By R Carter
If you’re a member of the chronic pain community following how government and public health have responded to opiate related deaths, then you also know that labeling it a prescription opiate crisis relies on skimpy evidence, half truths, assumptions, some twisted logic and inconclusive data, all of which is cherry picked to fit an ideological point of view. While you can connect the dots between abuse and doctors in some cases, it is anything but a solid conclusion that this is the primary driving force.
There was a heroin epidemic in the 1980’s, a crack epidemic in the 80’s and 90’s, and a methamphetamine epidemic in the 90’s and 00’s. Obviously, we cannot blame the pharmaceutical industry or doctors for those; nobody prescribes crack to patients. The point is that humans have a tendency to abuse drugs and become addicted to them. This has been a rather well-known phenomenon since we discovered alcohol.And with opiates supplied from illegal sources where there’s no clear way to estimate the impact, making doctors out to be the blame is a convenient scapegoat.
At the end of the 1990s, US physicians were chastised for the collective under treatment of pain. At a time when the Veterans Administration, Joint Commission, and others were describing pain as “the fifth vital sign,” the Medical Board of Oregon sanctioned a physician for undertreating pain, and two California-based physicians were sued in civil court for elder abuse because they failed to adequately relieve pain.Sounds familiar right? Only in reverse with today’s fad of demonizing opiates.
By 2001, the Joint Commission added assessment of pain, treatment of pain, and several consequences for failing to treat it, to its accreditation standards for health care organizations. Buoyed by the success of treating cancer-related pain with opioids, many physicians rose to the challenge of doing more for their patients suffering with chronic pain. This led to an increase in the number of prescriptions for opioids, which had the unintended consequence of more opioids ending up in medicine cabinets in more homes, ultimately giving more people (not patients) access to these valuable medications for nonmedical purposes.Not unlike dads liquor cabinet which doesn’t have a lock.
Silently operating in the background and encouraging doctors to prescribed was managed care. Insurance companies who had driven down fees charged by prescribers, forcing them to see more patients in less time, thus taking short cuts to a solutions, while also paying bonuses for keeping patients away from expensive diagnostic and treatment procedures. Thus prescribing pills for pain was encouraged by the standards of care adopted by nationally recognized and government supported agencies, and by insurers seeking ways to lower costs and improve profits.
The current opioid epidemic, which began in the late 1990’s, unfolded in phases, and key milestones changed the course of the crisis. First was the recognition of pain as a key element to assessing a patient’s health and wellbeing. Tens of thousands of government and private funded research studies had thoroughly documented the negative consequences of failing to adequately treat pain. Beyond the mental, emotional and physical consequences for the patient, more than 45,000 research articles were written just on the economic consequences of untreated pain for business and industry. Treating pain was seen as good for government, business and the patient, by opening up new opportunities in business, industry and healthcare, with increased tax revenue for government and in helping to keep and maintain a highly skilled and productive workforce. Everybody was a winner!
Drug abuser capitalized on this opportunity relying on several niches to fake chronic pain conditions for obtaining scripts.
- Pain can’t be measured by any type of test
- Due to reduced reimbursement from managed care, primary care providers now have to limit time with patients to between 10-20 minutes per office visit, causing doctors to take short cuts and rush to judgement.
- Managed Care insurers begin denying payments on diagnostic procedures such as CT Scans and MRIs that aid doctors in diagnosing chronic pain conditions.
- Even when diagnosed, Managed Care insurers deny non-opioid treatment options such as radiofrequency assisted micro-tubular decompression and nucleotomy
- Lack of medical board standards for guiding physicians on prescribing
- Unscrupulous prescribers who prescribe for profit deliberately addicting patients and the lack of Medical Board grievance procedures for disciplining unethical actions
The common themes underlying all of these is profit and cost cutting measures. Treating pain or the perception of pain is good for the economy and has the full support of government and industry. And in the shadows are entrepreneurial criminals who also exploit this trend for their own purposes. Clever abusers are exploiting both aspects of this environment fueling a run away addiction rate that goes unnoticed for more than a decade.
In the midst of this proopioid, protreatment boom and due to growing concerns about abuse, in 2010, Purdue Pharmaceutical took prudent steps and released an abuse-resistant formulation of OxyContin. If a drug abuser tried to crush it for injection, it would turn into an unusable gummy mess. Simultaneously, doctors started becoming reluctant to prescribe opioids to patients, so prescriptions began to decrease. This marked the beginning of the heroin epidemic. Despite all the good intentions, addicts and other recreational drug users who could no longer overcome the obstacle of a doctor limiting their access, turned to heroin. Now in an environment of unrestrained self-medicating, monitored only by a drug dealer whose motives were profit at your expense, opioid-related deaths have continued to increase.
