Both Sides of the “Crisis”

One of the fashionably bipartisan Washington topics for chest beating is the opioid cris-, sorry, “THE OPIOID CRISIS!!!”  I’m one of the apparently few physicians who thinks that there should be no federal role in the provision of daily health care, based on several decades of observation: everything in health care that Uncle Sam touches gets worse.

I learned in residency to give enough opioids or benzos, sometimes, and quickly learned (the hard way, just like you) that patients will lie their way into more and at the very least, make me look like a fool.  Over the next few years I was generally tight-fisted with the happy pills, loosening up sometimes by what I observed in colleagues, then clamping down again when I realized I’d been had, to the point where my habits got very consistent and effective.  When I was moonlighting in rural ER’s, I thought those particular locals were abnormal drug hot spots; later I realized that everywhere is drug-strewn.  At one point reps were trying to sample nasal Stadol in my office, which I firmly declined.  Good thing too, since a year later our small office had a very bad run-in with an addict employee that could have cost us dearly.  While Big Pharma was pushing Oxycontin, I was writing it minimally, then later, only for terminal patients.  I was also making the occasional trip to the ER parking lot as another blue and apneic oxy-shooter was being hauled out of someone’s car.  I learned what worked, what didn’t, and what safe limits were for myself and my patients during the JCAHO-Big Pharma crony corporatist push to sell ‘dem beans and keep that fifth vital sign WNL.  

Later, when the government decided to pull the rug out from under the junkies and pushers they helped create, it didn’t change my prescribing habits one bit.  It’s insulting as hell that state law requires me to check the drug database every time I write a controlled script, proof to me that the system is less about awareness than pinning accountability to the doctor.

But now USAToday reports that, “Doctors are misusing 2016 opioid pain medication guidelines, federal officials said … Doctors that set hard limits or cut off opioids are also misapplying the government’s guidance, CDC said.”  The government told us all to prescribe more, so many of us did.  Then Uncle Sam wagged his malevolent finger and told us to prescribe far less, or face major legal trouble, so many of us complied with that, too. NOW the CDC is accusing doctor of being guilty of a “misapplication” of the opioid guidelines.  Pending new options, “people in the middle of cancer treatments, having acute sickle cell crises’ or with pain after surgery shouldn’t be affected by the earlier recommendations, CDC said. These patients were outside the scope of the guidelines, which were intended for primary care doctors treating chronic pain patients, CDC said.”

So oncologists and trauma surgeons had nothing to fear from a deceitful, media-fueled government after all? So primary care physicians, for all the their years of training, board certifications, comprehensive experience, and unproven, worthless, extorted MOC fees aren’t smart or experienced enough to manage acute or chronic pain?  The entire issue has become so schizophrenic that I have heard educated, thoughtful people damn both the government for allowing suffering, and damn doctors for creating addicts.  And sadly, in some cases they are right.

“If doctors are already prescribing opioids at higher dosages – at or above the 90 MME limit – they should continue doing so if needed, CDC said.”  Whew, thanks for letting us know, otherwise bumbling primary care physicians might flood their local ER’s with withdrawals. But for all the CDC compassion, did the DEA get the memo?  Will claiming the CDC said I “should continue doing so if needed” be an adequate defense when then the jackboots ring the doorbell?  (It’s a trick question – they don’t ring doorbells, they have flash-bangs and heavy weapons).  

The article helps by reassuring, “America’s Health Insurance Plans, the lobbying group for commercial health insurers, unveiled a new strategy that aims to help doctors and patients manage chronic lower-back pain without using opioids.”  It’s no surprise to see an industry that helped build this trap develop some rapid-response, comprehensive ass-covering.

“Along with warning doctors against too much caution, CDC underscored the need for several safeguards. It recommended doctors:  

• Avoid prescribing opioid pain medication and benzodiazepines – such as Xanax – together whenever possible.

• Expand the use of non-opioid treatments.

• Review risks of continuing on high-dose opioids – with empathy

• Work with patients who agree to taper to individualize, minimize withdrawal.

• Monitor patients on high-dose opioids to prevent overdose.”

Aw heck, why didn’t you and I think of that??  

Every current major initiative in health care is designed to minimize the influence of physician judgment while making the doctor accountable for any bad outcome, which includes anything the government may retroactively deem to be a bad outcome. The lesson of this latest “crisis” is that medicine is now fear-based, and physicians must proceed accordingly. 

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