The US Opioid Crisis – Misdiagnosed, Mistreated and Mismanaged Part Two

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By R Carter

To follow this series from the start follow this link to Part One.

After reading thousands of articles and opinions since 2000, on what caused the opioid crisis I fail to see any single cause or primary contributor. So I’m going  posit my own theory on the opioid crisis, in part for what may have caused it, but also broader look on how we got here and why it’s viewed today as a prescribing problem. I offer no details or proof  in this post, simply an opinion from my gut, rendered from what I’ve read and know from 30 years of practicing anesthesia and 18 years of being a chronic pain patient.

  1. The majority of us contributed to how we got here. Through a trillion times a  trillion individual choices, whether by action or inaction, by intent or ignorance, this is a problem of government, industry and it’s citizenry, there are few innocents, so ultimately it’s a problem not just with our systems but with our humanity.
  2. Most of us were looking the other way, blinded by our day to day quest for a better life and personal gain.
  3. When the problem seized us by surprise, as a scientific, data driven society, we looked to the only things we could measure and control, our existing healthcare system, ignoring those causes which couldn’t be categorized, tallied and quantified, us.

And for these same reason, we continue to look for complete answers in places where there’s only half truths. So the solutions continue to elude us as broad as they are and the problems will go on until we correct not just our broken systems but our broken selves.

When I examine each piece which contributed to this, there is only a few common themes which are prevalent among them all. Raising profits, lowering costs, reducing efforts and assuming someone else is responsible for doing what’s right.

 

The profit motive and its impact on legislation

Our US history of legislation and regulation often favors profit for one group at the expense of others to balance the scales in some respect. At other times it may be nothing more than throwing a bone to one group because they asked for it.

Take for example Day Light Savings Time, which was first initiated in the US in 1916, but was later repealed under pressure from dairy farmers because cows must be milked on a regular schedule and cows don’t run by our clocks.  It was reinitiated and repealed multiple times for different reasons until 1966, with the adoption of the Uniform Time Act. This bill was lobbied heavily by the golf, restaurant and recreational industries for obvious reasons. The law has been amended many times; the last occurrence was in 2005 which moved the spring forward date from the 1st Sunday in April to the 2nd Sunday in March and the fall back date from last Sunday in October to the 1st Sunday in November. Each amendment has been lobbied by specific industries. The last change favored the candy industry, increasing their sales prior to Halloween, making Halloween the 2nd largest commercial holiday second only to Christmas.

Profit comes in two forms, increased revenue or decreased costs. Even when changes are driven by altruistic motives, such as decreasing overdose deaths from opioids, government regulation is often influenced by profit and not all profit is monetary. Take for example the number of federal legislators who came out with bills supporting the use of fixed caps and limits for prescribed opioids. Most had election races in the coming year. Some would call this pandering to your base at the expense of patient safety, others would call it representing the will of the people, but in the end, the question you gotta ask is. Who profits from such actions?  

 

Motives need a justification

In an age of supercharged, instant communications and so many voices either supporting or opposing regulation; it’s hard to sort through the voices to find original truth. Even then, different people interpret that truth differently.

Addiction is one of those problems where for more than a hundred years, everyone keeps looking for simple explanations which allow them to wrap it up and put a pretty bow on it, then tuck it away in some corner so they can say it’s done. When in fact they don’t have a clue on how to solve it, just put a band-aid on it and move on. Each new generation that comes along ignores lessons learned from previous generations and repeat the same mistakes again.

That’s where asking the question of who profits from these regulations can provide some insight. This quote from a 2018 study funded by the National Institute of Health shines some light on motives.

The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness. Over reliance on opioid medications is emblematic of a health care system that incentivizes quick, simplistic answers to complex physical and mental health needs. In an analogous way, simplistic measures (which) cut access to opioids offers illusory solutions to this multidimensional societal challenge.

Key elements in the statement are:

  • They claim the single causative vector is over prescribing.
  • Behind that are economic and social upheavals, (the rich get richer, the poor get poorer).
  • The motivations of the addicted is to find a refuge (or an escape) from physical and psychological trauma.
  • The healthcare system (providers, insurance, pharmaceutical makers, distributors, pharmacy chains) contribute to this problem because they incentivizes quick, simplistic answers to complex physical and mental health needs.
  • The use of the vector model as a solution to this, cutting access to opioids, offers nothing more than an illusory solutions.

These five statements are the hinges on which our current efforts hang. Let’s address each one separately.

 

The causative vector is over prescribing

If taken at face value, without any further digging for meaning, the take away is, doctors over prescribe. From this follows all efforts to address this issue. The study goes on to say that “physicians are unwitting conduits and pharmaceutical companies are selfish promoters”. While the authors didn’t disagree with recommendations made in CDC’s prescribing guidelines or of State medical boards who apply fixed prescribing limits, they did advocated for more research into identifying preferred treatments involving chronic pain based on clinical data and outcomes. But this remains a step which government has been unwilling to fund because it does fit the simplistic view.

