By R Carter
All things are subject to interpretation. Whichever interpretation prevails at a given time is a function of power and not truth.Friedrich Nietzsche
Body counts and balance sheets.
After starting my research in 2010, for a while, I was tempted to abandon my deep dive into the opiate crisis and focus more on how the healthcare industry had changed. But as the opiate crisis evolved, it was clear that this subject, with its polarized, radioactive opposites, exposed a kind of denial and blind irrationality in our most trusted institutions. Also revealed was a hint of what I hoped was unconscious bias and privilege by those at the forefront of this issue. After researching for eight years I believe little if any of the steps taken by government and industry have been unconscious, the pattern and consistency indicates just the opposite. With a constant push to remedy government financial concerns over all others, there was a denial towards other issues screaming to be heard but a government unwilling to listen or take action.
Like a frustrated homeowner trying to herd cats into a corner, government had taken a tactic of rounding up everyone using opiates and either placing them into treatment, prison or creating such barriers to accessing pain management services, that only the most severe patients had a chance of access. The truth of this bore out as government released guidelines which addressed acute pain services such as surgical post-op and intractable pain for terminal cancer patients. Guidelines for non-cancer chronic pain were essentially non-existent and if reviewing CDC guidelines, most on the information for chronic pain is focused on defining the CDC’s point of view on how likely opiate over doses are to occur with essentially no information on how to actually treat and manage chronic non-cancer pain.
Now nearly ten years after it began, government appears to be ready to declare it’s first battle victory as the number of opiate prescriptions has steadily dropped. All the while, that same government data shows a significant rise in deaths from illegal street opiates, begging the question, how many of these deaths are from patients who have been unable to access a healthcare system bereft of any comprehensive solutions other than trying to prevent opiate overdoses with poorly thought out reforms. Despite such glaring facts and obvious questions, some states want they’re citizens to believe that prescription opiates are still a major contributor to illegal opiate abuse. While there is some truth in this, the research backing such conclusions are far from comprehensive and seem cherry picked to fit an agenda.
What amazes me about such dogma as this is that government has access to the same experts, literature and data that we as healthcare professionals have and we’ve known for more than seventy years that the answers to addiction are just not that simple. If it were, addiction, alcoholism and related deaths would have been stopped cold in the 1940’s. Now decades later and having declared another crisis, one hand of government thinks it’s contagious like a disease, another covers it under government backed or sponsored health insurance like any other medical condition, while another hand of government wants to coerce prescribers into not prescribing via threat of sanctions against their license. Still another wants to solve the problems by placing arbitrary daily limits on analgesics that are half that recommend by the standards of care which have guided us successfully for the last one hundred years. How rational can that be? With such an knee jerk response, government only shows us they can be as dangerous and irresponsible as those abusing opiates and dying from it. And while failing to find a physician who believes government prescribed treatment guidelines is a good way to practice medicine, more than 99% of all physicians are afraid to speak out publicly against government intrusion into treating pain. It’s as if the medical profession has lost its spine and only wants to insure a steady flow of claims to bill out. Most people would crumble under the shame of such duplicity, but as long as the public is willing to blindly trust medical professionals, who wouldn’t take advantage of that ignorance to have a steady flow of income?
More alarming is that government and prescribers appear to have no interest in answering such questions, possibly too afraid that the answers may reveal the one sided nature in which both have approached an issue which is both a social disgrace and a medical necessity. Proving yet again, that dishonesty is a tell-tail sign for the lack of good character for those leaders in whom we have placed our trust. By using a shotgun approach of blasting opiates on every front and the flip side of that which is, “a one size fits all” approach to chronic pain management, both sides only demonstrate how irrationally fearful and ethically nearsighted they can be when addressing such a complicated issue.
Rather than being the solution it should be, one which strikes a balance between all its citizens, government has in some ways, become a net contributor to the problem. As in previous efforts over the last one hundred and fifty years, government has failed to learn from the mistakes and successes of the past. In doing so, they abandon real people with legitimate medical needs; leaving some no choice but to turn to the illegal element. And the losers are those law abiding citizens who have been kicked to the curb and forced to survive through illegal means by a government insensitive to everything except its own needs. Good people who prior to such conditions only desired to return to normal and find gainful employment.
Turn on the news, surf social media and listen to the sound bites of our modern media. The headlines only emphasize the drama, not the solutions, the more outrageous the claim, the more attention it garnishes. And when real news is reported, the focus is on the financial successes or failures. If human lives are saved or lost in the process, they are but mere adjectives, designed to emphasize the greater concern. Such over stated drama and simplistic views dehumanize the real purpose of government and healthcare which is to improve and maintain quality lives, not keep track of body counts and balance sheets.
As I dug for answers one of the bigger surprises came from the healthcare industry, the one I least expected to be a major contributor. While billions of dollars had been spent on research for drug addiction and treatment, producing thousands of studies and terabytes of empirical data, essentially nothing had been spent on research for treating chronic pain with opiates. What little research existed, was limited to opiates for treating intractable cancer pain and for periods less than one year. The facts are, we have no body of empirical data on which to draw objective and rational conclusions for the use of opiates in treating long term chronic pain. A fact which has encouraged government to create all types of myths and disinformation in support of its real goals which have grown beyond cutting the cost of opiate related deaths and now includes an ideological battle supporting a right winged form of morality, one which supports exclusions based on classes of individuals rather than inclusions based on our shared humanity.
As I dug through archives of research on pain management, opiate research and related subjects, what I ended up seeing more often than not were Op-Eds or opinion articles, which at best can only speculate as to the risks and benefits of treating chronic pain with opiates. Until that changes neither government nor healthcare have a clear and rational path to making policy which serves the best healthcare interests of the public. This also means that there is a distinct possibility that our government’s current policies, with regards to managing prescription opiates, is little more than a poorly thought out knee jerk response to a criminal and law enforcement dilemma which has languished for decades.
Now into the 10th year of active efforts to thwart the opiate crisis, with its rising death rates from illegal street drugs such as heroin, Fentanyl and now Carfentanyl, knowing that the sources of these substances now include China, Mexico as well as South America, the obvious question to ask is, have we emphasized the wrong groups, targeting domestic healthcare over law enforcement?