August 10th, 2016
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.