Oxycontin or Fentanyl ? Or would you like a cocktail, Sir?

      The great Canadian Physician, Sir William Osler, said:
 One of the first duties of the physician is to educate the masses not to take medicine.

     The mounting number of deaths of  people from abuse of drugs in Canada is tragic but not surprising.  What is  surprising is the  failure to relate this  to the permissive attitude to taking drugs that is prevalent and is now regarded by many as 'normal' and a right of folks to put anything into their body that they think will give them a little relief or even pleasure, with no evidence of other than short term effectiveness in  the conditions that they are seeking to relieve.  It is a natural consequence of the trivialization of taking both prescribed and unprescribed drugs that has led to the fatal situations that are so much more common than it was just a few years go.
      Television and other advertisements frankly misrepresent the 'miraculous' advantages of various drugs and have found slick ways of fulfilling the obligatory requirements of the supervisory bodies to publish their sometimes very serious side-effects  in a manner that de-emphasizes their seriousness.  Doctors have become used to dealing with unreasonable requests based on such information but are nevertheless sometimes pressured into prescribing things that they would not normally use.   Over the counter preparations continue to proliferate and powerful drugs that only a few years  ago would not have been available without prescription are freely available, mainly because this is perceived as cost saving device that will reduce doctor visits.   Many of these drugs have serious side-effects and interact with  prescribed medications.  For a variety of reasons physicians may sometimes be unaware of some of the medications a patient may be taking.  In addition, there is an increasing movement to have pharmacists to prescribe.  All of this has contributed to the view that more is better and there is little or no downside to the increasing drugs that the population consumes.
       Social permissiveness has made drugs such as marijuana universally available for people with  no medical  indication despite its potential for long-term harm.  The pretense that there is a need for marijuana farms to supply the rare medical need is absurd.  It could be provided by the same means as other drugs with  a potential for addiction and constrained in  the way they once were.   Instead the social trend has been to make those prescription drugs that were once at least partially controlled as available as marijuana is.   The disastrous consequences of this is an alar increase in death and disability from drug use and perhaps even worse, an acceptance of this as a normal risk,
      Doctors, of course, have contributed to this culture in no small way.  Some patients need to be on this sort of medication,  some are difficult to get off when they could be tapered to something milder and some never needed to be on it in the first place and will never quit as long as they can get it in some way.  Unfortunately, physicians have been the means of obtaining it for a significant number.  Often, it is hard to discontinue, because no one can feel another's  pain, so one gives the patient the benefit of the doubt.  Sometimes refilling a prescription seems to be the only way to get the patient out of the backlogged office.
     Sometimes I used to send such complicated patient to the pain specialist, to get help in  tapering them off  narcotics when I thought them ready, only to have them return on an even heavier doses.  The attitude that the resolution of many of these problems is permanent doses of narcotics is patently false.  The increasing flood of prescription narcotics on  the street would certainty confirm that far more narcotics are being prescribed than necessary. 
       So while Oslers's maxim requires the addendum, 'unless it is proven necessary', the concern expressed is valid.  Taking medications that are not necessary, for whatever reason, have the potential to cause serious side-effects, up  to and including death.