Preventing Opioid Abuse Ignores Patients’ Pain

Preventing Opioid Abuse Shouldn’t Mean Ignoring Patients’ Pain by Subhash Jain – Aug 2019

I’m surprised and delighted that this article was published in the respected “Harvard Business Review” so that it reaches the people making the rules from their seats in the executive suites of medical corporations.

From lawsuits by several states against the manufacturers of opioids to criminal prosecutions against pharmaceutical executives, much has been made about pain medications and their misuse. Unfortunately, if you just pay attention to these headlines, you’re likely to miss an important fact:

Pain medications are an important and medically necessary part of many patients’ treatment.

Hurrah, another doctor pushing back against the widespread policies of reducing long term opioid use to almost zero. 

Hard to believe, but there was a time when pain was ignored by the medical profession — and when patients who needed pain treatments never received them. We are teetering dangerously close to returning to that time.

The guidelines were intended to help guide primary care clinicians who treated adult patients with the intent of improving “clinical knowledge, [changing] prescribing practices, and ultimately [benefiting] patient health.”

And, yet, before long, the CDC guidelines were used to more broadly restrict access to these medicines among patients who might need them.

Pharmacies, health plans, medical groups and others began invoking the CDC’s name to implement draconian, across-the-board solutions.

The CDC was forced to issue a clarification of its own guidelines after several studies showed that, in the wake of those guidelines’ release, the number of patients who could not get insurance coverage for their pain prescriptions tripled

Things got so bad, in fact, that more than 300 medical experts, including three former White House drug czars, took the unusual step of writing a letter to the CDC in response to these guidelines in which they said the guidelines were harming patients.

The letter’s authors made special note of “payer-imposed payment barriers…high-stakes metrics imposed by quality agencies, and legal or professional risks for physicians, often based on invocation of the CDC’s authority.”

Cancer patients and patients at the end of life in particular need the opportunity to live the end of their lives pain free. Isn’t that what we would all want for ourselves and our loved ones?

Confusing and arbitrary prescription guidelines are not the answer

We must curb our rhetoric and acknowledge that opiates are appropriate medicines for some types of patients.

Retrospective reviews of clinician prescribing practices are a far better deterrent to indiscriminate opiate prescribing than restricting access to patients in a moment of need.

We must return to a place where the prescribing physician feels both empowered and responsible for doing the right thing for their patients in their moments of need.

The sentence above succinctly states what needs to be done for both doctors and patients, while the current trends are going exactly in the opposite direction.

And then follows a gruesome story:

Back in the late 1970s, I was a young resident doing a rotation in orthopedics when a victim of a motorcycle crash came into the hospital. “Greg” suffered multiple fractures all over his body.

He was in immense pain, and I can still remember his cries of agony.

The senior physician with whom I was rotating followed the protocols of the era. He gave the man 60 milligrams of Demerol every six hours. Still, Greg screamed and cried.

When I asked why we weren’t giving him more medication for his pain, the senior physician explained that he was following protocols, before adding (without any knowledge of the patient other than his tattooed body) was probably a drug addict acting out in order to get high.

For six weeks, I listened to Greg cry out in pain. “It hurts like hell inside this cast!” he screamed. But nobody changed his medication dosing because, according to the guidelines, he was getting what everyone was supposed to get.

Back then, whether you’d had abdominal surgery or leg surgery, no matter whether you were a 200-pound man or a 100-pound woman, you got the same 60 milligrams of Demerol every six hours regardless of how badly you said you were hurting.

“Back then” is now: standard and insufficient opioid doses are being established for all, no matter the patient’s problem, no matter the patient’s size and age, no matter the patient’s reported pain.

After six weeks, we finally cut open the patient’s cast. His whole limb was black and blue — the patient had developed allodynia, a crippling hypersensitivity pain syndrome. It struck me as inhumane that the patient’s pain was managed so bluntly without consideration of his real problem and his real need.

That’s when I decided to dedicate my life and career to the management of pain — pain that for many patients went ignored by our health care system.

I’m so grateful for doctors like Dr. Jain, who are willing to resist the trend of under-medicating pain.

