Article in the New Yorker- "WHO IS RESPONSIBLE FOR THE PAIN-PILL EPIDEMIC?"

[314117]

http://www.newyorker.com/online/blo...emic.html?mbid=gnep&google_editors_picks=true

---

Members don't see this ad.

 

[Aether2000]

Many good facts, some supposition, and a little ignorance about chronic pain mixed together in one article.

 

[jettavr6]

Who is responsible? Our modern day society is the culprit. Patients want a quick fix pill to every problem that exists in their life - and they want it right now. Therapy and conservative treatment? That takes too long, and why waste that kind of time if one can just take a pill for pain, fatigue, depression, anxiety.... and overall feeling in general. Instead of paying the doctors copay, why not just spend the cash at the local pot dispensary.

Big pharma marketed heavily to the masses not because there were a lot of people with chronic pain, but because they knew there is a large population of people (not necessarily patients) who need a pill to fill a void in their lives.

 

[SeniorWrangler]

I was struck by the detail that she cut the patient off opioids after 3 consecutive UDTs that were negative for the prescribed meds and positive for cocaine.

 

[101N]

I was struck by the detail that she cut the patient off opioids after 3 consecutive UDTs that were negative for the prescribed meds and positive for cocaine.

"He warned me that he would give me “one more chance.” This is the air of opioid entitlement that Russel Portenoy caused.

 

[Paddington]

It's ludicrous to say the Pharmaceutical companies were responsible. I don't remember Oxycontin being seductively sold during the Superbowl, but maybe I missed it. Opioids have been around for ages, but up until the 1980's the consensus was that they were for acutely sick (surgery/trauma) or terminally ill patients. The subsequent opioid epidemic was almost entirely the fault of the - now - old guard of Pain Physicians in the community and at university hospitals who were very much pushing the idea that the only thing that matters is the patient's subjective pain score and there's no upward limit to the amount of opioids that should be prescribed to make them happy. I remember hearing such nonsense as a 2nd year medical student with no clinical experience and knowing instinctively that there had to be something wrong with that sort of "science".

I was struck by the detail that she cut the patient off opioids after 3 consecutive UDTs that were negative for the prescribed meds and positive for cocaine.

It's also a failure of the system.

What I've noticed that most doctors will give these patients multiple chances. They keep getting their pills for a year before the final ultimatum, at which point they just switch to another doctor and start over. With even podunk cities having dozens of Pain physicians they can doctor shop all they want.

Also, most doctors feel an immense amount of pressure to keep the PCP's (and other referring sources) happy. They don't want patients complaining about them. If you don't give patients what they want, they complain to their PCP's, but never about that. They'll say you were rude or behaved inappropriately or some other BS.

 

[Aether2000]

--My take on "pain physicians" being responsible is BS. Even at the apex of prescribing nationwide, the vast majority of overdose deaths, substance abuse, and diversion are due to out of control prescribing by family physicians, not pain physicians.
--As for the three negative UDTs and positive for cocaine- this rises to the level of professional incompetence, medical malpractice and probably criminal behavior given that these drugs are probably being diverted. The physician is certainly maintaining an addiction and is engaging in reckless prescribing- should have the license to prescribe opioids surrendered (state and DEA). The physician may be charged with aiding and abetting in the commission of a crime if the drug dealer-patient is charged with dealing. The physician is deemed in such cases to be aware or should have been aware of drug diversion given the three failed UDTs. There is no longer any room in our society for naïve physicians hiding behind the mantle of medicine to protect them in cases of substance abuse or drug diversion. If they do not act definitively to stop the behavior and give chance after chance after chance after..... they need to have their privileges to prescribed controlled substances revoked permanently.

 

[emd123]

--There is no longer any room in our society for naïve physicians hiding behind the mantle of medicine to protect them in cases of substance abuse or drug diversion.

I agree with this. But take the physician who wrote the article in the OP, for example (I don't know her, but a google search shows her bio: http://celinegounder.com/bio/ ). It seems to be written from the perspective of someone (primary care/ID at NYC HIV clinic) who trained under the "treat the pain first" and "pain is the fifth vital sign" mentality most of us were. She's concerned enough about the issue to take a stand and write an article about it in the New Yorker, and call for change. She struggles with trying to treat pain in a high risk population in the midst of a prescription drug epidemic on one hand, yet having been taught to "treat the pain first" and that "addiction is less than 1%" in Pain patients, which we know now was based on opinion, not evidence. She's concerned enough to drug test, and look for abuse/diversion and gives an example of a patient she discontinued opiates on due to aberrant behavior.

