The Opioid Crisis is All Your Fault

The fingers keep pointing our way.  We, as physicians, obviously caused this crisis. Forget all the articles and lectures back in the early 2000s about how bad we were at assessing and treating pain.  It turns out that WE are 100% to blame. Not the narc seekers. Not the pill mills that were left unchecked.

Forget the fifth vital sign nonsense they made up (Joint Commission in conjunction with Purdue Pharma).  Forget doctors getting sued for NOT treating patients pain adequately.  Here is a nice paper in PubMed from 2001:

Another message to physicians implicit in these verdicts is that there is a standard of care for pain management, a significant departure from which constitutes not merely malpractice but gross negligence. Even if professional boards might not hold their licensees to that standard, juries will. With the implementation of the new pain standards by the Joint Commission for the Accreditation of Healthcare Organizations, which recognize the right of patients to the appropriate assessment and management of their pain, public expectations will likely increase exponentially. To match these expectations, physicians will need to urgently improve their knowledge, skills, and attitudes toward pain relief.

Makes you feel all warm and fuzzy inside, doesn’t it? You see how the Joint Commission was complicit in all this?

Here is the new attempt to blame us (from AMA Morning Rounds):

Nearly one-third of outpatient opioid prescriptions lack medical explanation, study indicates

NBC News (9/11, Fox) reports on its website that according to research published in the Annals of Internal Medicine, a review of medical records from 2006 to 2015 “showed that a physician gave no explanation at all for writing an opioid prescription in 29 percent of the cases.”

The Boston Globe (9/10, Finucane) reports “inappropriate prescribing, bad recordkeeping, or a combination of both were possible reasons for the missing data, according to the researchers.” Study author Tisamarie Sherry said, “Whatever the reasons, lack of robust documentation undermines our efforts to understand physician prescribing patterns and curtails our ability to stem overprescribing.”

The study was a massive fish net of visits that they evaluated.  How many pill mills were in there?  No one knows. Most of the cases of “non-explanation” were for patients already on chronic pain meds and were given a refill at the visit:

Absence of a pain diagnosis was more common among visits in which an opioid prescription was continued (30.5% [CI, 29.0% to 32.0%]) than those in which an opioid was newly prescribed (22.7% [CI, 20.6% to 24.8%]).

At visits with no pain diagnosis recorded, the most common diagnoses were hypertension, hyperlipidemia, opioid dependence, and “other follow-up examination”

So, opioid dependence was not a diagnosis? Lack of documentation is not great and I get that. It does NOT imply causality, however.

Watch the media drill us for this.  We are the scapegoats and yet I fully believe good docs were either stuck HAVING to give pain meds (due to dependence) and/or satisfaction survey fear or gave pain meds appropriately.  I believe the opioid crisis was mostly started by:

  1. Moronic educators who claimed we didn’t treat pain adequately
  2. The Joint Commission
  3. Big Pharma (like Purdue)
  4. Narc Seekers
  5. Pill Mill docs
  6. Metrics pushing satisfaction surveys that forced doctors to make patients happy no matter the cost

None of the things recommended by so-called experts have fixed the above.  Word on the street is that there is legislation out there to outlaw pain (thanks, Michael Chiampi MD, for that one).  I hope it passes.

For a laugh, get Dr. Farrago’s Diary of a Drug Rep Here

By the year 2000, pharmaceutical companies were spending more than $15 billion dollars a year on promoting prescription drugs in the United States. It was not uncommon to see doctors going to extravagant dinners, amusement parks and golfing events, all sponsored by these companies and all orchestrated by what are called drug reps.
In 2002, I first pieced together a fictionalized, diary-like version of this tale, which spread virally on the Internet and became an instant hit, especially with drug reps. Initially called Diary of a Pharmaceutical Representative (Drug Rep), it was reproduced first in my humorous medical magazine called the Placebo Journal and then in his book The Placebo Chronicles. It even inspired a 2005 NY Times article called “Gimme an Rx! Cheerleaders Pep Up Drug Sales”. In Diary of a Drug Rep, I expanded this initial vignette, giving the reader a unique look into how drug reps lived, worked and “sold” their products in their heyday. The intent of this book is not to belittle this profession, but rather to understand it and, ok yes, laugh at it a little. Diary of a Drug Rep will give readers insight into a very peculiar profession that affects us all more than we even know.
121590cookie-checkThe Opioid Crisis is All Your Fault