42. The Iatrogenic Opioid Epidemic

April 29, 2017

For forty years I have been adamantly against the over-prescription of opioid pain medications: typically Percodan or Percocet. The generic name for the main ingredient of those medications is oxycodone. See: https://en.wikipedia.org/wiki/Oxycodone

With the rise of “pain clinics” in the 1990’s, physicians who believed, or pretended to believe, the myth heavily promoted by drug companies that opioids, when given for actual pain, would not addict the recipient, convinced the medical licensing boards in California and elsewhere that doctors as a rule were shamefully “under-treating” chronic pain patients. Acting upon that false narrative, those boards, in turn, chastised doctors for this purported “under-treatment”, and forced them to take special courses as part of their Continuing Education requirement, encouraging them to prescribe opioids for any claimed chronic pain, whether the source of the pain was or was not able to be demonstrated: whether the pain itself made any rational sense or had a medical explanation.

This movement, I believed then and I believe now, was closely allied with the politically liberal “legalize pot”, (“legalize everything”) permissive agenda. I, on the other hand, having believed my 1962 medical school pharmacology teachers on the topic of opioids, benzodiazepines and other addicting substances, and after enduring the frustration of trying to wean a couple of patients off Percodan originally prescribed by other practitioners, never again prescribed Percodan to any but hospitalized patients with very severe, acute pain. And never prescribed even codeine for more than two or three days.

That was my policy, but since I, as a family doctor, never actually had sole hospital responsibility for a patient with fracture or post-operative pain, such patients usually being under the care of the orthopedist or surgeon on the case, in practical terms it meant that I never again prescribed oxycodone in any form. To any patient coming to me demanding opiates, I offered to help them get off addicting drugs and on to non-addicting analgesic medications and physical modalities to reduce pain. None ever took me up on my offer.

Recently a friend, citing physician income figures alone, attempted to make the case that physicians generally were significantly motivated by money. I disagreed, citing the much lower ‘dollars per hour of work’ figure and the many other rewards for altruism. But to the extent that there are physicians who are essentially in it for the money, I have always suspected the “pain management” crowd, and those doctors who make a living prescribing methadone, buprenorphine and other opioids to heroin addicts in the name of what is called a “harm-reduction” strategy. Their theory being that it is better for addicts to take a legally prescribed oral narcotic paid for by the state than to rely upon street drugs injected with dirty needles.

As one often involved in group interventions and referral of alcoholics to 28-day treatment programs, in a specific practice setting that yielded a 96% recovery rate, I have always questioned the fact that “addiction maintenance” practices are not associated with programs or efforts to actually detox the patient and get him or her beyond the phase of actual addiction to the substance in question. It has always seemed to me that such “maintenance” programs were examples of what is called “enabling” behavior and benefitted mostly the prescribing doctors. Some might find that a harsh position, but as a recovering alcoholic and nicotine addict with 40-plus years of abstinence from both substances, I am quite convinced that actual recovery is possible, and that for a physician to give up on that option and switch to a maintenance or “harm reduction” strategy is disturbingly self-serving. If some doctors are that pessimistic about treating addictions themselves, if it is not for the money, why not practice some other branch of medicine? Then again people in the helping professions are often from backgrounds that breed codependency. So there’s that possibility.

Today we are living with the consequences of the ill-advised public health policy adopted by state medical licensing boards. The huge upswing in overdose deaths from prescriptions painkillers became undeniable, and medical licensing boards are now participating in the swing of the pendulum in the opposite direction. I predict that despite our best efforts, it will take twenty years to undo the harm that the “harm-reduction” ideology has wrought.

The following excerpt is from the newsletter of Arizona Senator John McCain and represents movement in the right direction.

As the dangerous opioid epidemic continues to grow and devastate communities across the country, it has never been more important to advance solutions that will stop the scourge of these addictive drugs at the root. One of the main causes for the alarming increase in drug overdoses in the U.S. is the over-prescription of highly addictive opioids, which have increased by 300 percent over the last 15 years. In fact, people who are addicted to prescription opioids are 40 times more likely to become addicted to heroin.

We need to stop addiction before it’s too late. That’s why I joined Senator Kirsten Gillibrand (D-NY) this month to introduce legislation that would combat opioid addiction and abuse by limiting the initial supply of opioid prescription for acute pain to seven days. Opioid addiction and abuse is commonly happening to those being treated for acute pain, such as a broken bone or wisdom tooth extraction effecting individuals as young as teens. This legislation is modeled after laws in several states, including Arizona and New York, and it builds off Governor Doug Ducey’s work last fall that directly tackles the root cause of over-prescription.

Veterans, many who continue to carry the wounds of war, are especially susceptible to over-medication of addictive opioids, which can often lead to suicide. Since 2001, the rate of veteran suicide has increased by 32 percent. After controlling for age and gender, this makes the risk of suicide 21 percent higher for veterans than the average U.S. adult. Since 2001, there has been a 259 percent increase in narcotics prescriptions. In the largest veteran populations, veterans die from accidental narcotic overdose at a 33 percent higher rate than the rest of the population.

I recently introduced the Veterans Overmedication Prevention Act to combat this problem by directing the VA to conduct an independent expert study on the deaths of all veterans being treated at the VA who died by suicide or drug overdose in the last five years. This review would ensure that the VA has accurate information about the relationship between veteran suicides and prescription medication.

Stopping the over-prescription of addictive opioids is critical to putting an end to this tragic epidemic. These pieces of legislation build on important efforts to end the tragedy that continues to claim far too many lives far too soon.