 

Behind that are economic and social upheavals

The authors point out that the current methods of treatment, based on a vector model associated with infections, fails to address the root causes for abuse and addiction. In other words, sending people off to treatment centers is not going to solve this epidemic. Furthermore the resistance of insurers to cover the cost of treatment leads to incomplete and failed attempts which actually fuel overdose deaths as witnessed by the relapse rates. They go on to say, “By ignoring the underlying drivers of drug consumption, current interventions are aggravating its trajectory”. In essence their saying we need fundamental changes at a social and economic level in order to address this issue. Another way of saying it would be, as long as the opportunity to grow and thrive remains a privilege reserved for the affluent, this problem is going to stay with us. Such conclusions incorporate lessons learned since the 1940’s in treating alcoholism and other substances of abuse.

Yet over the last twenty years billions have been spent on trying to develop non-addictive pain medications to no avail. They’ll likely never occur due the manner in which nervous systems are built and because out survival behaviors are built on seeking out rewards. Whether those rewards are as simple as food and water or something more abstract like alcohol. Opioid receptors in our bodies are located throughout our nervous system, they are not exclusively in our brains. Attempts at eliminating the euphoric effects of opioids without impacting their pain relieving capability have failed because these receptor sights are responsible for both pain relief as well as the euphoric effects we feel the medications which activate them.

In like manner, billions have been spent on researching substance abuse treatment with no improvement in success rates over what we’ve used since the 1940’s. Ignoring what we’ve learned, we fail to address underlying causes, which occur at a social and economic level, resulting in high levels of recidivism, or treatment failure.

 

The motivations of the addicted is to find a refuge (or an escape) from physical and psychological trauma

Fueled by the growth of Medicare and Medicaid between 1966 and 1990, healthcare became primarily profit motivated, pushing to the back burner altruistic motivations which are less profitable. As more patients were treated for painful conditions, advances led to a greater need for pain management due to longer survival rates from chronic conditions, insurers pushed back with the development of managed care. Managed care was intended to rein in escalating healthcare costs and as the debate raged on, the patient became a silent recipient of the consequences negotiated between healthcare and insurers.

Higher expectations from patients combined with longer lived age groups, fueled the patient side of expectations for pain management. An Institute of Medicine report attributed the rise in chronic pain prevalence during the 1990’s to the following:

  1. greater patient expectations for pain relief,
  2. musculoskeletal disorders of an aging population,
  3. obesity,
  4. increased survivorship after injury and cancer, and
  5. Increasing frequency and complexity of surgery.

 

The healthcare system (providers, insurance, pharmaceutical makers, distributors, pharmacy chains) contribute to this problem because they incentivizes quick, simplistic answers to complex physical and mental health needs

 

A financial opportunity for all in healthcare

In 1980 chronic pain was frequently treated with opioids or propoxyphene (Darvon and Darvocet), the latter was the second most prescribed medication. In fact early signs of what was to come became evident in the 80’s as Darvon became a popular street drug known as “D”, dillies and yellow footballs.

Over time pharmaceutical innovation propagated extended-release formulations, transdermal patches, nasal sprays, and oral dissolving strips. Each innovation had the same basic active ingredient, the driving force behind such innovations being, protectionism from generics and higher profits for specialized formulations related to a delivery method. By 2000 chronic pain was big business which led to incentivations such as kickbacks to prescribers, lucrative speaking fees, government lobbying efforts and minimization of risks. The glut of money poured into these efforts led to some violating the law for the sake of profit.

When all these sources are taken into consideration, there is no single entity responsible for the opioid crisis. Everyone was either complacent or culpable in some capacity, including government as the public.

Up until 2000 we had a healthcare system which was built around trust but don’t verify, allowing the fox so to speak, to be in charge of the hen house. Each of the industries around the production, distribution and dispensing of opioids, operated on a premise of self-reporting. In government, advisory boards at agencies, were at times staffed by members from the pharmaceutical industry or physicians active in pain management. Even compliance and reporting regulations from the DEA were setup to self-report. With no police force to police compliance, during an era where making a profit and giving the appearance of ethical behavior was all that mattered, there were billions of dollars to be made for those willing to cross a line into a grey area.

Prescribers driven by Managed Care requirements and lower reimbursement rates, tried to retain their earnings by taking short cuts in treating patients. Some patients quickly learned how to apply the right kinds of pressures so that prescribers could be manipulated into prescribing higher doses. These and all the fore mentioned elements worked together to collective prime the pump for an opioid crisis.

To say as a nation we were unprepared for this is an understatement, for at every level, individuals in every industry and government agency were blinded by some motivation unique to their position, to seek those things which benefited them.

More simply put, everyone was getting what they wanted and no one was counting the cost.

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