The Oct 25 issue of the New England Journal of Medicine has a Perspective piece – Why Doctors Prescribe Opioids to Known Opioid Abusers – that instructs beyond its immediate content. Written by Anna Lembke, MD, a member of Stanford’s Department of Psychiatry, it deals with one of medicine’s two core purposes, the relief of pain. In the first half of the article Dr Lembke cogently describes a relatively new problem in pain management.
For years physicians under prescribed potent pain relieving drugs, mostly opium derivatives, in fear of causing addiction. Lembke cites evidence that there are now 2.4 million opioid abusers in the and that this number increased by 225% between 1992 and 2000. She attributes much of this problem to physicians who she says (without a citation) are prescribing 60% of the opioids that are abused. I’m not sure she’s right, but let’s assume she is.
She attributes the change in prescribing practice to changes in attitudes and regulations. Until fairly recently physicians were reluctant to prescribe powerful pain relieving drug like morphine because of their fear of inducing addiction and because of different normative views of pain. “Today, treating pain is every doctor’s mandated responsibility.” I suspect that the approach to pain is very different in California compared to Texas as are many other attitudes, but that’s just an opinion. Physicians under my purview consistently under treated pain.
In 2001 the Medical Board of California issued a regulation (Lembke says it passed a law, but that’s the prerogative of the legislature) requiring all physicians in the state (pathologists and radiologists excepted) to take a full day course in pain management. Understandably she thinks this was an unwarranted intrusion of medical practice. Parenthetically, physicians will soon have so many government required courses, reviews, mandatory credentialing online sessions, and other hallucinatory wastes of their time that patient care will have to be eliminated from the practice of medicine.
She goes on to cite a very recent paper in the NEJM – Alleviating Suffering 101 — Pain Relief in the United States. She disapprovingly quotes from this paper: Pizzo and Clark [the authors of the paper cited above] urged health care providers as well as “family members, employers, and friends” to “rely on a person’s ability to express his or her subjective experience of pain and learn to trust that expression,” adding that the “medical system must give these expressions credence and endeavor to respond to them honestly and effectively.” It seems that the patient’s subjective experience of pain now takes precedence over other, potentially competing, considerations. In contemporary medical culture, self-reports of pain are above question, and the treatment of pain is held up as the holy grail of compassionate medical care.
Dr Lembke believes that a cultural shift on the part of patients and a professional change by doctors has resulted in the over prescription of addicting drugs which predictably has lead to more addicted patients. A cultural change contributing to physicians’ dilemma is the “all suffering is avoidable” ethos that pervades many aspects of modern life. Many Americans today believe that any kind of pain, physical or mental, is indicative of pathology and therefore amenable to treatment. (The recent campaign to label “grief” a mental disorder is just one small example of this phenomenon).
Adding to the obvious sources of the dispute just outlined is that Dr Lembke belongs to a department of psychiatry while Dr Clark is in the the Center for Managing Chronic Disease at the University of Michigan. Thus there may be a turf battle underlying this conflict. Further piquancy is added by Dr Pizzo’s job; he’s the dean of which medical school? Stanford, the same place that Dr Lembke works. I can’t help wondering if there’s a prankster in the editorial offices of the NEJM 3000 miles away in Massachusetts.
Let’s leave fun aside. What does Dr Lembke recommend to fix iatrogenic drug addiction? Another mandatory course. I’m not kidding. Some short-term changes that can help address this problem include mandating that all physicians complete a continuing medical education course on addiction, just as, since 2001, they have been required to complete one on pain treatment. Physicians need to learn to conceptualize addiction as a chronic illness that waxes and wanes — an illness similar to diabetes, heart disease, or other chronic illnesses that are influenced by patients’ behavior. Dr Lembke doesn’t believe grief is a disease, but is convinced that drug addiction is no different from diabetes. I don’t want to underestimate the seriousness of substance abuse, but it’s not the same as diabetes. You can’t will yourself out of being diabetic. Forty million Americans have, usually on their own, stopped smoking.
Society sees the two very differently. You don’t get sent to jail if you have an insulin reaction while driving and kill someone. You do get jail time if you’re drunk behind the wheel and take a life. Addiction is serious and may have tragic or even lethal consequences; therefore, it deserves serious attention, but it’s not the same type of problem as diabetes. Medicalizing bad or self destructive behavior has thus far failed to solve a major problem. Our understanding of why people act the way they do will not soon equal our comprehension of why kidneys fail. I admit that the line between bad and/or self destructive behavior and a true disease like schizophrenia is blurry and that many will disagree where I’ve put it or rather have smudged it.
Dr Lembke wants to take more of physicians’ time: all physicians in every state should have access to a database for prescription-drug monitoring and should be required by law to query the database before writing an initial prescription for opioids or other controlled substances. Dr Lembke has placed part of the blame for the writing of narcotic prescriptions on the scarcity of physicians’ time; ie it’s easier to write a scrip than spend half an hour or more trying to otherwise deal with a patient demanding powerful pain medication. Good doctors know how to manage pain. They use good clinical judgement. Their practice is unlikely to be improved by another mandatory snooze session or a time consuming database search. Every one of life’s problems does not require new rules.
And then there’s the indoor pachyderm. Alcohol can kill you, same for tobacco. But what’s the deleterious effect of opioid addiction? It’s dangerous when it’s illegal because the drug is impure and the supply unreliable. But when it’s supplied by your doctor what bad things happen? Unless you intentionally overdose the drug per se is not likely to have a bad effect on your health. After all, you’re taking it under the supervision of a physician. It’s obviously better not to be on a drug that you don’t need than to be taking it, but there are far worse drugs than opioids that patients routinely and chronically take with shaky indications. Again, best to stop them all, but opioids likely aren’t near the top of the list of dubious drugs especially if patients say they’re relieving pain.