Pubdate: Sun, 03 Apr 2016
Source: New York Daily News (NY)
Copyright: 2016 Daily News, L.P.
Author: Frank Huyler
Note: Dr. Frank Huyler is an emergency physician in New Mexico.


How a Shift in Health-Care Delivery and Big Pharma's Hunger for 
Profits Have Driven the Opioid Epidemic

I was walking past, and happened to see him behind the partially drawn curtain.

There he was, lying on the gurney, head back, mouth gaping. White, 
25, covered in tattoos, not breathing, his lips a fine pale blue.

We ran into the room. The nurse pushed Narcan, a drug that reverses 
opiates. And 30 seconds later he woke up as if a switch had been 
flipped. Narcan is like magic; it literally raises people from the dead.

"What are you doing?" he said, ripping off his oxygen mask.

Paramedics had been called for a heroin overdose in a park. They'd 
given him Narcan He woke up. They'd taken him to the ER, where he'd 
been put in a cubicle. Someone had partially drawn the curtain. He 
should have been on the monitor, but wasn't. He waited.

And then the Narcan had worn off. Heroin lasts longer than Narcan. So 
he'd stopped breathing again, when no one was watching. This is why 
heroin overdoses are observed for several hours before they're sent home.

Opiate overdoses, like drowning, kill people in just a few minutes. 
But no one struggles, no one yells for help. They just lie there.

Opiate overdoses in the United States are a public health 
catastrophe, and are finally getting the media attention they 
deserve. Last week, President Obama quite remarkably said that the 
opiate epidemic is as great a threat as terrorism. He also announced 
$1.1 billion in federal spending, and a host of other measures, to 
combat the problem.

By the numbers, he's more than right. Last year, nearly 30,000 people 
died in the United States from opiate overdoses. The death rate has 
tripled since 2000. Put in perspective, 5,000 people die annually 
from cocaine overdoses.

Almost 3,000 people died on Sept. 11, 2001. Opiate overdoses produce 
ten 9/11s every single year. And the rate is rising.

There are two basic categories of opiate overdose. The illegal - 
cheap and abundant heroin and other street drugs. My 25-year-old 
patient. The underworld. The war on drugs.

And the legal, responsible for almost double the number of overdose 
deaths: prescriptions. Doctors. The pharmaceutical industry.

It is in many ways a meaningless distinction.


The answer is actually simple. The deaths are a tragic synergy, a 
lesson in regulatory failure, and a chilling reminder of organized, 
predatory commercial self-interest that seems to bedevil us as a 
country at every turn.

Pain, like hunger and thirst, it something that we all agree is bad. 
Yet pain has also, in recent decades, been cultivated, and commodified.

Many things hurt, like fractures and surgery. Opiates have been the 
mainstay of treatment for acute pain for hundreds of years, and are 
very effective.

But chronic pain is a modern conceit, and a far more complex problem. 
It's defined as symptoms that last for three, six, or 12 months, 
depending who you talk to. Chronic pain is essentially defined as 
something that hurts more than it should for longer than it should. 
The definitions are arbitrary, and based largely on self-reporting.

Numerous psychiatric, social, and physical conditions such as 
depression, anxiety, stress, socio-economic status, physical 
conditioning, gender, and a host of others play very large and poorly 
understood roles in chronic pain.

According to the Institute of Medicine, as many as half of Americans 
- - 116 million people - are living with some form of chronic pain as 
currently defined.

Traditionally, pain has been significant to doctors mostly for what 
it represents. Doctors care about the heart attack, not the pain it 
causes. Medicine has a long history of callousness in this way and 
has long undertreated acute pain. A lot of pointless suffering has 
occurred as a result.

This cold view, of course, changes entirely when one is in pain 
oneself. Patients, rightfully, care a lot about pain.

In the 1990s a new movement arose in the Veteran's Administration 
urging caregivers to treat pain as a vital sign, like blood pressure 
and heart rate. Hence the question: On a zero to 10 scale, how would 
you rate your pain right now?

The increased attention paid to pain undoubtedly arose from good 
intentions, and caught the eye of regulators. In 2001, the Joint 
Commission - a governing body that provides hospital accreditation 
for virtually every hospital in the U.S. - adopted the VA's approach 
and imposed it on hospitals around the country. Patients were told 
they had a right to have their pain treated. Hospitals were required 
to document that pain was being treated. And that question - on a 
zero to 10 scale, how would you rate your pain right now? - became ubiquitous.

A Joint Commission visit to a hospital is treated with an almost 
comic degree of gravity. One would think Stalin himself was about to 
inspect the tank factory. Hospitals need Joint Commission 
accreditation to stay in business. So they do exactly what they are told.

