Sunday, November 8, 2015

Physicians as Pushers

So much for white privilege. At a time when many in our nation are railing against white privilege, it turns out that the mortality rate of middle-aged whites has been increasing.

Whatever the ultimate cause, the proximate cause seems to lie in the overprescription of opioid medication. For that the responsibility lies with medical professionals.

To the extent that physicians are the problem, then the solution must come from them.

So says Dr. Richard Friedman in calling out his fellow physicians in the New York Times today:

THERE has been an alarming and steady increase in the mortality rate of middle-aged white Americans since 1999, according to a study published last week. This increase — half a percent annually — contrasts starkly with decreasing death rates in all other age and ethnic groups and with middle-aged people in other developed countries.

So what is killing middle-aged white Americans? Much of the excess death is attributable to suicide and drug and alcohol poisonings. Opioid painkillers like OxyContin prescribed by physicians contribute significantly to these drug overdoses.

Thus, it seems that an opioid overdose epidemic is at the heart of this rise in white middle-age mortality. The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.

How bad has it become? Friedman continues:

The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.

Pharmaceutical companies developed a product, called OxyContin, and marketed it aggressively. Physicians took the bait:

But starting in the 1990s, there has been a vast expansion in the long-term use of opioid painkillers to treat chronic nonmalignant medical conditions, like low-back pain, sciatica and various musculoskeletal problems. To no small degree, this change in clinical practice was encouraged through aggressive marketing by drug companies that made new and powerful opioids, like OxyContin, an extended-release form of oxycodone that was approved for use in 1995.

The pitch to doctors seemed sensible and seductive: Be proactive with pain and treat it aggressively. After all, doctors have frequently been accused of being insensitive to pain or undertreating it. Here was the corrective, and who in their right mind would argue that physicians shouldn’t try to relieve pain whenever possible?

Well, doctors clearly got the message: The medical use of these drugs grew tenfold in just 20 years. Nearly half of all prescriptions by pain specialists are for opioids. But strikingly, primary care physicians, who generally do not have any particular expertise or training in pain management, prescribed far more opioids overall than pain specialists. For example, in 2012, 18 percent of all prescriptions for opioid analgesics were written by family practitioners, and 15 percent by internists, compared to 5 percent for pain specialists. (This partly reflects the fact that there are fewer pain specialists than primary care doctors.)

One has to ask how gullible physicians are. Is it possible that they are like marionettes who do what pharmaceutical representatives tell them? Or were they brought up at a time when illegal drugs were not considered to be such a big deal. How many of said physicians had tried cocaine themselves, for example?

Apparently, every physician is aware of the problem. It is not a deeply guarded secret:

The consequences of this epidemic have been staggering. Opioids are reported in 39 percent of all emergency room visits for nonmedical drug use. They are highly addictive and can produce significant depressive and anxiety states. And the annual direct health care costs of opioid users has been estimated to be more than eight times that of nonusers.

Unfortunately, the research has shown that these medications are not very effective as a long term therapy for pain. Other, safer medications do the job better.

A large review article conducted between 1983 and 2012 found that only 25 of these were randomized controlled trials and only one study lasted three months or longer. The review concluded that there was little good evidence to support the safety or efficacy of long-term opioid therapy for nonmalignant pain. (In contrast, there is little question that opioid analgesics are highly effective for the relief of short-term pain.)

Dr. Friedman asserts unambiguously that the medical profession created the problem and that doctors should be in the forefront in solving it:

WHAT is really needed is a sea change within the medical profession itself. We should be educating and training our medical students and residents about the risks and limited benefits of opioids in treating pain. All medical professional organizations should back mandated education about safe opioid treatment as a prerequisite for licensure and prescribing. At present, the American Academy of Family Physicians opposes such a measure because it could limit patient access to pain treatment with opioids, which I think is misguided. Don’t we want family doctors, who are significant prescribers of opioids, to learn about their limitations and dangers?

It is physicians who, in large part, unleashed the current opioid epidemic with their promiscuous use of these drugs; we have a large responsibility to end it.

