By R Carter
Part 1 of this poll covered the demographics of patrons who participated in the poll. Poll results were compiled for two groups, healthcare professionals plus individuals who work with patients but don’t hold a professional degree and patients. Part 2 covered poll results with regards to medical board regulations and their impact on prescribers and chronic pain patients. Part 3 we look at perceptions around the use of opioids in medicine vs abuse and addiction.
Knowing that there are no tests which measure the amount of pain a patient is having, treatment primarily relies on the judgment of the physician based on the facts at hand. This requires reviewing a medical diagnosis which may have been done by another clinic and physician, x-rays, MRI’s, CAT-scans and performing a detailed examination to confirm these findings. Even then such facts may be insufficient to identify anything concrete. Most treatment decisions rely on the known history of an injury, disease process or typical outcomes from surgical procedures. The more complicated the diagnosis, usually involving multiple conditions and procedures, the more likely the need for pain management.
Questioning Medical judgement
It’s this aspect of judgement which is now under attack by those who oppose the use of opioids in treating pain. Those who oppose them cite the risks involved with their use, pointing a finger at opioid abuse outside the boundaries of medical care which is essentially an apples and oranges comparison. Another comparative analogy would be similar to saying a citizen can’t brew alcoholic beverages in their homes or own a winery because they may drink too much. Again, it comes back to individual judgement.
But opponents against the use of opioids want to take medical judgement out of opioid prescribing. Some beliefs and nationalities are based on the substances themselves. Large amounts of alcohol for example affect the brain so that someone who drinks excessively is noticeably drunk. Opioids on the other hand don’t have this effect; large amounts of opioids can be tolerated without obvious signs of intoxication, making it more difficult to spot an impact on behavior.
Those who oppose opioids cite addiction, specifically the physical dependence which occurs, as reasons for why they shouldn’t be used. They cite examples from unsupervised use, individuals chasing a high and the deteriorating conditions which accompany this kind of use. These types of events rarely happen when opioids are used under medical supervision. To combat this fact; law enforcement pits one doctor’s judgement against another. The public, for the most part, is unaware of these nuances. They listen to the propaganda and don’t think to question the source, at least until it impacts them directly. So the general narrative continues to be, opioid use leads to criminal and self-destructive behavior. Most doctors who know the difference don’t have the courage to speak out and worse yet, the media is not interested in covering their views because it does sell clickable content.
So we asked patrons this question. The longer a patient is compliant with opioid use, the less at risk they are for opioid use disorder, true or false? Keeping in mind that about 77% of respondents were chronic pain patients taking opioids, some as long as a decade, 77.2% said yes this is true, 11.2% said this is false and 10.5% were uncertain. The disparity represented by actual experience vs no experience is consistent with a public perception which also has no actual experience with long term opioid use.
But if you search the internet using this question, you’ll not likely find any scholarly articles to support the view of those who responded True to the question. Yet prior to 2016 when the CDC published its guidelines on prescribing opioids by primary care providers, the CDC’s own research confirmed these findings. After 2016 they took this research down as it directly contradicts the current politically motivated point of view. Fortunately CERGM captured some of these views before the links came down.
The CDC’s original research found that only 0.62%, or less than 1% of chronic pain patients treated on long term opioids became addicted, showing classic signs of misuse and abuse. While a common non-opioid treatment such as spinal cord stimulators carry significantly higher risks for complications, upwards at a rate of 70%. The NIH has known for years that the addiction rate for alcohol is 10x that of opioids, at 6.7% yet no action has been taken to reduce consumption of alcohol. Why are there two standards for a similar problem?
Next we asked patrons to identify after what length of time a patient was no longer at risk for opioid use disorder. 13.1% said they were no longer at risk after 3 months. 23.6% said 6 months. 21.7% said 1 year. 11.8% said 2 years. And 29.6% said they are always at risk.
Research done by the CDC prior to 2016 showed that with each passing year, the risk for opioid use disorder dropped in a patient on long term treatment, by half as much from the previous year. For example, for patients on opioids longer than one year the CDC recommends routine urine drug screens once a year. As most would expect though, as long as someone is taking opioids, a certain amount of risk is always there, even if it does drop 50% each year.
Knowing there is always some risk, however small, we asked patrons to answer this question. If a patient is non-compliant with opioid use, or fails a urine drug screen only once, it would be appropriate to? We allowed up to two answers to be chosen.
The combined answers can be seen on the chart above, but for the individual answers the results were: 48.4% said evaluate for OUD. 36.2% favored more frequent office visits. 34.6% said let them off with a warning. 10.6% said get a psychiatric evaluation. 5% said lower the dosage.
