Last week President Trump declared the opioid crisis a public-health emergency, pledging to “liberate our communities from this scourge of drug addiction.” Opioid addiction kills more Americans than AIDS and has taken a terrible toll on families in my state, Oklahoma. From 2007 to 2016, drug-related deaths there grew by nearly 70 percent, with two-thirds of them involving opioids. What pains me most as a physician is the knowledge that this epidemic is largely man-made, fueled by federal regulations linking pain management to Medicare reimbursement. That linkage encouraged many physicians to treat common aches — such as lower-back pain — with powerful opioids meant to blunt pain from serious diseases.
Nearly 2 million Americans are addicted to or abusing prescription opioids, according to the CDC. As physicians and many states move to reduce over-prescribing, patients who have become addicted shift to cheaper and more accessible street drugs, including heroin and synthetic opioids (fentanyl) from China.
States have taken some effective steps to stem the crisis. Prescription-drug-monitoring programs (PDMPs) collect data on all prescriptions dispensed in a state, allowing physicians to track “pill shoppers” who go from doctor to doctor getting prescriptions. Currently 37 states, including Oklahoma, have operational PDMPs, while another 11 states have proposed legislation that would implement them. Putting this information in doctors’ hands will help ensure that they don’t prescribe opioids to those who will abuse them.
For the most part, however, states are taking the wrong approach.
Rather than admitting that the current crisis is the result of unintended consequences, state attorneys general are hunting for deep-pocketed scapegoats to offset their states’ drug-treatment costs. Attempting to replicate the success of the coalition of state attorneys general who successfully sued “Big Tobacco” in the 1990s, eight state and local governments have filed lawsuits against pharmaceutical companies that produce opioid pain killers. Each suit is slightly different, but the central allegation is the same: As Mississippi attorney general Jim Hood has argued, “Pharmaceutical companies have made billions of dollars in profits by misrepresenting to tens of millions of doctors and patients the significant dangers of prescription opioids.”
The move to treat the pharmaceutical industry like the tobacco industry misses the mark. This is not to deny that pharmaceutical companies have played a role; I firmly believe that there should never be another FDA-approved opioid approved that does not have an abuse-deterrent formulation. (In September the chair of the president’s opioid commission announced a partnership with the pharmaceutical industry to boost the development of non-addictive medicines.) But we need to recognize these lawsuits for what they are: a billion-dollar lawsuit lottery for the plaintiffs’ bar that ignores the government’s own role in the genesis of the crisis.
Put simply, the opioid epidemic is the result of a massive shift in public policy surrounding pain management, introduced by an array of special-interest groups, including the American Pain Society and the influential Joint Commission on the Accreditation of Healthcare Organizations, and pushed forward by physicians who were inattentive to the risks. Throughout the late 1990s, these groups aggressively lobbied for mandated pain assessment and treatment in all health-care settings and stressed the safety of opioids to health-care providers.
Put simply, the opioid epidemic is the result of a massive shift in public policy surrounding pain management, introduced by an array of special-interest groups.
The makings of a perfect storm were in place when the Centers for Medicare and Medicaid Services (CMS) introduced the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in 2006. These patient-satisfaction surveys, which CMS considers when determining the amount of incentive payments a hospital will receive, contain questions about pain management, such as “Did hospital staff do everything they could to help with your pain?”
Every doctor learns in medical school that patients with chronic pain tend to develop a tolerance to opioids. In theory, every doctor should realize that prescribing opioids to treat chronic pain is dangerous, since patients will look for higher doses as time goes by. However, as doctors were overwhelmed with dictates from Washington, tying patient satisfaction to hospital reimbursement incentivized time-pressed physicians to put patient demands above their own training. This meant prescribing more opioids, even when inappropriate.
I watched the consequences unfold in real time. I was still practicing medicine when HCAHPS went into effect, and I can recall one night when a patient who had been in a car accident was brought into my hospital. He wasn’t badly injured, so after a standard exam and treatment procedure, I discharged him without a second thought. When Medicare reimbursed us for this particular treatment, we received 5 percent less than we should have — all because I hadn’t prescribed the man an opioid. I knew then that Medicare’s reimbursement system was flawed, and would only encourage doctors to neglect the true practice of medicine.
Last November, Medicare removed all questions related to pain management, “to eliminate any financial pressure clinicians may feel to overprescribe medications.” On Wednesday, the president’s Commission on Combating Drug Addiction and the Opioid Crisis urged the president to immediately order HHS to “remove pain questions entirely when assessing consumers so that providers won’t ever use opioids inappropriately to raise their survey scores.” The report also explicitly names “seeing pain as the fifth vital sign” as a cause of the opioid crisis and states that this perception “must end immediately.” These are important reforms; unfortunately, they came a decade too late.
The unintended consequences of HCAHPS are staggering, but they are part of a much larger trend. Studies show that physicians spend around half of their time filling out paperwork. This is a dramatic increase from just a decade ago, where paperwork only consumed a third of doctors’ time. The increase has been driven primarily by the expanded role of Electronic Health Records (EHRs), code-based computer systems that, ironically, were supposed to help save physicians time.
The opioid crisis is part of a larger crisis in American medicine: Physicians spend more time complying with government regulations, or typing codes into a computer, than they do listening to patients and thinking through the right course of treatment. Yes, the government should roll back harmful regulations and pharmaceutical companies should develop more addiction-deterrent therapies, but ultimately, the best way to combat overprescribing, and to prevent any future crises on the same scale, is to allow doctors to practice the art of medicine, not cookbook recipes handed down from Washington.
Doctors who spend time really listening to their patients, rather than worrying about payments and paperwork, will be more attuned to their patients’ needs and more willing to trust their own judgment about the pain-management strategy they should employ in particular cases.
There isn’t a lawsuit that can bring back the art of medicine, or undo the pain and suffering that government regulations have helped inflict on a generation of American families.