Dr. Friedman does not offer any explanations for why this should have come to pass. If he and his fellow physicians can solve it, we do not need to probe too deeply into the causes. And yet, how many physicians, for example, believe that drugs of all kinds can cure whatever ails you? How many of them believe that pills can make you, as Peter Kramer suggested, into someone else?

But, if we might, and with all due respect to those who are overprescribing these drugs, they are functioning as pushers. And if they are functioning as pushers perhaps they are motivated by… greed.

If Motrin and Tylenol can control long term pain as well as OxyContin, one difference between the two treatment regimens is that the one requires a prescription while the others do not. OxyContin will fill your waiting room while Motrin and Tylenol will empty it. An addicted patient is a patient for life. Keep in mind, if the patient is not addicted to an opioid, he might be addicted to Valium or some other highly addictive psychotropic compound.

[Addendum: I recommend to your attention the remarks by Dr. KC Fleming in the comments section. Evidently, he has a far better understanding of the issues involved than I do, and also, it appears, than Dr. Friedman does. I am grateful to him for clarifying them.]


Anonymous said...

I wonder if a break down covering the increase of doctors according to the following criteria would lend some insight:
1. Foreign born; received their degree in the United States
2. Foreign born; received there degree outside the U.S.
3. Native born; Affirmative Action degree.
4. Native born; Non-AA degree.
5. Sex of doctors from each group.

Couple these stats with the rate of increase of prescription pain killers and maybe some new questions will arise that, when investigated, may put a better perspective on the problem

Just a quick thought.

Stuart Schneiderman said...

Great questions... I suspect that it will be impossible to get the answers. We do know that in some specialties there is a lack of good candidates, if there are even enough.

KCFleming said...

At the same time OxyContin was released there was a national push to be more aggressive in treating pain as "the fifth vital sign."
It resulted in changes in out- and inpatient evaluations to include a required pain scale, which is still in use.

Physicians were scolded then for under-treating pain, and now are scolded for over-treating it.
Fact is, there aren't many drugs available for treating chronic pain, and none are reliably successful.

Acetaminophen, NSAIDS, narcotics, alpha 2 delta ligands, then Cymbalta, trazodone, injectables.
Chronic pain is behind some of this abuse, and meds aren't terribly successful for that disorder.

Now there are increasingly difficult rules to follow to prescribe narcs, so they won't be prescribed.
Then what?
Back to 1994, with no plans for managing chronic pain.

I don't have the answer, but I am a strong advocate for CBT approaches to the disorder.
Not enough physicians seem aware of that method as yet.

KCFleming said...

At medical conferences, the majority of MDs voice displeasure with treating these patients and do not want to care for them.

These patients are not 'profit centers' but cause significantly higher costs and stress.
They are overutilizers of medical appointments (for many complaints besides pain), often unhappy with their treatment, require considerable free labor (paperwork, phone calls, pharmacy forms, work forms, government forms, disability requests, etc.)

MDs are more than happy to advise OTCs, but most of these patients claim they 'don't work.'
MDs also seem unaware that narcotics often make pain worse (option-induced hyperalgesia).
I would wager most MDs would be happy if these patients fired them.

I do agree there are bad actors in medicine who do abuse their prescriptive authority and overprescribe narcotics, but all across the country I give talks and MDs usually express genuine frustration and confusion about how to handle these patients.

Instead,I think the problem is a poor understanding of chronic pain.
And what we need are more tools for managing that disorder.

KCFleming said...

"Opioid-induced hyperalgesia."

KCFleming said...

One more problem with the article in the NYTimes is that the fact that opioids are being abused does not mean they were legally prescribed. I don't know the epidemiology, but there is considerable illegal use alongside overprescription.

I suspect the correct approach would be aggressive perioperative and trauma narcotic and other pain medication use (to prevent pain-induced hypersensitization), with rapid tapering to prevent opioid-induced hypersensitization.
Long term narcotics for pain should be abandoned for most disorders save for endstage cancer.