Before discussing the topic of law enforcement and asset forfeiture in Part 4, let’s use an example of back injuries and back surgery. It’s a well-known fact that a patient with a two level spinal fusion may have more pain than a patient who’s had a five level fusion. A patient with Lyme’s disease may have more pain than a back injury. Generally speaking though, the more widespread the damaged tissues, the more pain a patient experiences.
With back injuries and surgery it all depends on how extensive the original injury was and details with regards to how the injury was repaired and how well the patient healed. This gap between findings and patient response is one of the issues which make pain management diagnoses difficult. Patient complaints must be taken in good faith with known facts, and treatments must be evaluated for months before an accurate assessment can be formulated with regards to response.
When law enforcement uses a trained imposter with fabricated diagnostic tests then accuses the same physician of prescribing outside the boundaries of accepted medical care, this is at least disingenuous and at worst exploitive, bordering on entrapment because it exploits the wide gap between documented proof and medical judgement based on years, even decades of medical experience.
Law enforcement is aware of this wide gap and they deliberately exploit it by pitting the judgment of one physician against another; and they’re allowed to get away with it. This wide gap between treatment facts and judgement, personal experience, medical ethics and personal morals is where the art of practicing medicine takes precedence. There’s no clear and concise method to connect the dots from prescribing opioids to opioid abuse, but many are trying to convince the public there is. Profit and personal gain, most often, are the motivations.
Those in law enforcement and those who oppose the use of opioids frequently cite ridiculously low levels of criteria for proving failure or wrong doing. We’ve seen doctor prosecuted because a patient becomes addicted to street drugs years after leaving the treatment of a physician. Or a patient, no longer under a doctor’s care, dying from an overdose of street drugs years after they were treated. These are not hypothetical, in California both have occurred with some frequency.
What proponents of these standards don’t tell you is this, there are more than 250,000 medical mistakes made each year which contribute to or cause a death while a patient is under the care of a physician. Yet the States aren’t lining up to prosecute these and why, because no one group can be blamed. Opioids were different because a small number of companies manufactured them, making it easy pickings for greedy States.
A report published by the CDC in 2018, uses a new method of collecting data regarding the contribution of prescribed opioids to opioid overdose deaths. Between 2016 – 2017 less than 2% of all opioid overdose deaths could be attributed to prescription opioids alone. For all practical purposes that blows a hole in claims that prescription opioids caused the opioid crisis, yet I’ve seen no media outlets pick up the story because it doesn’t sell clickable content.
Why then are there two standards? One for all other deaths caused by medical mistakes and another for pain management prescribers? Again, profit and personal gain for those who prosecute and support such actions.
Such disparities continue to be ignored by the media, law enforcement, our attorneys and our courts. Everyone is on the sue opioids gravy train because the public supports it, the fact that it is being disproven is a fact such individuals don’t want disclosed, especially States who want to sue big pharma.
There are also ideological motivations which hide behind misapplied standards of care. Supporters of the sue opioids mind set play on the grief of others and use media’s desire for salacious content to manipulate and enrage the public. If the same low standards to prove failure were used everywhere, every doctor practicing medicine today would leave their practice for something safer and no one would have access to healthcare.
With so many examples out there, it’s obvious our medical boards are corrupt, so is law enforcement, our courts and the attorneys who pursue these, all opportunistic predators looking for a quick and easy buck.
Simply stated, if there’s enough profit in it, anyone today can make any argument and the only ones winning are the attorneys on both sides. Science and facts are less relevant than emotional appeals and vengeance, as long as the payoff in the end is big enough. It’s on this stage that law suits against big pharma have been set and the attorneys are winning. Like Oklahoma vs Johnson and Johnson, there’s insufficient evidence to prove harm so they claim a public nuisance and award half a billion in damages.
Disease or Choice
The decision to take opioids is a choice, always, at first. So when does it become a disease? Can a court of law prove when that transition occurs? When is a drug company meeting a necessary medical need and later exploiting unsuspecting patients. Oklahoma courts seem to have skirted these critical questions to arrive at a conclusion.
Over dosing on opioids is on some level a personal choice, because the same person also has a choice to seek treatment. We see these choices too, made daily all across America. So it follows that such choices are not that different than choosing to pick up a gun and rob a bank, or picking up a bottle and drinking in excess. Why are opioids in a class by themselves? The best answer I can find for now is that it’s the fad for this era.
I used to believe our law makers and those in law enforcement, as a collective group, were individuals who had the highest caliber of common sense and ethical standards. But I find myself questioning that as more time goes by. I believe now that personal gain, whether it is financial, influential or something else more esoteric, carries more weight than dedication and commitment to our collective moral and ethical values. If you can sell it and profit from it, then anything goes.
With all these competing interests, we asked patrons if they believed the quality of medical care had improved or gotten worse, 95% thought it was worse.