August 10th, 2016
Harrison Reed, PA-C
You are sick of hearing it, but we need to talk about this one more time. By the end you might be angry or frustrated; you might even hate me a little. That’s OK. It’s worth it.
America’s opioid epidemic is nothing less than a crisis. I could bury you under CDC statistics but I think the numbers have lost meaning. After all, the evidence is probably not far from where you are reading this right now. It is cold and hard and lying on a stretcher in the emergency department, in a cooler in the morgue, or in a nearby house sprawled on the bathroom floor.
And while that truth is harsh and tragic, we have compounded it with a second insult. We, a healthcare workforce of medical professionals, have decided to deflect blame and cast ourselves as the victims.
While researching the opioid epidemic for a recent editorial, I ran across the same narrative over and over again. Whether it is social media or popular blogs (or this Medscape post), the refrain is the same: they made us do this.
First, let’s get everyone on the same page. Opioid use, both illicit and prescribed, has skyrocketed over the past 15 years. Compelling evidence from the CDC suggests that many people currently addicted to illicit opioids like heroin began with prescription drugs, and a trend in increased prescriptions has coincided with an explosion in overdose deaths. This year, the CDC updated its recommendations to take a scientific stance on long-term opioid prescriptions: there is little to no compelling evidence of long-term efficacy and a plethora of proof of significant harm.
Now the waters get murky. Many clinicians will protest that they are subject to much larger forces driving the opioid prescribing epidemic. The general explanation goes like this: federal mandates from the Centers for Medicare and Medicaid Services (CMS) have linked reimbursement for healthcare services to specific scores and standards. To evaluate these standards, CMS employs companies like Press Ganey—in what has become a multibillion-dollar industry—to survey patients about their experiences. Among other topics, these surveys place a high emphasis on pain. After all, the Joint Commission told us this was the “fifth vital sign,” right?
Facing financial and administrative pressures, time and resource-crunched clinicians have had no choice but to appease the growing demand for pain control with the use of opioid drugs. The expectation of the patient is to be pain-free, and the expectation of the payer and the employer is a satisfied patient. The prescriber is merely surviving in an environment that has him practicing with a proverbial gun to his head.
I don’t dispute this logic or the truth it holds. There are major forces at work in our industry that make doing the right thing very difficult. But if we hide behind that shield, or worse, use it to absolve ourselves of all blame, then we are confessing to a voluntary violation of our deepest principles.
We made no promises to pharmaceutical companies. We swore no allegiance to Press Ganey or survey scores. We pledged nothing to financial viability or industry business models.
But every physician and PA stood in a room somewhere, in front of mentors and peers and family, and took an oath to above all else protect our patients, to do them no harm. When we prioritize financial reimbursement or job security, we betray the purpose we were meant to serve.
There is plenty of blame to share with others, and the easiest choice is to point fingers, change the subject, and carry on. But let the other parties scramble for moral cover. Let the Joint Commission renounce the fifth vital sign and let those who have never held a crying widow obsess over arbitrary performance measures. We need not do the same.
We are highly educated, financially secure, outspoken professionals. We can do more than complain about patient surveys. We can do more than moan about the injustices of a system that has brought us so many rewards. We can stand for something bigger than the self-interest that others rush to protect.
But first, we need to stop playing victim.
There are real victims in this tragedy. They are the patients with chronic pain who think narcotic dependence is the pinnacle of medical care. Or they are in comas from which they will never wake. Or they died alone. Or they buried their children.
We can play a different role. We can become leaders for a solution. We can change our prescribing culture. We can open a dialogue with hospital leaders. We can contact our government representatives and force them to listen.
But as long as we deny our part in the problem, we won’t be able to embrace our role in the solution. And in this epidemic, that denial is lethal.
The issue is obviously very important, but this should have been written as a call to action, minus the biased sanctimony.
You have decided to call out doctors for blaming others on the basis of… social media and a medscape article? What does this contribute to a complicated and nuanced problem that requires a multifaceted intervention?
This should be revised to include more substantive content, and less ad hoc outrage.
This blog serves as a very specific response to clinicians’ (please note I am addressing everyone with prescriptive authority, not just physicians) denial of contribution to the current opioid crisis or of the emphasis of blame on third parties. I wrote a more comprehensive editorial on the topic (linked in the above blog) and I hope you will take the time to read that one as well. Here is the link again:
In it I reference an Ohio poll that shows the vast majority of physician respondents admit to feeling pressured by outside influence to prescribe more pain medication. While I admit this is less than scientific methodology, it certainly points to a very real vulnerability to modify our actions as clinicians based on the influence of others.
