Foster: Roots of our pain-pill addiction

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(Credit: Christopher Serra Illustration)

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The Centers for Disease Control recently issued an alarming report about the growing American public health epidemic of narcotics addiction. No foreign drug cartels are involved. The narcotics, opioids, are all perfectly legal drugs, prescribed by physicians.

"The system is awash in opioids -- dangerous drugs that got people hooked and keep them hooked," says CDC director Thomas Frieden.

Sales of hydrocodone, oxycodone, morphine and other opioid pain relievers have skyrocketed 400 percent in the last decade. In the state of New York, prescriptions written for the most popular street drug, oxycodone increased 82 percent between just 2007 and 2010.


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Lawmakers in Albany are currently considering bills that would bolster the ability to track these prescriptions, and with good reason. This tsunami of narcotics is killing people. In 2008, the most recent year for which national figures are available, nearly 15,000 people died from prescription opioid overdoses.

As an emergency physician, I've asked myself how physicians could have become bigger purveyors of addicting narcotics than the drug cartels. How, as the CDC has reported, could we have more deaths at the hand of physician-written opioid prescriptions than from heroin and cocaine?

In a chilling illustration of the law of unintended consequences, many of us who are front-line physicians believe that this wave of addiction is primarily the well-intentioned creation of the medical establishment itself.

Opioids have been used for centuries to alleviate pain, and have offered blessed relief to millions suffering from short-term acute pain or cancer pain at the end of life.

But they have the dark side of addiction. In addition, with chronic use, opioids often have the perverse effect of actually "rewiring" the brain to make it even more pain sensitive. Thus, in chronic pain, the cure is often worse than the disease. Patients not only still have pain, but they become afflicted with addiction, too. For these reasons, physicians for most of the last century were very cautious about prescribing long-term opioids.

Physician reluctance to prescribe opioids began to change several decades ago with the rise of a number of pain-oriented advocacy groups and academic societies. Arguing that pain in America was an undertreated condition, these groups slowly succeeded in making the issue a hot topic in the medical community.

 

They often framed the discussion as one of bias against patients with chronic pain -- an argument that resonated well within the academic community at a time when issues of social discrimination were playing a growing role in American politics. Pain control gradually became something of a cause célèbre. The pain management movement grew in fervor and took on almost political overtones, as if freedom from the pain that life and our physiology inflict on us was a new civil rights issue.

At medical conferences, university academics advised physicians that we were treating pain inadequately and that it was not the doctor's estimate of pain intensity that counted, but the patient's perception. "Pain is what the patient says it is" became the common catchphrase. Physicians were advised to prescribe medication until the pain level was deemed acceptable to the patient.

As front-line physicians, my colleagues and I were assured by medical academics that opioids carry a very low risk of addiction. Physicians began to fear charges of discrimination against patients with chronic pain if they refused to prescribe narcotics.

Soon the drumbeat was picked up by state departments of health and national regulatory bodies, most prominently the Joint Commission, the major accrediting body for American hospitals. In 2001, the commission published a new set of hospital standards establishing pain management as a patient right, mandating frequent pain assessments, and requiring patient education about pain management.

Better relief of pain -- an indisputably worthy goal. Hospitals hopped right to it. Pain was declared the "fifth vital sign." All patients were asked to rate their pain on a 1 to 10 scale. Brochures informed patients of their new rights, reassuring them that addiction was unlikely and urging them to take their pain medicine. Patients were additionally informed that tolerance to their pain medicine might occur and that they might need more medicine. Although not mentioned by name in the Joint Commission brochures, in the real world that invariably meant opioids.

Under the combined pressures of academic medicine and regulatory bodies, physicians began writing prescriptions for narcotics as if they were candy, figuring that their former reticence about prescribing narcotics was no longer the contemporary standard of care.

Health care providers began to witness an explosion in the number of patients claiming chronic pain. New diagnoses like "chronic pain syndrome" were created to describe patients who had no objective, documentable source of pain.

The emperor was wearing no clothes.

 

By 2004, according to the International Narcotics Control Board, the United States was consuming 99 percent of the world's hydrocodone production.

Meanwhile, those of us in the daily practice of medicine witnessed a profound cultural shift in patient expectations. Patients in our ERs demanded immediate pain relief, claiming allergies to all medications except their favorite narcotics.

Many of the academic and regulatory groups influencing physician practice underestimated the addiction potential of prescription narcotics and failed to foresee the epidemic that was coming. Worse, the assertions that opioids are effective for chronic pain and carry a low risk of addiction were based on flimsy evidence. A recent editorial in the Archives of Internal Medicine notes that evidence of opioid efficacy for chronic pain is astonishingly weak, and concludes that the studies citing a low opioid addiction rate were poorly designed to detect addiction.

The CDC reports that the medical costs of this needless epidemic may be as high as $72 billion. But the societal costs are probably much higher. Many of these addicts become unemployable, dependent on public assistance and end up on disability. Their pain is measured in lost jobs, incarcerations, shattered families, addicted newborns and death. The repercussions of medically sanctioned addiction will echo for generations.

The American prescription opioid crisis is a stunning example of the way that even the scientific academic community can get caught up in a well-intended movement. It illustrates the perils of micro-regulation, and the distortions in medical practice that regulation can produce.

Ultimately, this tragic epidemic leads us to realize that the highly subjective issue of pain should never have become a regulatory pursuit in the first place.

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