It’s within this context that opiate related deaths have been labeled an overprescribing problem caused by doctors. But doing so completely dismisses and holds harmless the role that government played:
- In funding research for chronic pain
- Supporting the pharmaceutical industry by:
- FDA approval of a wide variety of opiate formulations
- Approving prescribing and labeling instructions which down played the risks of abuse
- State medical boards largely made up of physicians for:
- Failing to create mandatory continuing education requirements
- Failing to create prescribing guideline for physicians
- Failing to limit prescribing to qualified specialties
By 2010, recognizing its mistake but failing to take responsibility for its role, government began taking corrective action, both at a state and federal level. At this time the NIH estimates that 2.1 million people in the US were addicted to prescription opiates and another 467,000 to heroin. Taking corrective steps is all good, except that neither states nor the federal government had a clue on how to separate legitimate use of opiates from illegal use. As proof, a careful examination of how government collects the data they quote in statistics, quickly reveals that death data from a death certificate has no provisions for capturing deaths caused by specific types of opiates, also see Part 2, 3.1 and 3.2. A coroner has only one option which is to list the cause of death as related to opiates and specify whether or not it is heroin.
For the NIH to compute these estimates they like many states rely on questionnaires and reports completed by individuals admitted to drug treatment centers, hospitals and Emergency Rooms, the same individuals they claim are notoriously dishonest. Furthering complicating estimates made regarding prescription opiates are facts such as:
- Heroin converts to morphine 30 minutes after injection
- Heroin is cut with Fentanyl because it is cheaper
- Toxicology results can’t distinguish between illicit and legitimate sources of morphine and Fentanyl
- The inability to identify the true source of a substance drives the presumption that overdose deaths are due to prescribed opiates
The only reliable way to connect the dots between toxicology results and prescribing physicians is by matching the drug and the patient to the prescribing physician, which only became possible around 2018 with the implementation of a nationwide prescription drug monitoring program. But even this is not 100% reliable as toxicology results indicate that 80% of overdose deaths include up to 6 drugs, but coroner reports do not require identifying the primary agent responsible for death. And finally the manner in which opiate related deaths are reported through the CDC, does not allow addressing all the concerns listed above, so the default assumption remains one of being a prescription opiate problem even though common sense dictates otherwise.
Also around 2010, with a public outcry for action and increasing costs for states in dealing with the growing number of opiate related deaths, Physicians for Responsible Opiate Prescribing (PROP) rises to national attention. Seizing the opportunity in a vacuum created by government’s failure to govern, PROP takes a less scientific, rational and objective point of view. PROP offers credibility to a government ready to cherry pick the data and take swift actions for a problem they did not see coming, throwing all other common sense out the window. Offering solutions which have no scientific basis, PROP makes physicians the scapegoat absolving government of any failures. This is a match made in heaven for legislators, regulators and law enforcement, such as the DEA admitting they can no longer arrest their way out of illegal drug abuse. Government now has the convenience of citing views from doctors without the liability of being responsible for disregarding the science they paid for in helping to create the problem.
The combination was a hit with the public as well, for everyone wants a simple answer which will just make the problem go away, a problem most American’s believe belongs to anyone but themselves. Such a reaction is understandable considering that 86% of the population consumes alcohol, with an addiction rate of 6.6% yet by government estimate only 12% of the population uses illicit drug of all types with an addiction rate of 0.78%. For each person addicted to opiates there are 8.5 people addicted to alcohol. But like everyone who consumes mood altering substances believes, they can handle it, until they can’t. So the old biases emerge as people believe what they are told and say yes, we need to do something about addiction, as long as it’s not my drug of choice. And so denial now plays out at a nationwide level.
There have been many honest and objective healthcare professionals, doctors with 20 and 30 years of clinical experience in pain management, who have also written on this topic, drawing the same conclusions and offering the same indictments of government and public health for labeling the problem as a prescribing problem for chronic pain which doctors created. Finding these facts for yourself only requires investigative diligence as most of the information is publically accessible. Yet news and media outlets rarely look beyond headlines of public announcements, further spinning the myth that doctors are to blame when in fact, there are no innocents. Whether intentional or by innocent neglect, everyone whose even come close to this issue, has played a part in how we got here.
When I step back and look, I see different groups acting independently of each other but each trying to maximize profits or simplify their lives naively thinking it’s someone else’s responsibility for patient safety. And as unethical as that is, some now want to sue pharmaceutical companies to recover costs. Others want to drive honest hard working physicians out of work to set an example. Most are willing to throw chronic pain patients under a bus to score political points or save their own skin. While all of us continue to believe we are moral and enlightened agents living in the greatest nation on the planet. I ask, what about any of this makes us moral or great?
For corroborating coverage of these facts, watch this 45 minute video from KLAS 8 News Las Vegas, Nevada.