by The Country Doctor

The blessings and curses of opium have been around for a while- 4000 years, give or take.   Opium, known as “God’s own medicine” by Sir William Osler (a fabulously revered doctor in the 1800’s), was perhaps one of the only useful medications used by physicians prior to modern-day medicine.  It could ease the pain of soldiers with severe war injuries, comfort those that were suffering and dying, soothe the disabling cough of tuberculosis, and slow the incessant diarrhea that was common with the consumption of contaminated water.   Opium was sequentially distilled into modern day opioids – powerful medications that are still an essential component to our medical armamentarium.  Unfortunately, these medications seem to have gotten us into a pickle.  Well, maybe more like an epic struggle between life and death; quality of life and unbearable pain.  The current situation is not new – the merry-go-round of opiates, relief of suffering, revenue generation, dependence and addiction, laws against opioids, illegal drug activities, death from overdose, practice reformation, etc. has been spinning for hundreds, if not thousands, of years.  The current situation, however, is unsustainable.  You have heard the statistics – 91 Americans die every day from drug overdoses (3 of those Coloradans); drug overdoses are now THE leading cause of death for Americans  under the age of 50 (this beats fatalities from firearms; or motor vehicle accident deaths).  The problem seems to be specifically deadly to Americans – even though the United States makes up about 5% of the world population; we use 75% of the world’s opiates.  How did we get into this upsetting situation?  The problem, as well as the solution, is complicated.

Most physicians/practitioners went into medicine to help people, alleviate suffering, etc.  This made them sitting ducks for the introduction of oxycontin in the mid 1990’s – a blockbuster drug that was heavily advertised as a safe, minimally-addicting, efficacious medication to mitigate pain. Unfortunately, this claim was based on a few poorly done studies that have since been discredited; and pharmaceutical companies were fined millions of dollars (a slap on the wrist) for their unethical false advertising practices.  But the damage had been done – patients were already dependent and/or addicted to the narcotics, and comfortable profits had been made- well, are still being made, to the tune of 17.1 billion dollars a year.  

Around the same time the producers of oxycontin were running amok with their wildly successful and unscrupulous promotion campaign, the American Pain Society (incidentally the recipient of significant funds from the producers of oxycontin) came up with a concept known as “pain as the 5th vital sign”.  I really can’t fathom how or why this concept took off- how could a bunch of meticulous scientists ever agree to incorporate subjective information (pain) into a cluster of objective/measurable data (vital signs)?  As good scientists, this rubs ALL us physicians the wrong way.  The assessment of pain is important; we get that – but for every appointment for a flu shot, off- colored booger, or blood pressure check, we have to evaluate/document the “5th vital sign”.  And because the symptom of pain is considered a vital sign, we must presumably deal with it promptly- as we would any other vital sign (such as an oxygen level of 80%.  Or a blood pressure of 200/120).    At any rate, what we did to address the abnormalities in the new vital sign, was prescribe opioids- enough to annually  dope up every man, woman and child in the United States for 3 weeks.  Hooray!  Abnormal vital sign addressed.  


Regrettably, the Joint Commission joined the dark side of the force in 2001 – they required physicians to use the dreadful pain scale, touted the safety of opioids, and framed pain management as a “patient rights” issue.  This understandably caused a lot of fear about punitive actions (real and imagined) if the patient’s reported pain was not adequately addressed.  On a side note, what the heck are we supposed to do with a report of pain that is a 15/10?  In case you were wondering, this impossible data is usually dismissed -just as a report of a purple unicorn galloping across the Fraser valley would be surprising, but ultimately, disregarded.  Anyway, what physicians did in response to the pain scale (fearing for our jobs and not wishing to violate patient rights) was manage pain with more opioids.   

Adding to this growing avalanche of pressure on the physicians/practitioners was the awful patient satisfaction score.  Now hospital/physician performance was rated (thus subsequently reimbursed) according to a good score, which was heavily dependent on control of pain.  These surveys were created by evil monkeys that were mostly concerned about two things: 1. making a crap ton of money off these surveys, and  2. the patient/customer comfort level during their hospital/spa stay.  The surveys were unconcerned about whether the patient survived the hospital stay, or that the correct diagnosis was made, or that the appropriate treatment was given.  Ironically, multiple recent studies have demonstrated that the more “satisfied” you are as a patient (as reflected in the patient satisfaction score), the more likely you were to get really sick or die.  But I digress.  So after CMS (Centers for Medicare/aid service) decided they would tie a significant amount of hospital reimbursement to the patient satisfaction score; hospital administrators made sure the physicians were providing the ultimate hospital/spa experience for patients (by withholding pay or providing bonuses); and practitioners were pressured to prescribe opioids when patients demanded them; even if they had reservations about doing so.  This phenomenon subsequently infested emergency departments, urgent care centers, surgery centers, and outpatient clinics.

All these practices, and probably more, have spiraled into the current public health emergency.  And today us health care providers are privy to some sobering information:

  1.  ALL of the opioids can cause dependence and addiction.  This can happen in as little as 3 days: a recent CDC study found that 20% of patients become long term opioid users after just 10 days of prescription opiate use.  Yikes.
  2.  Opiates actually make pain worse:  just a few days of taking these substances can up-regulate pain receptors and cause over activity of nerve cells  that respond to pain – thus increasing pain to minor stimuli (making a paper cut agonizing) and prolonging pain (the paper cut is agonizing for weeks, even after it is healed)
  3. Opiate addiction is a chronic disease (much like hypertension, depression, and type 2 diabetes).   
  4.  Pain management techniques that have good evidence for efficacy include physical therapy, exercise, cognitive behavioral therapy, treatment of concomitant psychiatric illness, tens units, injections, spinal stimulators, acupuncture, massage, chiropractic and osteopathic manipulation, and good old acetaminophen and ibuprofen.   Study after study, narcotics have not made the list of effective pain treatments; they do continue to demonstrate significant risk.  As CDC director Dr. Tom Frieden wrote in the New England Journal of Medicine (regarding opiates) – “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently”.  

Addressing the current situation will be a monumental task.  It will involve a revolution in physician/practitioner prescribing practices.  It will take a seismic shift in our culture that is wired to take a pill or get a surgery for a quick fix.  It will require insurance companies to actually cover the modalities that are proven to treat pain; and to cover addiction treatments.  There will need to be access to practitioners and programs that can address the chronic medical condition of addiction.  Ubiquitous availability of naloxone (to reverse opioid overdose) will be needed.   It will require change to a health system that makes the prescribing of opiates expected and convenient.  Physicians, practitioners, and patients need continuing education on the actual benefits and harms of opioid use.   We will all have to work together to stem this tide of disease and death- we have done it before!  We can do it again.