Tuesday, December 18, 2018

What Were They Thinking?

I am not sure that Dr. Abigail Zuger answers the question. Yet, it’s a good thing that she addresses it. The question is simple. What were physicians thinking when they recklessly prescribed opioids to their patients? Better yet, were they thinking at all?

Zuger suggests that physicians are weak. That they lack moral courage. That they took the path of least resistance. They were not overprescribing opioids because they were evil people or because they were aspiring drug pushers. They were morally defective.

Is this a valid explanation? In many ways I think that it is. It might not gin up your moral outrage, but still, it does not let physicians escape scot free. Surely, physicians should do some soul searching or do a serious moral inventory. Zuger points in this direction, so I credit her for making an important contribution.

She is reviewing a series of books about the opioid epidemic. And she knows that responsibility must be shared between physicians and drug companies. She should have mentioned the government bureaucrats who branded new classes of opioids safe and effective.

She begins:

These authors all covered a similar territory of clueless doctors, rapacious drug sales forces (both the corporate and the criminal varieties), hurting patients and their frantic friends and relatives.

Some may wonder what America’s doctors could have been thinking all those years, doling out quantities of potent narcotics like so many aspirin. Granted, a few of us were criminals, methodically defrauding Medicaid in pill-dispensing “mills.” But mostly we were just well-intentioned schlubs with prescription pads, dutifully following then-current practice guidelines.

True, some physicians belong in jail. They were committing criminal actions. But, Zuger explains, most of them were simply weak. A lot of people have suffered for their moral cowardice:

It is impossible to overstate how difficult it was a dozen years ago to ignore the resounding calls for effective pain control by any means possible, narcotic dependency be damned. Our leaders, our teachers, our regulatory agencies and our patients demanded no less. The slick ad campaigns backing OxyContin and all the other addictive prescription opioids assured us all would be well.

Rather than paint a portrait of the physician as a gladiator going into life or death combat against a dread disease, Zuger shows us that physicians are easily manipulated. They know better but go along... lest their patients go elsewhere for the magic pills. One does not understand whether gender plays a role here, but we should not exclude the possibility.

She adds a thesis offered by Dr. Anna Lembke, namely that physicians are ill equipped to deal with pain. Say what? Why are they in the profession of they are afraid to face their patients’ pain. Are they excessively empathetic, excessively sensitive to pain they feel themselves… and does this make them willing to do anything to stop it.

Dr. Anna Lembke’s small but powerful “Drug Dealer, MD” summarizes other seldom-enunciated reasons doctors became complicit. A specialist at Stanford in addiction medicine, Lembke delivers a bottom line as bizarre as it is true: Most doctors hate and fear dealing with pain, and are utterly unequipped to do so. Treating pain properly requires specialized training; it consumes vast amounts of time few doctors have. It requires an ability to set limits and negotiate and to fail and fail again.

And, as Lembke points out, doctors are a group chosen for more or less exactly the opposite characteristics. We are habitual pleasers, accustomed — even addicted — to patients’ admiration and gratitude. We like to do what we do well, and most of us don’t do pain well. So it’s no big surprise that when we find ourselves in a pain-filled room we just want to escape fast, and prescribing another round of pills lets us do just that.

Of course, physicians who are deficient in pain management skills might also refer their patients to colleagues who are less squeamish.

As for the pharmaceutical industry, it is largely motivated by greed. And it has happily bought the favors of physicians who like to be treated like kings and queens:

Back in 2004, Dr. Marcia Angell, a former editor of The New England Journal of Medicine, wrote in “The Truth About Drug Companies” that the pharmaceutical industry “has moved very far from its original high purpose of discovering and producing useful new drugs.” Her book presents instead a vision of an industry motivated largely by greed. Pretty much every specific outrage critics have identified in Purdue’s behavior appears in Angell’s analysis, including the “jaw-dropping” gifts doctors may receive for prescribing a company’s drugs, the subtle advertisement masquerading as education and the lukewarm, often ineffective protestations by regulatory agencies.

I would place more emphasis on the role that regulators played here, but still, Zuger offers a fair assessment of how the moral weakness of physicians helped produce our current opioid epidemic.


Anonymous said...

Many MDs got through their studies and residencies by pleasing authority figures, and once actually in practice, they have no skills for dealing with disapproval and disappointment. They can’t say no becaseu they’ve never heard no.

Christopher B said...

Could you please describe the reasoning behind denying pain control to a person with physical injuries consistent with requring medication?

Ares Olympus said...

I'll agree in a general sense we're all "morally defective", and we all tend to have a low threshold for pain now, and an absent threshold for pain later. We don't step back and look a the bigger picture, and so solution lies in doing more. So we can ask doctors to document their own choices to give pain meds, and see how which patients fall into addiction, and if they take good notes, and they can record their decision process in each case, and later in the failures see what signs they missed, or where a different choice should have been made.

And given opioids have diminishing returns, we should accept any chronic pain that lasts more than days or weeks, needs alternative treatments.

But perhaps the biggest problem with meds is 90% of doctors might have high standards and say no, but patients willing to find that 10th doctor will have their addictions enabled. So that suggests opioids should NOT be prescribed without consulting a primary doctor of care.

Anonymous said...

In my case, I’m on warfarin—which is the only drug, besides injecting myself with lovenox, that works for my clotting problem. I haven’t taken painkillers for the last 9 years, including anesthesia for dental work. They say Tylenol is ok, but it shoots my INR through the roof. Opioids are one of the few drugs that don’t interact with warfarin, but good luck with that. No painkillers should at least make me a better person, but so far only learned that I hate pain.

Anonymous said...

Dr Lembke makes money and earns fame by playing to the notion that there is an opiate crisis. The CDC report has been criticized multiple times for failing EBM. The report was written by people who benefited from the idea that there was an addiction crisis. SAMSHA has surveyed the rate of misuse of prescription drugs since 1974. They have documented that the rate has been decreasing over time. The CDC technical reports themselves admit that there is no uptick in opiate use or death from narcotics. A recent MMWR finally read the death certificates and admit it has been heroin, fentanyl, and cocaine followed by methamphetamine. Dr Zuger is an infectious disease physician whose writing in the NYT follows fashion, not EBM. Please see the recent increase in suicide of poorly treated pain patients along with articles suggesting that up to 50% of prescription overdose deaths are suicide. (CDC MMWR shows oxycodone leads list in known suicides) This is a complex issue and like most complex issues the last place to shed light is the NYT. (There is no famine in the Ukraine, There is no holocaust, There was a Russian conspiracy)

Anonymous said...

Some great comments. I, too, have been shaking my head of this notion of "overprescribed opiates." In Midlandia where I live, it's difficult to even get nitrous oxide at the dentist. Have multiple root canals, and they'll tell you to take ibufprofen. Not only is it not overprescribed here, but I've lived in 5 states over the past two decades, working in schools, and though I've seen families with probs concerning meth and heroin, prescription opiates are just not a problem.

Have been trying to figure out the why's. All I can think of is, two alkaloids in Kratom, which helps with opiate w/drawal, have been patented by Big Pharma and the plant itself is increasingly being banned. That, taken along with the high cost of ever-changing forms of suboxone, seems to explain it. And DT, because he is staunchly anti-drug and alcohol, is taken in by those who would make money from it.

The comment above and others I've read saying they are in chronic pain and can no longer get appropriate care for it, mirror what I've seen in real life. There's no prescription opiate crisis.