We can’t retreat to and again be complicit in denying access to pain care to patients like Greg who need our compassion and our care.

Subhash Jain, MD, recently retired after 40 years of practice in pain management. He was the founding chief of the pain service at Memorial Sloan-Kettering Cancer Center in New York City.

2 thoughts on “Preventing Opioid Abuse Ignores Patients’ Pain

  1. Kathy C

    Often the business pages offer more insight into topics, since they are used by investors to stay informed on investments. It is very likely that the way that people with pain and addiction have been treated by the medical business, increased their chances of becoming addicted. The specter of addiction, allows physicians to ignore pain, for the patients own good. No one has researched this dynamic, at all, choosing to claim that various shortcomings of the patients are at fault not the healthcare system.

    Day after day more mindless propaganda, get reported across the media, often following a false narrative. PBS has a series “Second Opinion”
    A group of physicians weigh in on various medical cases. This patient was already dead, from an Overdose. The tale told by the parents had all of the usual elements, parental denial, the lack of addiction resources, and the initial misdiagnosed multiple times painful medical problem.

    The dead patient was let down by multiple physicians, due to the lack of any kind of insight on pain, addiction or diagnosing these disorders. They gloss over the routine repeated failures of the treatment industry too. One physician of course brought up “Opioid Induced Hyperalgia” even though that is rare, it is always blamed for opioid deaths, instead of the lies and propaganda, and mistreatment of patients. The poor guy may have had a misdiagnosed pancreatitis, and already had an alcohol problem, which may have contributed to it.

    These kinds of anecdotal stories have not increased any kind of understanding, in fact they fueled a lot of deaths. The grieving parents, who just did not know, and thought that the treatment provider that was available, was competent. How could they know that treatment is not based on outcomes, facts or science. There is no standard for treatment. they would not have had any access to the outcomes, by design. The doctors gloss over all of that, and how many people die after these short term gimmicky treatment programs. The parents would have had to rely on what they saw on TV and in the media, their only source of information.

    The TV show, which they portray as informational is paid for by a large insurance company, which lobbied against providing treatment or behavioral health services. The large insurance companies are still peddling alternate facts and misinformation when it comes to healthcare. The lies, misinformation and propaganda all designed to increase corporate profits at the expense of patients and sick people, are being spread by the insurance, pharma and medical industries. Corporate lobbying marketing, and direct payment to policy makers created this epidemic. All of these years out, these physicians won’t identify the problem, because the show is funded by the very same groups. They engage in paltering, including just enough factual information to misinform the public, and avoid accountability. These powerful corporations even made sure the data could not be collected, telling congress that it was “government overreach.”

    The ethical problem with using this young mans death for corporate marketing and public relations, is a whole other matter. It does explain why 22 years out we are still dealing with all of it, and worst of of all the denial these physicians were quick to apply, to protect their corporate sponsors. it is pretty easy to see why a young man in his position overdosed, it follows a common theme, which they had to create a riveting false narrative for in order to protect their business model.

    There was a reason that there used to be laws against deceptive health marketing. This TV show is a toxic mix of marketing, pseudo science and paltering. It should be considered not ethical to use a persons death this way, after all he did not sign a release. Using the parents grief to misreport on addiction and the systemic failures illustrated by his death, is horrific. There is no lengths these huge corporations won’t go to to increase their profitability. These corporations made billions, exploiting these deaths and many others. They were instrumental in undermining our healthcare system, our media, and our government.

    Liked by 2 people

  2. Flutterby

    I agree for the most part with Kathy. What we are seeing now is diagnosis of a painful injury/condition/disease, and that’s about it. Go home, take Tylenol and ibuprofen, and we will blame the patient when they can’t do PT due to pain and that acute pain turns chronic. The majority of the ones who are already diagnosed with severe intractable pain have been tapered either off their meds completely, or to levels so low they’re in constant pain again. There have been some articles making it into the light recently, but that doesn’t bring back those we have lost to the undertreatment of pain. And we have lost so many….

    Liked by 1 person


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