I chose not to call out specific authors in this blog as I do not want to target individuals or even individual professions, but our entire community of prescribing clinicians. However, you can find the mindset I describe expressed quite vocally on websites such as kevinmd.com, if you are interested.
I hope upon some reflection you do see this as a call to action. This problem exists due to factors at the federal, state, institutional, and individual levels. However, unlike other authors I do not expect change to happen from the top down (where apathy for the patients can be the greatest), but by the overwhelming demand from the bottom, by individual clinicians (where empathy can be the greatest). My intention is to suggest that our community is more useful as a voice of change than as a not-so-innocent (and too often, silent) bystander. But first we must ditch the denial.
Perhaps “ad hoc outrage” is exactly what we need.
I do not agree that most drug addiction comes as the result of prescription medication. It is a far larger problem than previously recognized, no doubt. It is a convenient way for the government at all levels to shift attention away from their laughable attempt to interdict street drug trafficking and diversion of legal drugs from hospitals and other sources. Remember the guerneys of fentanyl from Emory in the streets of Atlanta? I have listened and modified my prescribing habits but do not agree that I caused the whole mess. Exactly similar is the constant bleating that Physicians have caused an upsurge in antibiotic resistance-all while farm animals are stuffed full of them. Wake up-all this is a part of CMS’ grand plan to reduce you and me to the level of minor subservient bureaucrats. Thank you for a wonder and thoughtful discussion of a problem that has more facets than some would have us know.
Thank you very much for reading and even more for taking the time for a thoughtful comment.
Please note that I did not say “most” drug addiction is from prescription drugs; I said “many people” begin a drug habit this way. But since we are on the topic, prescription opioids are implicated in more overdose deaths than any other particular drug, according to the CDC. And I feel it is important to acknowledge the dangers of these deaths even if they lack the stigma of illicit drug overdose. More info here:
I agree that there are many facets to this problem. It is why is spent my entire editorial at JAAPA.com (linked above) and a large portion of this blog outlining them. Don’t forget I said: “I don’t dispute this logic or the truth it holds.”
However, I think we must admit that we have the most control of our own actions and thus should direct the most attention there. The second to last paragraph briefly outlines some ideas to address the other players in this situation. I tried to be fair in this blog but please realize my purpose was to argue a particular perspective, one I feel is under-represented in the conversation.
thank you for even noticing my post. I agree with all you said. What I am afraid of is that we are being made into scapegoats. We are now the cause of the third leading cause of death in the country?! Again, I am flattered that you even took your valuable time to respond. Thanks.
You said it well.
As an EM doc >30 years, I saw this wave rise, curl and swallow.
All this talk about opioid epidemic, deaths, illness, treatment leaves out the first and most important step in any public health crisis:
Where is the discussion about not starting this stuff initially?
There’s a lot of $ thrown at a brand name drug to suppress cravings with no discussion on how to decrease demand/need for this brand name drug.
Anyone with a DEA number can actualize an addict’s predilection.
So let’s not do it.
Let’s stop creating customers for reversal and suppression drugs.
I agree with your outlook on this problem. Prevention in any situation is often easier and less costly that the subsequent damage control. I’m sure your experience in EM has shown you the dire consequences of a problem like this; it also puts you in a position of authority to speak on possible solutions. I hope you remain vocal about prevention and offer ideas and support to this cause. Thank you very much for reading and commenting.
Don’t forget that the Joint Commission jumped in with the enforcement of Pain Scores and the dictum that “pain control is a right”. I agree with this in the ICU and acute care setting but most of “old heads” we’re trained to wean opiates fairly quickly . The pressures on all of us to prescribe in outpatient setting rose significantly over the preceding 20 years.
Well said Harrison. Thank you.
What a timely and thoughtful essay. I had not thought of our place in the debate in this way but the author is absolutely correct. We have been unwitting co conspirators in spreading this “disease”. But in our defense we are subjected to undue pressure from families,the State regulators who gravitate to the chronic pain patients in facilities and then cite us for poor pain management. I think part of the answer is to make ourselves more aware of other modalities for pain control and vow to restrain a knee jerk impulse to order opioids when something less toxic will do. Educating patients and families is also a big part of this. If we have alternatives this will go a long way to decrease their concern and anxiety.
Dr. Hyman I agree with your remarks. The purpose of the opioids is pain relief and has been thus for thousands of years. I strongly object to being labeled non-compliant and self-indulgent because I request pain relieving medication. Which idiot is going to tell me that since I am 78 I should just bear my back pain without complaint or treatment.
