You are likely aware that the United States is experiencing an unprecedented opiate crisis. You may be less aware that the federal and state governments have essentially deputized your doctor into the fight against that crisis, in ways that have profound and unintended consequences for our healthcare system and for patient well-being.
In fact, if the American healthcare system is ever to rise above its own well-publicized problems, this practice needs to be stopped and we must return to the old ways of trusting doctors to make (admittedly imperfect) judgements about how and when to prescribe opiates without constant regulatory oversight.
First Get ‘Em Hooked…
A bit of background. About twenty years ago, under lobbying from the pharmaceutical industry, the government and other regulators pressured doctors and hospitals to prescribe more opiates.
The medical profession was criticized for under-treating pain; doctors who failed to be more liberal in their prescribing habits of opiates were put under scrutiny. Thus, it was in large part an impetus from federal regulators that helped launch America’s path toward opiate addiction.
…Then Crack Down on the Results
Rates of opiate abuse began to spike, accompanied by overdoses, deaths, and a rise in the use of street drugs like heroin and fentanyl. The government reversed course and started to pressure doctors to prescribe less opiates. The medical profession responded. By the time I was a resident—this was about ten years ago—we were trained to view even the most reasonable patient pain medication request with a cynical lens.
Over the past few years, doctors have sharply reduced the number of opiate prescriptions. The rate of overdoses and deaths however, has continued to rise, suggesting that we’ve entered a new phase in the war on opiates, one in which the prescribing behavior of doctors has little impact on rates of abuse.
The prescribing behavior of doctors no longer has much impact on rates of abuse.
If doctors were merely impotent to affect a major impact on opiate abuse, pressure to prescribe less of these substances would be no more than a waste of time and effort. However, the government’s exertions toward limiting prescriptions have, I submit, contributed to the bureaucratic maze that doctors must now navigate daily, worsening physician burnout and demoralizing doctors, all while harming patients.
Even the most zealous of drug warriors will admit that there are medically legitimate uses of opiates, and yet the mere act of writing a script for a drug like morphine now requires reams of documentation and an unwieldy computer process in which a doctor (not an assistant) must personally navigate through a half dozen computer screens in order to transmit a prescription to a pharmacy. What should be the simple act of prescribing a patient a few Percocet for, say, a broken wrist, has been turned into a minutes-long ordeal.
Then there are the patients who are “holdovers” from the more generous days of prescribing. I have a dozen or so of these. Men and women who were started on medications like oxycodone for chronic pain (persistent back pain after a failed spinal surgery is a common scenario) by their last doctor and whose care I’ve inherited. Perhaps these folks should never have started on opiates to begin with, but now that they’ve been on them for a decade or more, it would be quite difficult to discontinue them. And so, every month (because we are not allowed to prescribe more than a month’s worth of medication at a time, nor provide for automatic refills, the way we might with a medication for cholesterol or blood pressure), I need to go through the above ritual.
The bureaucratic maze that doctors navigate to prescribe pain medication worsens burnout and harms patients.
Does Government Know Best?
To further dissuade doctors from prescribing opiates, the government has engaged in what I can only charitably call the Mafia treatment. I once received a personal email from a high-up in my state’s department of health, inviting me to attend a seminar on safe opiate prescribing as “one of the top 400 prescribers” of opiates in my state. “Where exactly did I fall on this list of 400?” I asked, pointing out that presumably there is a very large gap between Doctor Number 1 and Doctor Number 399. The high-up replied with an admonition that I need not be so defensive (can anybody receive a random email from a government official vaguely suggesting that they might be enabling the illegal drug trade without getting defensive?); he just “thought I’d like to know” that I was in the top 400 prescribers. I never got an answer as to where in that company I fell.
“We just thought you’d like to know,” must be a favorite phrase at my state’s department of health, because a colleague of mine got the same answer when an official showed up to his office in the middle of a working day, and pulled him out of an exam room to tell him that government records showed he was prescribing opiates to 30 patients on a monthly basis. My colleague, an older gentleman who has both the workaholic tendencies of a prior generation of physicians as well as the accumulated wisdom of many years in medical practice, pointed out that he treats over 3,000 patients, and hence 30 patients is less than one percent of his panel. “Is that a lot compared to other doctors?” he asked. “We’re not here to discuss that,” he was told darkly. “We just thought you’d like to know.”
Faced with reams of red tape and the ever-present threat of being harassed by a cross between a government bureaucrat and Ray Liotta’s character in “Goodfellas,” it’s not surprising that many doctors have simply stopped prescribing opiates altogether.
Hot Potato Patient
“Dear Doctor Bittermilk” began one typical letter I received from a neurologist a few years back. “Mr. Smith has been my patient for nearly 20 years. During this period we’ve tried nearly every medication imaginable to treat his severe migraines, but the only thing that has consistently worked has been Vicodin. Mr. Smith has been a responsible patient with this prescription and has never given me reason to believe he is misusing or abusing this drug. However, my practice policy is changing, and henceforth, I will not be prescribing opiates to any patients. I therefore hope you will take over the prescribing of this substance so that Mr. Smith can continue to get the care he needs.”