Simultaneously, over the last few decades, there has been a profound 
corporate-driven paradigm-shift in medicine. Patients are 
increasingly seen as customers rather than as people with diseases. 
Approaches developed for the retail economy - car dealerships, 
restaurants - have been applied to healthcare.

Physicians and other health-care providers have been put under 
consumer-based subjective scrutiny, in the form of 
patient-satisfaction scores and other indirect measures of competence.

Often, reimbursement and employment is tied to these assessments. 
Customer service, in many cases, is prioritized over actual outcomes, 
in part because the latter is harder to measure. Yet the conceit of 
medicine as retail and patients as customers to be satisfied is a 
deeply flawed one, because in medicine, the customer is not always 
right. In fact, the customer is very often wrong.

Like many specialized fields, medicine and medical decision-making is 
opaque and mysterious to most people. It is difficult to know whether 
one is getting good care.

Understandably, people fall back on cues from the service industry to 
decide. Were they nice to me? Did they make me wait? Did they bring 
me that extra blanket I asked for? Was my pain treated?

The new definition of pain as a vital sign dovetailed perfectly with 
these consumer-based satisfaction models as arbiters of quality of care.


In 1996, Purdue Pharmaceuticals released a new opiate, OxyContin, 
onto the market with FDA approval. There was no evidence that the new 
formulation worked any better than other off-patent older opiates. 
Purdue's strategy was as cynical as it was chilling.

OxyContin was directly marketed to doctors whose narcotic 
prescription patterns had been studied. They were known to be opiate 
overprescribers. OxyContin was also provided free of charge to 
patients for limited time periods through a voucher system.

Doctors, pharmacists and others in health care were treated to an 
onslaught of direct marketing. Primary care physicians were 
encouraged to prescribe OxyContin liberally for chronic pain of all 
kinds, and OxyContin was deliberately and falsely presented as a drug 
with a small risk of addiction. Purdue was later found guilty of 
criminal charges in this misrepresentation.

In only a few years, OxyContin became the leading cause of opiate 
prescription overdose in the U.S. Purdue also made a lot of money, 
and four years after it was introduced, OxyContin was generating more 
than a billion dollars in annual sales.

Yet the actions of Purdue Pharmaceuticals, and the disgraceful story 
of OxyContin, are only one cause of the current scourge.

Much of the responsibility lies with prescribers. Beginning in the 
late 90s, and armed with the dangerous, industrydriven, and false 
idea that opiates should be used liberally to treat chronic pain, 
numerous "pain management" clinics began springing up around the 
country. The primary business model of such clinics is opiate 
prescriptions; in many cases the thinnest of justifications was used 
by unethical physicians who often had little or no formal training in 
pain management.

Yet now they had cover. They had the assertion that pain was a vital sign.

But pill mills, as they're called, don't fully account for the 
problem either. Much of the blame also lies with ordinary doctors, 
both primary care physicians and specialists, who simply write 
narcotic prescriptions in the interest of patient satisfaction and efficiency.

Patients with chronic pain are difficult to take care of. They are 
often demanding, and, rightly or wrongly, are distinctly unpopular 
among both doctors and nurses.

Chronic pain, as the Society for Pain Management tells us, is best 
treated with a multi-pronged approach. Yet that multi-pronged 
approach is time consuming, expensive and not that effective. And 
patients know what they want. They want narcotics.

So most of the time, busy primary care physicians and others can't be 
bothered. It's so much easier to write the prescription, and get them 
out of the office or the ER .

And so we've come to this: an original good intention - the relief of 
pain - seized upon by special interests. The pharmaceutical industry, 
physicians and other prescribers, hospitals, and the FDA are all to 
blame. This complicity continues to kill people every day, and has 
caused the unnecessary deaths of tens of thousands of Americans over 
the past 15 years, many of whom were in the prime of their lives.

There is also a terrible irony: studies have not shown any collective 
improvement in chronic pain.

Meanwhile, on the other side of the law, cheap and abundant heroin 
continues to flood into the country. Heroin is everywhere. And four 
out of five new heroin users began by misusing prescription opiates.

A couple of hours passed. I went back to the cubicle. I sat down. I 
pulled the curtain. I told my patient how close he'd come to death. 
It's my usual speech: you should be afraid. You need to stop. Another 
couple of minutes, and you wouldn't be here. He looked at me, and 
shrugged. "Can I go now?" he asked. So I discharged him. He took the 
paperwork - a number for narcotics anonymous, a boilerplate warning 
about the dangers of opiate abuse - and then he put on his jacket and left.

He was so lucky. And the difference was a glance, a flicker in the 
corner of my eye, when I just as easily could have looked the other way.
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MAP posted-by: Jay Bergstrom