Prescription opioid abuse is on the political radar. “Painkillers” are a recognized cause of thousands of deaths a year. But what to do about it?
A FDA Panel recently recommended mandatory training for physicians who prescribe opioids. Congress passed a bill calling for more education, presumably physicians as a prime target. We’ve actually been down this road before, but possibly not how you think.
The politicians and pundits used to complain that pain was undertreated. An article was published in William Mitchell Law Review in 2000 with a subsection labeled “The Cultivation of Ignorance.” In it, the authors wrote, “… the answer to the obvious question of why caregivers fail to provide adequate pain relief to patients in so many instances when it is in their power to do so, is … [p]hysicians are poorly trained to manage pain properly. They rely on drugs, … prescribe too small doses, and often wait for pain before they do something.”
Others chimed in. There was an “epidemic of chronic pain.” “One family in three includes a victim of persistent pain.” “[M]edical licensing boards [should] be disciplining physicians who fail to develop and maintain competence in pain management.” Eric Cassell, MD asserted in a widely quoted book that , “… the response of the medical profession [to pain] has generally been too little and too late.”
Physicians pushed back. They believed that in some circumstances the risks of pain relief with opioid analgesics often outweigh the risks. They named those risks as “premature death, drug addiction, respiratory depression, and compromised mental status.”
But the pain treatment zealots did not give up. They convinced healthcare system bureaucrats to force the issue. The VA system spearheaded the campaign to make pain the “Fifth vital sign,” meaning that it had to be assessed at every patient encounter. The Federation of State Medical Boards encouraged physicians to feel comfortable writing for larger narcotic doses. The Joint Commission (the thing that regulates hospitals) published opinions that physicians have “inaccurate and exaggerated concerns” about addiction, tolerance and risk of death.
Then the patient satisfaction obsession kicked in. Doctors who declined to write for narcotics for patients were given bad reviews on patient satisfaction surveys. Hospital administrators then jumped in to the fray, pressuring physicians to write more narcotic prescriptions so the hospital patient satisfaction scores would improve.
And so now the number of deaths attributed to prescription painkillers is 14,000 per year, which has quadrupled from 1999. Looking back, it turns out that some of the leading proponents of the pain pill pushing movement were heavily sponsored by the drug industry.
The only deficit education fixes is ignorance, and perhaps as a side effect, attitudes. Clearly we need more education in this country.
We need education for politicians, bureaucrats, and pundits that caring for complex patients with complaints of pain is complex and defies simplistic regulatory solutions. They need to be educated that there is no test to measure pain and there is no drug that is completely safe. They need to be educated that sometimes doctors have a greater purpose and calling than to appease a patient demanding narcotics inappropriately. Physicians have difficult risk/benefit discussions with patients every day, and sometimes those risk/benefit discussions include telling patients things they don’t want to hear.
With families of people who died of prescription narcotic overdoses testifying that something must be done, does anyone think that the Congressional or regulatory action plan will be for those politicians to commit to educating themselves on the unmeasurable complexities of patient care?
I doubt it too.