If you’re keeping track of the scorecard, the losers in the above story are the primary care doctor (add extra paperwork, and the likelihood that my stats with the local Stasi just worsened) and the patient. But it probably also includes the neurologist, who must feel that being henpecked out of giving her patient the best medical care she can is to lose yet another piece of her soul to the machine of the modern healthcare system. I wish I could say that the above letter is a rarity, but I’ve received many of them over the years, suggesting the absurd possibility that specialists are engaged in a pharmaceutical game of “whack-a-mole,” in which the prescribing of chronic opiates to some patients are not stopped, but rather shifted from one doctor who has given up on fighting the system to another.
If there were any evidence that these costs brought some benefit in the reduction of opiate deaths, perhaps they would be worth it. Again, however, while all this has been happening the opiate problem has only continued to worsen.
Doctors shift the burden of prescribing opiates from one to another, with no benefit to the patient or to solving the overall problem.
The heights to which this madness has risen has become truly absurd. Recently, while on call, I was paged by a patient. The night prior, he had been in a car accident, during which the tip of his finger had been amputated. He was taken by ambulance to the hospital, where a surgeon re-attached the finger. He was then discharged with instructions to follow up in the surgeon’s office a week later. For pain, he was told to take Advil, an ibuprofen.
At the time he called me, he was in severe pain, despite the Advil. He had already tried calling the surgeon’s office, but an answering service there informed him that the surgeon wouldn’t be returning his call, as they were under instructions to send patients who needed more pain control back to the emergency room. He didn’t want to spend the next ten hours waiting in the ER—who could blame him?—and pleaded with me to give him something to control the pain for a few days. I gave him prescription strength Tylenol and a few oxycodone to hold him over through the end of the weekend.
Chew on that for a moment. A human being literally had a body part severed off in an accident, but was given nothing stronger for pain than Advil, because the paperwork involved in prescribing him the correct medication—and/or the fear of government scrutiny—dissuaded the doctor treating him in the emergency room from doing so. Is this really what we want our government’s response to the opiate crisis to have come to?
Does Doctor Know Best?
Nobody is doubting that opiate abuse is a very serious problem in American society, and certainly we want doctors to be judicious in the provision of such scripts. But we must accept that, as with all human systems, there is no perfection possible here. We can trust doctors to use their professional expertise and training in deciding how and when to prescribe these medications, or we can continue to allow these to be so tightly regulated that doctors feel intense pressure to avoid prescribing them even when they might feel it appropriate.
The former policy will doubtless lead to overprescribing—some doctors being very liberal in their approach to giving out opiates, and some patients being very talented at deceiving doctors into getting what they want. But the latter policy is clearly a failure, depriving patients who legitimately need these treatments, and giving doctors yet another reason to feel micromanaged and demoralized in a system that is already teetering on the brink because of physician burnout.
Doctor’s Orders
I propose that governments, state and federal, stop deputizing doctors and other medical professionals into their war on drugs. They should roll back the burdensome restrictions that make it hard for doctors to respond when opiate prescriptions are called for, and they should make it crystal clear that, except in cases of egregious wrongdoing such as running a “pill mill,” they have no interest in prosecuting or harassing doctors for simply doing their jobs according to their best judgement.
Of course, we don’t want to return to the “bad old days” when too many doctors were overprescribing controlled substances. The above measures must be paired with improved education efforts for doctors and other healthcare professionals, and further investments into research on how to effectively treat chronic pain—an area in which our scientific knowledge remains woefully short.
We need more doctors who specialize in pain medicine and improved education for healthcare professionals on how to effectively treat chronic pain.
We also need more doctors who specialize in pain management. When a patient of mine has a serious cardiac condition, I don’t have difficulty finding a cardiologist to help me co-manage their medical care. But finding good pain specialists in my state is almost impossible; most have fled to other states, or quit prescribing opiates (opting instead to only provide the more lucrative and less regulated modality of joint injections) due to the excessive bureaucracy and fear of legal consequences. Primary care doctors are left to manage complex pain patients without the expertise that only a qualified specialist can provide.
Increasing the number of pain specialists can be accomplished by expanding training spots for pain medicine specialists and by making it clear to such doctors that they are not placing themselves in legal jeopardy for prescribing opiates in the absence of truly egregious behavior.
The opiate crisis was sparked in part by government meddling in the patient-doctor relationship. Now the backlash against that crisis—however well intentioned —is creating a new host of problems. The solution to this is to go back to the time-honored principle that most decisions are best left to the doctor and the patient. Failure to do so will only contribute to the suffering of patients, the stress of doctors, and the ongoing unravelling of our healthcare system.
This is one of an ongoing series from Dr. Bittermilk, offering solutions to a variety of issues surrounding the U.S. medical system.
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Dr. Reginald Bittermilk