(Disclaimer: I am retired, so have no personal stake in this other than patients’ welfare and concern for the increasing difficulty of practicing medicine).
I disagree! As is only occasionally mentioned anywhere, the increase in narcotic prescribing arose from dire warnings to physicians about the cardiovascular and other risks of NSAIDs, an issue also widely publicized in the lay press (remember the Celebrex controversy?) and leading to a change in official policy in many pain management facilities. “What’s a doctor to do?”
In addition, it was believed, even in the addiction treatment community, that patietns for whom narcotics were prescribed for pain relief were unlikely to becone addicted. Thus, doctors began a much more liberal prescribing pattern before the dangers becsme apparent.
Now doctors are caught in the binds described above, and in some areas are restricted from prescribing opioids to patients who have maintained non-escalating doses of narcotics to manage their chronic pain for long periods of time, apparently with efficacy.
As for the implication that patients’ desire to be pain free is some kind of modern self-indulgence, one should “walk a mile in….those…shoes.”
With all that, I certainly agree that the medical community needs to step up to the tragic epidemic of harm from medically prescribed narcotics, but I don’t believe that casting blame on doctors has any place in this.
Thank you very much for reading and even more for a thoughtful comment.
I agree that the side effects associated with NSAIDs have made these drugs a double-edged sword in our arsenal. I think they may be one of the more frustrating, oh-so-close meds when it comes to many conditions including pain resulting from chronic conditions. The search for an alternative answer has led the medical community down some dark paths to which you alluded.
Misinformation from the pharmaceutical industry may have played a role at first, but we as clinicians have always been in the vanguard of medical research and the dissemination of information. We have asked and answered our own questions without the guidance of commercial interests. If we chose to not further probe the efficacy and safety of opioids, or ignore the existing evidence (which highlights many dangers but reveals little proof of benefit in long-term use) then we are willing accomplices to our own ignorance.
You may not believe that any blame rests on prescribers, but everyone applying for a DEA number has alleged a level of responsibility for the use of Schedule II drugs. That responsibility cannot conveniently disappear when the side effects rear their ugly heads.
In reading many, many articles, across many medical and psychological disciplines, on the issue of overuse (“epidemic”) of opioid drugs, both prescribed and diverted, there are facts which I hold clear in my own prescribing philosophy.
I have been a licensed, nationally board certified PA since 1993 in disciplines as diverse as abdominal organ transplant, oncology, geriatrics, hospital palliative care and family practice. And two facts have been consistently true in every setting: patients have real chronic pain for which opioid medications are appropriate and safe and not all pain requires opioids for long term use.
Blaming anyone, doctors, patients, parents,or anything such as lax societal morals, selfishness, self-absorption for increased use of opioids probably misses the point which may be directing us to a possible solution. The point of every article on this topic of overuse, abuse, overdoses, taxpayer costs, and incarceration has, for the most part, been a rehash of the data. But behind every number is a person or a family and a doctor or PA, NP or Social Worker wondering if they missed a sign or if they contributed to the problem.
I maintain, through my years in practice ( anecdotal, for certain, but credible) that in many cases where I’ve been asked for pain medications I was also being asked ( sometimes silently, or within the patient’s history) to listen for five extra minutes, cut through layers and see somatic pain as real, though distinct from organic and functional pain.) Those differentiations make the critical path to successful pain management possible. Because then it is incumbent on me to ask of each patient what they are willing to do for themselves so that opioid medications are only one plank of their care planning.
Their willingness to possibly lose weight, exercise a bit more, alllow me to treat their depression, participate in group therapy, learn to cook, any of these or all of them gives me clear feedback about whether opioids will be useful or are more likely to become a crutch leading to ever increasing need.
I agree, without reservation, that our pledge to “do no harm” is the ultimate honor to which we are called. It underpins every privilege and trust we enjoy as Physician Associates, Physicians, Nurse Practitioners and Social Workers.. All of us must believe that we act as an intradisciplinary team in caring for patients in either acute or chronic pain. With every nearly instant communication tool now available to us in modern medicine, none of us should ever feel alone in managing the challenges of pain management. Asking for input, for suggestions and for help in the follow-up of patients should never be seen as weakness. Rather, it should be seen as the best care planning possible by thoughtful, respectful practitioners.
Pain may,in fact, be the most undertreated and poorly managed complaint patients bring to us. That is a separate discussion. But getting at the reasons for why pain is such a frequent complaint requires honest self-assessment from patients as well as providers about what they are saying and whether we are actually listening to what is said and left unsaid. Can this be accomplished in a pressured ten minute visit? Not usually.