Most primary care doctors, ortho, spine, ER, don't even drug test or check prescription monitoring reports, at all- EVER, for various reasons, let alone put a fraction of the thought into the issue that this non-Pain trained doctor has.

You can criticize, talk about criminal charges/loss of license all you want, and say she should have discounted the opiates sooner, and possibly be right about it, but I can tell you, the majority of doctors offices that that patient walks into, the patient doesn't even get a UDS let alone a PMP check, or discontinuation of opiates at all.

There's plenty of blame to go around for this, but we cannot forget the primary drivers of this problem: the people so intent on abusing the medications in the first place.

 

[Aether2000]

Fortunately we are making headway one state at a time in eradicating physicians that are so naive that they are perpetuating the drug problem in this country. It is no longer sufficient to order a urine drug screen if you are so incompetent that you did not know what to do with the results. Being compassionate is not a substitute for competence. We are making legal headway in legislating some common sense into the prescribing opioids when physicians clearly are devoid of such as in the original article.

 

[Birdstrike]

We are making legal headway in legislating some common sense into the prescribing opioids when physicians clearly are devoid of such as in the original article.

How so? Usually post on the EM forum but stumbled across this. Curious as to what is the latest on this.

 

[Aether2000]

Requirements to have certain education/credentialling, mandatory uds with board scrutiny of these results if there is a complaint, mandatory pmp checks, pill counts, many many criminal charges being filed against physicians, etc. Happening in several states

 

[101N]

If there is headway being made in Indiana it's not due to their 'pain' society: http://www.maphtc.iupui.edu/RxAbuseSymposium2012/
https://evbdn.eventbrite.com/s3-s3/eventlogos/44903757/pickmerxdrugsymposium2013v5.pdf

The IPS chairman is still claiming publically that there is no association between opioid dose and risk of OD. That claim is the definition of malfeasance and Zoeller should pursue it.

 

[Aether2000]

There may indeed be an association but the data is very low level to support such a supposition, and in fact is contradictory. When there is such data we will evaluate it with the same scientific scrutiny that should be incorporated rather than a knee jerk hysterical reaction. As part of the attorney general's task force, I guarantee there is no perception of malfeasance there. Zoeller has done an excellent job at bringing a major problem to the forefront of politics in Indiana- an issue that was not addressed by the legislature, state board of medicine, state board of nursing, state board of podiatry, state health department, or any other entity. The coroner of Allen County was the initiator of the seminal series of deaths from opioids. When the physician in question was evaluated regarding his role in the deaths, the evidence evaporated when 1. it was determined independent nurse practitioners wrote nearly all the prescriptions, and countermanded the physicians orders regarding no more opioids in some patients. 2. the coroner did not provide autopsies in some of the cases, and there were many other significant diseases that were discounted 3. half the overdose deaths involved the use of illicit drugs 4. the blood toxicology studies did not support the cause of death in many cases. Ultimately, it is hoped the expansive board action covering 3 full days of testimony will serve as a standard to determine the cause of death and expectations regarding physician behavior outside the state regulations. Incidentally, the nurse practitioners were never disciplined by the nursing board nor were prosecuted by the attorney general.

The IPS created standards 2 years before the enactment of any state rules and played a key role in the development of reasonable and rational prescribing rules. What is fascinating is that the IPS pushed the medical board to enact more stringent rules but the board opted to move in measured steps rather than create rules for prescribing of all controlled substances and to include all nurse practitioners. The medical board opted to let the independent nurse practitioners continue to operate independently without any of the state legislative opioid prescribing rules applying to them.

 

[ThomasLodi]

It's all about how they make their millions billions! They knew that people would get addicted, and do whatever they can to get their pills. It's something that will never change. Medical marijuana is going to only add to it. They'll make millions billions off that as well. Not only will people want to buy 60$ eighths, but why stop buying pills now as well? Since Obamacare is going to cover even more people and their abuse, the epidemic is only going to get worse!

 

[sblau001]

3 failed UDT's and positive for cocaine?! Agree entirely with algosdoc. This is questionably criminal behavior by aiding and abetting.