Pubdate: Thu, 28 Apr 2016
Source: Milwaukee Journal Sentinel (WI)
Copyright: 2016 Journal Sentinel Inc.
Contact: http://www.jsonline.com/general/30627794.html
Website: http://www.jsonline.com/
Details: http://www.mapinc.org/media/265
Author: Bhupendra O. Khatri
Note: Bhupendra O. Khatri is director of the Regional MS Center and 
the Center for Neurological Disorders in Milwaukee.

OPIOID ABUSE: HOW WE GOT HERE

Deaths from drug overdose now outnumber gun deaths in the United 
States. We should look at what got us into this situation.

In the 1990s, armed with the knowledge that nearly one-third of 
Americans will experience chronic pain at some point in their lives, 
and that 20% suffer from pain on a daily basis, Congress felt 
compelled to act. It could not bear the fact that "pain" was costing 
the country more than $125 billion a year. It went to work and 
expeditiously named the 2000s as the "Decade of Pain Control and Research."

A bill championed by Sen. Orrin G. Hatch of Utah was passed by the 
106th Congress and signed into law by President Bill Clinton in 1999. 
This Pain Relief Promotion Act encouraged practitioners to prescribe 
and administer controlled substances to relieve pain and discomfort. 
In fact, practitioners were encouraged to treat pain aggressively 
even when the treatment may increase the risk of death.

However, even before the government made it a criminal offense to 
undertreat pain, the Joint Commission on Accreditation of Healthcare 
Organizations (JCAHO) government-funded health care programs had 
declared that it was the right of every patient to have his or her 
pain assessed, treated and monitored without being influenced by that 
individual's social, economic or cultural background.

Pain was declared to be the "fifth vital sign," along with pulse, 
blood pressure, temperature and respiratory rate. Any facilities that 
failed to follow these requirements risked their accreditation. Since 
a hospital's revenue is greatly affected without JACHO's seal of 
approval, committees were set up to penalize doctors who would not 
prescribe narcotics for pain.

The doctors who failed to prescribe enough narcotics to control pain 
were now called "narcophobes." Some were forced to undergo training 
to become "narcophilic" doctors. "A patient is always right," 
declared JCAHO. A self-reported level of pain on a scale ranging from 
0-10 was considered to be the most reliable indicator of pain 
intensity. Health care providers were now told not to rely on the 
patient's facial expression or body language to gauge pain 
management. A report of "severe pain" on the scale had to be treated, 
regardless of the patient's clinical examination.

The 1999 law that "No disciplinary action will be taken against a 
practitioner based solely on the quantity and/or frequency of opiates 
prescribed," accompanied by other laws to persecute doctors for 
undertreating pain, resulted in a dramatic increase in prescriptions. 
The use of painkillers quadrupled between 1999 and 2010. Doctors were 
now writing about 300 million prescriptions a year for painkillers. 
That is enough for every adult American to be medicated around the 
clock for a month, according to the Centers for Disease Control and 
Prevention. For those patients who indicate the level of pain being 
high on the "pain scale," stronger pills are made available.

This mandate became a marketing opportunity for the opioid 
pharmaceutical industry. In 2009, Purdue Pharma's OxyContin, an 
opioid pain reliever chemically close to heroin, reached annual sales 
that topped $3 billion.

For JCAHO and the politicians who championed a "painfree America," 
this was a resounding victory, but it came with a most disastrous 
outcome. Alarming statistics are emerging. Little by little, 
physicians began to see that a systematic control over how and when 
and with what they could treat patients would become the industry 
norm in the years to come. But they surely did not predict that this 
"direct intervention by regulatory agencies" would also lead to some 
catastrophic results, the magnitude of which this country had never seen.

According to CDC Director Tom Frieden, while most things are getting 
better in the world of health, this situation is getting worse. 
Killing pain is what Congress set out to do, but the same weapon is 
not only killing people but has profound and far-reaching consequences.

The pendulum is now swinging the other way. The CDC has declared 
prescription drug abuse an epidemic. The lawmakers now are eager to 
take steps to correct the problem. The government is waging an 
aggressive war against pain doctors, making them the scapegoats for 
the failed drug war. The physicians present a better target than 
underground black-market drug dealers.

These new laws are time-consuming. In addition to performing a 
detailed history and physical, physicians are required to review 
mental health, opiate-addiction risk and pain assessment 
questionnaires filled out by patients. They need to discuss with 
patients the benefits and risks of opioid use. An individualized 
treatment plan with meaningful goals needs to be developed and 
reviewed at every visit.

Physicians are required to have patients sign a Controlled Substance 
Agreement that includes prescribing policies, consent to drug 
screening, permission to conduct random pill counts, requirements to 
take the medications only as prescribed and the consequences of 
violating the contract conditions. Additionally, physicians must 
order annual urine drug screening, review reports documenting 
narcotic prescriptions dispensed from pharmacies and see patients in 
clinic at least four times a year.

As a consequence, some physicians are now undertreating pain or have 
stopped prescribing narcotics. While physicians are being taken on a 
rollercoaster ride, it is the patients who suffer the most.
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MAP posted-by: Jay Bergstrom