Q: We hear scary stories about both antibiotics and pain medications. Which is worse, and what should we pay attention to?
A: In a way, your question is like asking, “Which do you fear more, ISIS or global warming?” It’s hard to say which is worse, especially since they don’t fit into the same categories of worry, but we definitely should pay attention to both. But there’s also a difference between the two questions: It’s hard to find anything good about either the Islamic State or climate change, but there are definitely good uses for both classes of drugs.
In both cases, health care providers (I’ll just call them “doctors” for short, but that also would include physician assistants and nurse practitioners, valued members of the health care team) are stuck between rocks and hard places, sometimes damned if they use them or damned if they don’t.
Although sulfa drugs had been used beforehand, and were moderately effective, true antibiotics got their start in the middle of the last century with the well-described discovery of penicillin by Arthur Fleming, who noted the inhibition of growth of bacteria on a growth plate around a contaminating Penicillium mold. Penicillin became a wonder drug, used initially in what would now be considered miniscule doses to successfully treat many types of infection, including pneumonia, syphilis and gonorrhea.
And then the troubles began: those smart bugs (bacteria) adapted so that more and more penicillin was needed to kill them. Some bacteria became entirely resistant to penicillin (staphylococcus, a common cause of skin infections and abscesses, was one of the first). Some bugs (especially viruses) are unaffected by antibiotics; it could have been predicted that the early studies of antibiotics to treat colds, for example, showed no effect.
And thus began a seemingly unwinnable arms race: new antibiotics were developed, larger doses of all antibiotics were needed, bacteria adapted. Repeat. Except that in recent years, the bacteria seem to be winning, continuing to adapt while the pace of new antibiotic development has slowed dangerously. The disparity is not surprising, given that there are “only” 7.4 billion people in the world, reproducing about every 25 years on average, whereas there may be 1000 billion bacteria in just one gram of the average person’s poop! That allows far more chances for bacteria to evolve than for humans to develop new antibiotics; bacteria are likely to win the arms race.
For the moment, we can still treat most bacterial infections with an effective drug. But what should we do for the future? Here are some suggestions: 1) Be sure that an antibiotic is truly needed when it is prescribed. Ask questions of your doctor. 2) Avoid many infections by immunizing your child and yourself. 3) Wash your hands! 4) Support research into new antibiotics.
As a former sufferer from a kidney stone, I know personally how useful pain killers can be. Maybe a little bit like bacteria becoming tolerant to small doses of antibiotics, relative human resistance to opiate (opium, heroin or morphine-like) pain medications does occur, so that people using these useful yet dangerous drugs may require more of them as time goes on. Fortunately, I didn’t need the drug for long enough to have that happen to me, but it does happen with people using opiates for prolonged cancer pain, for example.
The recent explosive rise in opiate use, opiate addiction and deaths due to opiate overdose has been extensively discussed. New Mexico has done better in the last year, but still is among the leading states in opiate overdose deaths, and the U.S. has the dubious distinction of leading the worlds in this unfortunate statistic. The opiate overdose death of pop star Prince is just one more recent tragedy in a long chain.
If we concentrate on the positive here, improvement in the number of opiate-related deaths, a 9 percent drop from 2014 to 2015 is definitely encouraging. But 492 New Mexicans dying in the past year remains unacceptable. Our Legislature, recognizing this, had eight bills introduced in the 2016 session to reduce the tragedies; three were passed and signed by the governor.
There are a number of other contributions to decreasing the toll: Doctors are required to take a course in responsible opiate prescription and are being more careful in writing for these drugs. Patients are asking questions. Online resources allow doctors to check to see a patient’s history of opiate use, especially to see if s/he is receiving prescriptions from multiple providers. The life-saving overdose-antidote drug naloxone is better known and more available. Addiction treatment may be more widely available.
As with antibiotics, I have some recommendations for you with respect to opiates: 1) Be sure that an opiate is truly needed when it is prescribed. Ask questions of your doctor (does that sound familiar?). 2) Dispose of unused pain killers when they aren’t needed anymore (the New Mexico Poison Center lists sites that take unused medications at http://nmpoisoncenter.unm.edu/disposal_info.html.) 3) If you or someone you know is addicted to these drugs, have naloxone available and get help for the addiction.
This particular column, written by a pediatrician, applies to people of all ages, from newborns affected by addicted mothers or infected by resistant bacteria to oldsters like myself.