Politicians, media muckrakers, and blood thirsty legal corporations have launched an all-out attack on prescribing clinicians for causing and/or contributing to the presumed “opioid epidemic”.
The first question in my mind is whether it’s really an “opioid epidemic”, or if it’s an “illicit fentanyl epidemic crisis” that has spun out of control as eloquently presented by Rose last April in Pain Medicine.
And when I say fentanyl, I don’t mean prescription fentanyl – I mean products not intended for human consumption that are up to 10,000x more potent than morphine and 1000x more potent than prescription fentanyl, most of which are used to lace heroin obtained on the street.
The DEA has not been made accountable for their inability to control this, and blame has indeed shifted to everyone but the DEA and the sources from which the arrive, namely China and Mexico.
Instead, politicians and media blame Big Pharma and prescribing clinicians for causing this problem, respectively by manufacturing and prescribing legitimate FDA approved opioids – there is a huge disconnect here!
Of those that overdose on prescription opioids, the far majority obtained them, not from a legitimate prescriber, but from a friend, family member or another source.
In many, if not most death instances of late that involve prescription opioids, they are often combined with other drugs including illicit fentanyl derivatives, alcohol, benzodiazepines, and/or other legal or illegal sedative hypnotics, and/or they are manipulated and ingested in a way other than prescribed or intended
It is mindboggling to me that the one entity that is probably most responsible for abusable prescription opioids getting into the wrong hands has not been held accountable, nor have they been sued by state governments, or exposed as the nemesis behind a much larger issue.
That group is third party insurance payers who for years have driven the opioid supply bus.
payers continue to promote and mandate the least safe alternatives unchecked. Why do they get away with it you ask? Simple, because they have a strong lobby in Congress and because prescribing clinicians and patients have succumbed to Learned Helplessness.
At the core, prescribing clinicians are bullied into various prescribing habits by what the insurance company mandates or allows according to their formulary policy. And, the prescriber is the one ostracized for poor outcomes.
So why do prescribers go along with this?
By definition, LEARNED HELPLESSNESS is “a mental state in which an organism forced to bear aversive stimuli, or stimuli that are painful or otherwise unpleasant, becomes unable or unwilling to avoid subsequent encounters with those stimuli, even if they are “escapable,” presumably because it has learned that it cannot control the situation”
That’s exactly what pain patients feel as well.
- We can not control our pain,
- we cannot control what our doctors will prescribe for us to relieve it, and
- we cannot control the sometimes unaffordable cost of the prescription.
Generic opioids are the most affordable because our insurance companies often place non-opioid pain relievers, like Lyrica, or the abuse-resistant OxyContin in their top tiers, which makes them prohibitively expensive.
Additionally, any kind of ongoing physical or psychological therapy is limited to just a few sessions, making those treatments impossibly expensive as well.
It is this concept that helps to explain and influences a clinician’s decision to select a more dangerous drug over a safer but more expensive alternative. And when I say “more dangerous”, that includes less clinically desirable alternative that affords the highest profitability for the insurance company and pharmacy benefits managers, the latter of which presents another conflict because PBMs are owned by large chain pharmacies and insurance companies. [See previous blog on PBMs HERE]
One might argue, “the doctor doesn’t have to prescribe the options offered”. Perhaps that’s true, but then a decision needs to be made of what can be offered to a patient that requires medication options because all other alternatives have been unsuccessful and/or payment was also denied.
So, what does a prescriber do? They give in to the payer so they can do something, anything, to help the patient. This serves to influence unsafe prescribing.
Doctors are free to prescribe any expensive drugs or treatments, but patients simply can’t afford them.
the insurance payers who are really influencing which opioid is prescribed based on maximizing profit have not disclosed their financial conflicts in guiding opioid selection. This has been and remains a dangerous precedent that is without a doubt responsible for opioid deaths.
And, to make matters worse, the very lawmakers that allow such nonsense are receiving millions in contributions from major healthcare companies as outlined on Open Secrets.
So, to all you attorneys and state agencies looking to make a fast million bucks on Big Pharma and some pretty smart clinicians that have patient safety, education, and the patient’s best interest at heart, you might want to gear up to go after the real money that is buried within the insurance industry bureaucracy.
My advice is to sue the pants off of them, because it is the insurance industry that influences prescribing, not the doctors, and it’s pretty easy to prove.
The opioid crisis as we know it is due to illicit fentanyl and government negligence in controlling just that, and a greedy insurance industry on the legal side of the fence.