Meeting of the Minds, Oct 23, 2017, A Medically Facilitated Catastrophe

   At a recent Wise Guys meeting, the issue of the opioid epidemic was raised

 and some asserted that the epidemic could be attributed to the medical profession. I write this blog as a physician who was caught up in this medical mishap. I was initially fearful of prescribing opioids lest such efforts result in patient addiction, but then subsequently became equally fearful of discipline from my hospital for failing to adhere to logarithms and “standard practice” for controlling pain. The purpose of this blog is to explore the crosscurrents of American medical culture that gave rise to the opioid epidemic and the efforts to ameliorate the damage that was done by well meaning people.

   Physicians have traditionally been wary of prescribing narcotics for fear of inducing addiction. As a result narcotic prescriptions have been confined to short-term treatment of acute pain.  All this changed in the 1980’s and more so in the 1990’s, spurred by a letter published in 1980 in the prestigious New England Journal of Medicine. The letter claimed that narcotic use as prescribed by physicians did not result in addiction. Despite the lack of corroborating evidence, the medical community accepted these conclusions since the letter originated from the Boston Collaborative Surveillance study from Boston University School of Medicine. The authors Jane Porter and Herschel Jick later claimed that they had no intention of furthering the use of narcotics for chronic pain. Nonetheless, the damage had been done. These impressions were then supported by a study published in 1986 in the Journal Pain by Dr.’s: Portenoy and Foley.  The article consisted of a review of 38 patients treated with opioids for chronic pain .The conclusion of the authors was that that there was no addiction potential by such treatment. This conclusion resonated with the New England Journal letter and thus supported the notion that chronic use of opiates does not lead to addiction.  Although the study was flawed In that there were no placebo controls, the medical community regarded the results as unassailable.

 Following these publications, a complex interaction between academic physicians, the pharmaceutical industry (Big Pharma) and governmental agencies furthered the notion that narcotics were being underused, to the detriment of the suffering patients. The professional medical societies led the crusade and included the American Pain Foundation, the American Academy of Pain Medicine and the American Pain Society, which teamed up with the Pharmaceutical Companies to encourage narcotic use.

   The pharmaceutical industry has always sought to influence academic physicians by supporting conferences, paying for foreign conferences and providing a new physician’s first “doctor’s bag. Although it was not clearly delineated, the physicians returned the favor to Big Pharma by prescribing their products, either consciously or unconsciously. With the apparent support of academic physicians, governmental regulatory agents joined the effort to encourage opioid prescriptions.  The Federation of State Medical boards issued a policy to reassure doctors that they would not be disciplined if they prescribed even large doses of opiates. They went even further by encouraging boards to punish doctors for undertreating pain. Soon regulatory organizations joined the fray, which include The Joint Commission on Accreditation Of Health Care Organizations, and the Food and Drug Administration. Under the influence of governmental agencies, pain was proposed as the 5^th vital sign. It soon became required to question patients about pain and attempts to quantify pain were made, Patients were requested to choose an icon affixed to their hospital room walls, indicative of their level of pain. This number was then incorporated into the other vital sings, BP, P, temperature. It soon became inevitable, that opioid use would assume in a new role in the treatment of chronic pain particularly with oxycontin, an oral narcotic with a prolonged action.

   It soon became evident that efforts to promote use of opioids led to an opiate epidemic with profound consequences. On November 11, 2016, the CDC declared a prescription drug epidemic and laid its cause at the feet of doctors overprescribing opiates.  This finding led to some back peddling of regulatory agencies. That same year, JACHO denied a role in fermenting this problem and sought to promote counseling of those affected by drug addiction. State medical societies shifted from promoting opioid use to treatment for addiction. Naloxone was promoted for non-MD treatment of overdoses.  The FDA although approving oxycontin in 1995 and fentanyl in 1998, began to pull back, requiring warning labels on opiates and education for physicians. Large suits were brought against Purdue, the makers of oxyconten for inappropriately promoting opioid use.  The drug company switched to an abuse-deterrent formulation. Oxycontin originally contained a large dose of oxycodone. By crushing the tablet, addicted Individuals could obtain a large dose of the narcotic.  The newer formulation was much more difficult to crush and snort. The FDA although approving oxycontin in 1995 and fentanyl in 1998, began to pull back, requiring warning labels on opiates and education for physicians. As oxycontin became less available, its cost differential to heroin widened, and heroin became the choice of narcotics on the street, and what was an oxycontin epidemic became a heroin epidemic, sprinkled with fentanyl, a highly addictive and potent narcotic.

   We now find ourselves in the role of crisis managers. The medical community is presently in lock step with governmental agencies and the pharmaceutical industry to control the epidemic. Unlike previous epidemics of narcotic addition, which were confined to poor black neighborhoods, the latest epidemic now involves middle class white communities.  It is now a hot political issue. Donald Trump has demanded a new crusade against narcotic addiction, with assurance of seeming unlimited financial support. These issues are dealt with in an accessible way in a book written by Anna Lembke, Drug Dealer, and MD. Johns Hopkins University Press, 2016. The reader is referred to this book for a readable review of these issues.

Posted by Arthur Banner