Attorneys general from across the country have begun to file lawsuits that blame the opioid crisis on large drug manufacturers. Missouri AG Josh Hawley argued that his state’s epidemic is the “direct result of a carefully crafted campaign of deception carried out by [the pharmaceutical companies].” Ohio AG Mike DeWine accused the industry of “unleashing a health-care crisis” and “fueling Ohio’s opioid epidemic.” Oklahoma AG Mike Hunter said that drug “companies are culpable for the tragic, heartbreaking number of Oklahomans who have become addicted or who have died as a result of the opioid epidemic in our state.”
As a doctor who is board-certified in addiction medicine and spent eight years treating the casualties of the opioid epidemic, I know firsthand that the causes of the crisis are much more complicated than Hawley, Dewine, Hunter, and their fellow attorneys general would have you believe. Mere corporate deceit didn’t precipitate the epidemic. It was, rather, the result of a perfect storm of other factors: lax health-industry accreditation standards, the treatment of pain as a “fifth vital sign,” the practices of insurance companies, and the transformation of our health-care system into what is essentially an assembly line.
The Joint Commission
The Joint Commission is an independent board that accredits and certifies nearly 21,000 health-care organizations. When the commission says “Jump!” hospital administrators ask, “How high?” In 2001, the commission published its Pain Management Standards, which required providers to ask every patient about his pain. The consensus at the time was that doctors were doing too little to treat patient pain. Since that time, opioid prescriptions have surged, helping to create the current crisis.
Unfortunately, the Joint Commission has refused to acknowledge any responsibility for encouraging doctors to prescribe more opiates. The Physicians for Responsible Opioid Prescribing (PROP), an education and advocacy organization, requested that the Joint Commission change its pain standards. PROP argued that the “Pain Management Standards foster dangerous pain control practices, the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families and communities.” The commission instead disavowed any link between its Pain Management Standards and opioid overprescribing.
This is unfortunate, because just as the Pain Management Standards have contributed to the opioid crisis, new commission policies could become part of the solution. Instead of requiring providers to treat their patients’ pain more aggressively, they could require the aggressive provision of alternatives to pain pills, and hospitals would be forced to comply.
The Fifth Vital Sign
In 1996, the American Pain Society designated pain as the fifth “vital sign” that doctors should use to detect or monitor medical problems. Doctors don’t test or measure anything without intent to treat, and so making patient pain the fifth vital sign obligated them to address it. Pain control thus effectively became a measure of patient satisfaction, which is sometimes tied to a physician’s compensation.
Yet aggressively treating pain does not invariably result in good medical care. The other four vital signs — blood pressure, heart rate, respiratory rate, and temperature — can be measured in reproducible numbers. Pain cannot, which means that doctors have only their patients’ often-unreliable perceptions to go on when determining its severity and how to treat it.
Categorizing pain as the fifth vital sign conditioned patients to expect that providers would ‘normalize’ it in the same way that they normalize the other four vital signs.
In recent years, the American Medical Association and others have started to recommend dropping pain as the fifth vital sign. That would be a helpful first step, but I’m afraid much of the damage is already done. Categorizing pain as the fifth vital sign conditioned patients to expect that providers would “normalize” it in the same way that they normalize the other four vital signs. They have, in other words, come to expect an opioid prescription.
State licensing boards already require doctors to obtain a certain number of hours of continuing education each year. If medical licensing boards started mandating pain-management courses as part of those hours, doctors could better serve their patients by recommending non-opioid treatment options for pain.
While pain specialists advocate using alternative treatments (steroid injections, spinal blocks, or physical therapy) to address chronic pain, primary-care doctors have been treating the problem with opioids. Insurance companies pay for primary-care office visits and for the patient’s pain-pill prescription, but they may not cover specialist visits or alternative treatments. Faced with an out-of-pocket charge they can’t afford, patients may have to chose between living in pain or taking the opioids their doctor offers. Understandably, many patients choose the latter, exposing them to a plethora of side effects and the risk of addiction. Assigning social workers to direct patients to addiction-medicine providers in their area, improving reimbursement for primary-care providers treating addictions, and including coverage for alternative treatments would all improve patient care and decrease costs.
The Business of Medicine
As larger medical centers gobbled up private practices, doctors lost control of their autonomy as well as their appointment books. Today, employed doctors are paid based on the number of patients they see in a day and the medical conditions they see those patients for. Stanford addiction specialist Anna Lembke, the author of Drug Dealer, MD, describes this process as “the Toyotazation of medicine.” A patient’s time spent with their doctor has become as much about meeting production quotas as about patient care. The incorporation of the electronic medical record has become a significant factor in this production process. Studies have shown that physicians now spend 37 percent of each patient’s appointment time just documenting the visit. I once saw a patient in the E.R. who came to be treated for hiccups. It took 137 clicks of my computer mouse before I’d satisfied that patient’s encounter-documentation requirements. Medicare should consider reducing such unreasonable and burdensome requirements. Doctors need more face-to-face time with their patients.
Other Contributing Factors
There’s plenty of blame to go around when it comes to America’s opioid epidemic. More than 30 percent of Americans have some form of chronic or acute pain, and the incidence of chronic pain in older adults has been estimated at 40 percent. In the absence of an accepted consensus around how to best manage pain, opioids became the go-to treatment. The genetic and environmental factors that place certain populations at greater risk for prescription-drug dependency — combined with the fact that half of the 20 million adults in the U.S. who experience a substance-abuse disorder have co-occurring mental illness — have made the resulting spike in opioid addiction that much harder to address.
Big Pharma may certainly have contributed to the crisis, too. But it is a calculated overreach to suggest that the industry’s “campaign of deception” is solely to blame. We all bear collective responsibility for the problem, and we will all need to bear collective responsibility for solving it. Once you’ve sailed into a storm, you need all hands on deck to get through it.