Welp, we’ve done it, folks. It’s finally come to this. There have been so many deaths from opioid overdose, so many addicts created, so many pills diverted, that the CDC is getting involved. Opioid pain medications, commonly prescribed to treat acute and chronic sources of pain, are a significant cause of morbidity (harm) and mortality (death) in America. In 2014, the CDC reported a total of 47,055 drug overdose deaths in the United States, 61% of which were attributable to opioids.
So how exactly did we get here? Like most things in medicine, there is not one simple answer. But it’s not that hard to trace things back a few decades and pinpoint some major influences.
Pain as the fifth vital sign. In an effort to standardize and improve pain treatment for patients, a national initiative called Pain as the 5th Vital Sign (P5VS) was rolled out in the late nineties. The well-meaning folks who began this initiative were trying to improve the health and well-being of the over 34 million patients in this country that suffer from chronic pain. Unfortunately, a study published in the Journal of General Internal Medicine in 2006 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/) showed no improvement in pain control after this initiative. However, this practice still persists throughout medicine, despite there being little evidence to support it.
One problem with assessing pain as a vital sign is, unlike blood pressure and oxygen saturation, it’s completely, 100% subjective. I can’t count the number of times I’ve had a patient tell me their pain – on a scale of 1 to 10 – is an “eleven” or even “ a hundred.” How do I, as a physician, interpret that? It’s impossible. Objective signs of pain – elevated heart rate, elevated blood pressure, inability to speak comfortably, and certain exam findings – don’t correlate reliably with patients’ self-reported pain scales. I’ve had patients writhing in obvious, excruciating pain who would rate their pain as a seven, and I’ve had patients casually texting on their smartphone who tell me they have 15/10 pain. Both of these people deserve to have their pain treated, but it often involves a little trial and error to get it just right.
Another issue with the initiative is that the goal is for pain to be a zero out of ten. Often, especially in the case of chronic pain, that shouldn’t be the goal. The goal should be getting a patient to the point that they can be functional, so they can reasonably do the things they need to do to be a productive member of their family, their community, and society as a whole. Unfortunately for those with chronic pain, the concept of being pain-free may be unrealistic. If you must be completely sedated before you experience zero out of ten pain, then we’ve missed the mark. We haven’t improved your life, we’ve erased it. There needs to be a happy medium.
OxyContin. The time-release version of oxycodone, OxyContin, was brought to market in 1996. It was heavily marketed, both to consumers directly and to doctors. It was supposed to be the best thing to happen to chronic pain in the history of chronic pain (i.e. civilization). We were told the chances of addition were miniscule because of the time-release formulation, and the potential benefits were unimaginable. The pharmaceutical company that made OxyContin (getting a new patent for a drug that had been around for the better part of a century) did a phenomenal job of getting their product out there, and doctors who hesitated to prescribe it were vilified. It was a veritable love fest, reminiscent of an Oprah Winfrey episode. “You get OxyContin! You get OxyContin! Everyone gets OxyContin!”
If you’re reading this, you probably know (or at least have a hunch) that things played out a little differently. Oxycontin became one of the most abused prescription drugs to date and is estimated to cause 100,000 drug-related deaths worldwide per year.
Of course, OxyContin isn’t the only prescription drug out there making its way through our communities. It seems there are too many to count these days. And at $10 to $40 per pill, they are worth more than their weight in gold. It’s not uncommon for people who become dependent on prescription pain pills to end up turning to heroin because it’s cheaper and easier to get than a Percocet.
Patient Satisfaction: Patient satisfaction is not, in and of itself, a problem. It’s not that we don’t want our patients to be happy. It’s quite the opposite. But since we’re dealing with health issues and not an ice-cream sundae, sometimes it’s just not in the cards. For example, sometimes we must tell a patient that their weight is negatively affecting their health. Or their smoking. Or any other number of bad habits. It’s the right thing to do. If we didn’t do it, we would be doing our patients a disservice. But it’s still not always nice for patients to hear. It doesn’t necessarily give them a warm, fuzzy feeling when leaving our office, nor does it make them want to send their friends and family to us to receive the same kind of tough love.
In a much talked about study published in the Archives of Internal Medicine in March 2012, Dr. Joshua J. Fenton and colleagues reported that the most satisfied patients had an increased hospital readmission rate, had the highest healthcare expenditures, and had a 26% higher mortality rate than their less satisfied counterparts.
It is not always satisfying to be seen by a doctor, told that you don’t need a test or prescription, and be sent on your way. But sometimes that’s the best care. Sometimes it’s a viral infection, and antibiotics are more likely to hurt you than help you, so we don’t prescribe them. Patients often don’t feel as if they’ve gotten their money’s worth when that happens, but it is important to remember that your doctor has had a minimum of seven years of training to be able to provide their expert opinion, and that it is much, much harder to provide reassurance than it is to write a prescription or order a CT scan.
In the case of opioid pain medication, not only is it often not medically indicated to use these medications, but we also take a significant risk each time we prescribe them. We risk our patient developing a dependence or addiction, we risk the medications being diverted or abused, we risk saddling patients with side effects that can be worse than their primary complaint (such as severe constipation and even narcotic bowel syndrome), and we risk someone dying from an overdose of medications we prescribed. Not only are we then “doing harm,” which we took an oath against, but we could even possibly be implicated in someone’s death. I’m sure no one’s forgotten Conrad Murray, the personal physician of Michael Jackson, who was convicted of involuntary manslaughter after Jackson’s death. That’s an extreme case, sure, but it can happen.
So, what can we do now that we’ve gotten ourselves into this mess? Stay tuned for my next blog post, The Opioid Epidemic: Where Do We Go From Here?
Originally published on Huffington Post May 8, 2016: http://www.huffingtonpost.com/kristine-scruggs-md/the-opioid-epidemic-how-d_b_9865680.html?utm_hp_ref=impact&ir=Impact
Pain as 5th Vital Sign: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/
CDC Morbidity and Mortality: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm
Patient Satisfaction associated with higher readmission and death rates: Fenton, Joshua J., MD, MPH, et al. Archives of Internal Medicine. March 2012.