So, perhaps we might look at changing our typical scheduling for appointments. There are certainly “experts” in time management within every health care system. En masse, medical providers need to present our requests for a new approach to scheduling patients with pain so that the quick default treatment isn’t just a prescription for an opioid and nothing else. I believe we are capable of much better, more thoughtful care planning which gives the patient a partial share in their own health and motivates them to take some step toward improving it with each request for pain medication. Without both elements, the outcomes are predictable.
A well thought analysis of a serious problem that has been years in the making. Yes, all the mentioned factors play a role in the current opioid addiction epidemic, but the fact remains, the buck must stop with the professional who writes the prescription.
There is no guarantee of a pain-free life and to use patient satisfaction surveys is absolutely wrong. The entities that use these surveys to assess the competence of a prescriber deserve no more than a passing look. What is needed is the time to discuss with a patient the available pain treatments and use opioids as a last resort except in the most severe pain—then only for a short time.
The addiction epidemic may be due to more factors than a written prescription, but is way past time for the medical profession to admit our complicity in it.
The over use of narcotics has been led by the pain initiative and the pain management zealots. Life isn’t measured by how much pain you have but by who you are and what you do. this also applies to your practice.
NO GUTS is what stops medical providers from becoming part of the solution. The desire for high patient satisfaction scores, no complaints of poor service and/or lazy or incompetent doctors cause much of the problem. When service scores are not an issue, income is, since patients won’t come back if the treatment recommended is OTC NSAIDS or physical therapy. Working for a large HMO in the late 1990’s I would get opoid seeking patients with no apparent need for them whose multiple prescriptions were noted in our database. Alerting patients’ primary care doctors to this drug seeking behavior did no good since most continue to inappropriately prescribe opoids to avoid patient customer service complaints or low service scores on customer surveys.
All I got for my efforts to try to educate patient on appropriate pain control meds and exercises was a multitude of patient complaints about “didn’t understand my problem”, “didn’t listen to me”, “was rude” and the like as well as low service scores. This earned me yearly “poor provider” reviews. However, since I was trying to do what was ethically and medically right, I was lucky my supervisors made no attempts to change my behavior… but they were obligated to write me up.
But the government encourages this by rewarding service providers/clinics for high customer satisfaction scores and penalizing those who don’t.
Do some people legitimately need opoids? Of course. However, many don’t but get hooked on them anyway because their medical provider doesn’t have the guts to say NO!
I have only sympathy for the patients who encountered you.
Plainly, patients who have pain for any reason……. seek relief of their pain. Of course they expect opioids since opioid pain relievers have been used for pain relief for thousands of years and in spite of all attempts by the pharmaceutical companies to provide alternatives, opiods are the most effective pain relievers. Patients want and request pain relief immediately, not eventually after a series of actions. And rightly so. Treat the pain immediately. Diagnose the cause and use prevention when possible, but first, treat the pain. Pain prevention in chronic illness is not always possible and pain treatment is always possible..
for example, for many years I suffered gastric distress with many manifestations. I was healthy in all other respects. Symptoms varied and were intermittent. After about 20 years I developed pyloric spasms. Sudden onset with griping pain that literally brought me to my knees. We could identify no cause and the only efficacious treatment was 100 mg IM morphine. When I presented at the ER I was always quized extensively. After years of this, a new proton pump medication came out, and after double doses for months I was eventually “cured” and have had no problems for about 15 years. In spite of sophisticated attempts to diagnose and treat the cause of my pain, there were no answers for 30 years. During that 30 years, pain treatment was always possible.
The patient population is aging. Over 70% have low back pain. They want and deserve pain relief.
I do not believe the big crisis in health care is opioid addiction. This is a myth promoted by people who are not medically trained. And If people abuse opiods, allow them to suffer the consequences. These advocates of absurd control who would deprive many of pain relief because of the irresponsible behavior of a few are foolish. Further interfering in Physicians practicing medicine using their own judgement. I do not want a minimum wage clerk in an insurance company making pain relief decisions for me. I now live in a Central American country where I can get anything OTC.
My sentiments exactly.
The people who consume the opioids are responsible for their behavior, choices and consequences. This should be the end of the topic.
Attempts to control peoples use and misuse of mood altering substances is futile. It has never been and will never be effective.
The more I hear on this topic, I see that the point that is being most advanced is to prevent patients from receiving pain medications unless they are hospitalized, where dosages can be controlled by the staff that is literally not feeling any pain!
