable. And once the prescription is finished, it is important to dispose of the medication safely — most pharmacies and police stations will take back medications, no questions asked. That’s the news from the Monitoring the Future study, which has been surveying more than 40,000 eighth, 10th and 12th graders about their drug use for more than four decades. While marijuana use has been steady, use of all other illicit drugs (including prescription amphetamines or narcotics being used outside of medical supervision) is down.

In 1996, 13% of eighth graders reported using illicit drugs (besides marijuana) in the previous year; in 2016, it was 5%. For 10th graders the number went from 18% to 10%, and for 12th graders it went from 20% to 14%. The marijuana news isn’t all bad, either; over the same 20 years, use by eighth graders went from 18% to 9%, and by 10th graders from 34% to 24%. It’s in 12th graders that it hasn’t budged; it was 35% in 1996 and 36% in 2016.

Why are things better? There are likely lots of reasons, and they are likely different for some groups of teens than for others. But an interesting possibility is that instead of using drugs for gratification, excitement, and social connection, teens are using their smartphones.

This is not the whole explanation, of course. The iPhone, which got the smartphone movement started, was introduced in 2007. According to the Monitoring the Future data, in 2006 the numbers already looked better than in 1996: 8% of eighth graders, 13% of 10th graders and 19% of 12th graders had used drugs besides marijuana in the previous year (for marijuana, the numbers were 12%, 25%, and 32% respectively).

There has certainly been a concerted effort on many different fronts to decrease drug use. From the “This is your brain on drugs” TV commercials and other such public service campaigns to school health curricula to more education of parents and pediatricians on how to talk to youth about drug use, our society has taken the problem seriously and sought to make a difference wherever possible. The current opioid epidemic, which affects more adults than teens, is covered substantially by the media and likely serves as a cautionary tale for many teens.

But it’s interesting to think about the role of the smartphone. According to a Pew Research Center study from 2015, 24% of teens reported being on their smartphone almost constantly, and 56% report checking it several times a day. Teens report more than six hours a day of entertainment media time — and many report needing to have their phones with them, and needing to check them all the time. Smartphones have become how teens connect, communicate, socialize, learn about the world, and play. Could it be that the stimulation and excitement of the constant connection works just as well for them as drugs? Could it be that it keeps them busy in a way that makes drug use less important or inviting? Might teens who find themselves in social situations where there is drug use be able to retreat into their phones instead of using drugs — and have it be not only socially acceptable, but possibly more rewarding than getting high?

We don’t know, of course. Much more research needs to be done. And given that there are clearly downsides to spending six hours a day on your phone (think of all the exercise, homework, face-to-face socializing, and creative endeavors that one could do in six hours, not to mention the safety issues created when your attention is on your phone instead of your surroundings), it’s not like parents should be pushing smartphone use as a means of avoiding drug use.

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