For Dr. Gary Sobelson who practices family medicine in Concord a recent study 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," Sobelson said on The Exchange.
Primary care doctors are increasingly prescribing drugs for such mental health conditions as depression and anxiety, as well as for pain. And they must assess these complex situations – including the potential for substance abuse -- with little time to interview patients, given the demands of the health care system, according to Peter Evers, CEO of Riverbend Community Mental Health.
“There are so many co-occurring medical disorders with people who struggle with mental illness that are not adequately treated,” he said. “There’s a close association of psychic pain and physical pain.”
The chronic illness of depression, Evers said, is associated with chronic physical illnesses such as diabetes, which can cause severe pain.
“Sedentary lifestyles, smoking, a diet that that isn’t paid attention to -- all contribute to those chronic diseases that are ongoing, so you’re likely to find somebody who’s going to present with all of those factors as well,” Evers said.
The solution to some extent lies in integrating medical services, Evers said – an approach Riverbend has been promoting through its Integrated Center for Health. In this way, mental health and primary care doctors can help each other better assess patients' backgrounds and risks. “If we don’t get to the point where we have proper integration of mental health and physical health we’re going to still struggle with some of these things,” 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.
“There 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’d find. And then we got the complete opposite of some of our assumptions. We found this very large, disproportional prescribing to this vulnerable group.”
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.
“We 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.”
He does have some theories, though, about why this might be the case:
“It 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. Patients with various mental health disorders may express their symptoms in a way that is different than someone without those disorders,” 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.
“So 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’m 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.”
“The definition of pain is a subjective phenomena of actual injury to the tissue. There is no biological measure for it,” Sites said. “So this is all subjective, so the mind-body interactions here are very, very strong.”
As Sobelson sees it, psychiatry also grapples with the issue of subjectivity, perhaps adding to the challenge of diagnosis and treatment. “It’s 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’s no blood test for depression or anxiety either.”
A physician's first instinct is to ameliorate pain, Evers said. "So to be confronted with this idea of, you shouldn’t prescribe to this person because they might have problems down the road when you don’t have much time and you’re looking at someone in pain… I think that’s a huge piece of this,” he said. “And 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 has not happened (elsewhere in the world).”
Although the U.S. makes up only 5 % of the world’s population, it consumes more than 80 % of the world’s opioids, Sites said. Despite this, Americans’ experience with pain, as a population, has not improved.
There are some good alternatives to opioids – such as nonopioid pharmaceuticals, cognitive behavioral therapy, medication, acupuncture, acupressure, massage therapy, Sites said. “But you need an infrastructure to support and deliver these,” 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. “Patients like to get things: drugs, procedures, imaging, especially when their deductible is met,” he said. 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.
“If there’s any delayed gratification—if 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’d won something, you wouldn’t spend all night pulling the lever. … And people do want the best results with the least amount of effort.”
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 marked reduction in pain complaints. “People’s ability to function improves markedly. Depression by itself is one of the world’s leading causes of disability and lack of physical functioning…. Some of our most effective treatments in psychiatry are actually not medication, are actually therapy-based.”
Possible improvements in New Hampshire but the crisis remains.
Sobelson said it’s important to consider the timing of the Dartmouth-Hitchcock research, which precedes some of the more heightened attention to the opioid crisis. New Hampshire, he said, now has several new laws requiring doctors to assess risks before prescribing opioids, for instance.
“Preliminary data is very encouraging. I’m not saying that means we’re going to eradicate opioid abuse or opioid over-prescribing even, but I do think it’s had a big impact.”
One impacts was perhaps unintended: “There is a judgment going on now. And there are physicians who are saying, Sorry, I won’t take a patient who’s on opioids," Sobelson said. "I know physicians – and this is more the norm than not – who will review patients records and if they are on chronic opioids, they will not accept them into their practices.”
Sites said even if New Hampshire has made some progress, the national picture remains grim. “We are in the midst of a crisis; it’s growing,” he said. “Our data is an underestimate. CDC numbers for 2015 are through the roof with prescription opioids. I’m not as optimistic that we have figured out a strategy to solve this. The major mechanism driving the opioid epidemic isn’t heroin, it is the opioid prescriptions. They are in essence a gateway drug.”