Furthermore all this bleating and blaming about opioid overuse etc ignores the facts that the population is aging and LOWER BACK PAIN is ubiquitous among people over 50. At 78, I assure you that I do not want to hear sanctimonious twaddle about opioid pain meds from some 30 year old who has never been ill or had pain and does not have a Medical Degree.
Unless someone can correct me, in 40 years of prescribing I have NEVER, created an opiate addict – including having worked in a Methadone clinic ( I reduced their addictions – ALWAYS). Opiate prescribing is a SKILL – inadequately taught in medical school – and usually inadequately learned if you didn’t get it then.
I propose that ONLY people who want to and have shown the capacity to be able to handle these drugs be given an license to prescribe them – and that it’s not “free” with every medical degree.
In that sense the medical profession is “responsible” for creating victims . . . .think about it.
As a Physician Assistant practicing in a pain management practice, I do not completely disagree with your comments. However, as some before me have mentioned already, there are so many more facets to the growing epidemic of opioid use and abuse. There are very legitimate cases of chronic pain out there. There are patients that have agreed to and undergone physical, occupational, massage, and aquatic therapy. They have had interventional procedures including medial branch blocks, epidurals, joint injections, trigger point injections, and RFA. They’ve lost weight, changed their diet, maxed out on NSAIDs, taken steroids, undergone surgical procedures…and yet, they still have chronic pain. With very strict prescribing guidelines and monitoring systems within a pain management practice, pain treatment can exist without outrageous and steadily increasing dosages. Taking the stance that certain classes of medications, such as opioids, are unnecessary and not needed by our patients is essentially writing off their condition and conveying to the patient that we simply don’t care that they’re in pain. Do no harm can apply in many different situations. Have you read any literature on suicides that have occurred because of untreated and uncontrolled pain?
This is a topic that has so many points to be made we could be here all day discussing them. But I implore you not to write off every person who complains of pain as the next addict, overdose case in the ED, or someone who expects to fix everything with a pill and be “pain free”. It’s just not that simple in the pain world.
a well written essay.
I agree with most. Dr Wells makes a compelling argument:
“A well thought analysis of a serious problem that has been years in the making. Yes, all the mentioned factors play a role in the current opioid addiction epidemic, but the fact remains, the buck must stop with the professional who writes the prescription.
There is no guarantee of a pain-free life and to use patient satisfaction surveys is absolutely wrong. The entities that use these surveys to assess the competence of a prescriber deserve no more than a passing look. What is needed is the time to discuss with a patient the available pain treatments and use opioids as a last resort except in the most severe pain—then only for a short time.”
The medical provider and patient both playa key role
Pain must be managed. Lets not return to the late 20th century when oncology patients begged for help. Pat sat scores do play a role but must be deemphasized. If a pt does not agree with their docs for pain relief they provide a low score. .What needs to take into account is if the pt is believed to be doing harm to themselves.
Metrics is not the sole answer
My clinic has discouraged over use and improperly prescribed narcotics since I opened my clinic. Unfortunately, I see so many patients on high doses of narcotics with just the need for more narcotics. They get referred to detox. Almost all of them are from primary care “practitioners” that get very offended when I try to stop the narcotics, benzodiazepines and frequently barbiturates and amphetamines! Be clear when you say pain management fanatics.
Thank you for your timely and well-spoken presentation. In my experience, primary care providers are often the standby prescribers in the community for patients with all sorts of unhealthy habits. In my practice, I see cocaine abuse or even methamphetamine abuse excused because the patient promised to “clean up”. Some of these patients have been discharged from 2 or 3 local pain management clinics for street drug abuse. Unfortunately when they return to their primary care provider and present their arguments for leniency, they are still given dangerous combinations of high potency opioids, benzodiazepines, and muscle relaxants. It does not even strike my co-workers as irregular that the most resquested drugs also have the greatest street value. I have begun making the needed changes in my prescribing, while also looking for a new job. This is the sad reality of today’s primary care landscape.
The person responsible for addiction is the one who ingests the drugs.
It is not the supplier.
Supply side approach to preventing or treating addiction does NOT work, has never worked and can never work.
Physicians are not responsible for creating addicts out of healthy patients. Physicians will never be able to decree that patients will make healthy choices in any area of life.
Thank you for your response. It is very hard to stand by your convictions, especially when they seem to run counter to the professional culture in which you are immersed. If your conscience drives you to such drastic steps as to change jobs or environments, you have my respect. Please know that you are not alone, even if it feels that way,