Nearly every day we read headlines about the serious prescription drug problem in America. Increasing heroin addictions and deaths from illicit drug use are taking a severe toll on far too many families and communities. While we must feel enormous sadness for the families experiencing these tragedies, we must not overlook the other major health crisis that is often associated with the opioid abuse problem: chronic pain.
The chronic pain crisis in America receives far too little dialogue and education in the medical establishment or coverage in the press. The 100 million Americans who suffer some type of ongoing, persistent pain, according the Institute of Medicine, often face a frustrating and dehumanizing search for medical professionals who can help them. They find themselves set adrift in a healthcare delivery system that does not reimburse appropriately for evidence-based, alternative therapies and treated by clinicians whose medical training lacks even the most basic instruction on managing pain.
Fixing all of this takes time, commitment and — most crucially — money for research and education, all of which fall short. Meanwhile, prescription drug abuse and opioid drug-related deaths are a full-fledged epidemic. Drug overdoses have tripled since 1990 with prescription drugs as a driving factor. More than 12 million people reported using prescription painkillers (i.e., opioids) without a prescription in 2010, and emergency department visits have skyrocketed in recent years also.
To combat these tragic numbers, unfortunately, the legal system’s strategy has become prosecution of doctors who treat patients using opioid analgesics, even when criminal intent on the part of the prescriber is indisputably absent. I served as an expert witness in one such recent legal case that clearly stands as an example of prosecutorial overreach.
Accused of involuntary manslaughter in multiple deaths in his Des Moines, Iowa, practice, Daniel Baldi, DO, was, thankfully, cleared of any wrongdoing when the judge dismissed two of the nine charges, citing lack of evidence, and the jury acquitted on the remaining seven charges.
Testimony in the trial, far from proving the prosecution’s contention that the doctor’s reckless prescribing led inevitably and predictably to the deaths, instead revealed that the decedents died from a variety of causes and contributing factors that included worsening medical conditions, the use of medications not prescribed by Baldi, and the abuse of illicit substances. Tragically, Baldi is financially ruined and professionally scarred, and the legal system offers no recourse for such injustices. Prosecutors can levy charges that ruin careers without any accountability.
My colleagues and I at a former Salt Lake City, Utah, pain clinic have also dealt personally with the tragedy of patients who die, not as a result of treatment, but in spite of it. The Drug Enforcement Administration (DEA) opened an investigation related to overdose deaths at the Lifetree Pain Clinic, beginning with a raid on the clinic in 2010. After nearly four years, the U.S. Attorney for the District of Utah declined to pursue charges and the case was dropped.
Yet the ripple effects of such actions are felt in the medical community, as practitioners reduce their willingness to prescribe strong medications, even when they are indicated. Why take the risk of taking the blame when a patient dies of any cause? This is sad reasoning indeed.
There is torment in the dilemma between treating patients to help them escape excruciating pain and running the risk of being targeted for prosecution if, in some cases, under specific circumstances, the treatment plan involves opioids. The dilemma is worsened when one realizes how close is the link of chronic pain to suicide. The scientific literature tells us people with chronic pain are at two to three times the risk of others for suicide.
Regardless, most of the focus is on enforcement measures. A recent report in the New York Times cites a 23% decline in overdoses in Florida, crediting policies and enforcement measures implemented to address the state’s overdose crisis. The elimination of “pill mills” in Florida using enforcement should be applauded as these mafia-like clinics were not remotely legitimate providers of care.
However, because policies and enforcement were necessary and effective in Florida does not mean aggressive enforcement tactics are the most effective methods to address the problem of drug abuse or overdoses elsewhere. Reasons for abuse and overdose are multi-factorial and to think that more aggressive law enforcement or regulations will solve the problem is short sighted if not harmful to our communities and particularly to people in pain who are increasingly struggling to find someone to treat them.
Furthermore, the report dismissed the dramatic overall reduction in overdose deaths in Utah (approximately 33% from 2007 to 2013), which ignores a potentially more effective and sustainable approach to preventing harm. The Utah approach was not centered on policies and enforcement but education. We must not forget the real problem is how to treat chronic pain safely while preventing harm from opioids.
Opioid medications are not the only or the best therapy for all patients or all types of pain. They clearly bring risk and should be reserved for those patients who truly need them, administered by clinicians with the training and will to assess and monitor patients in accordance with accepted medical guidelines. However, every patient with chronic pain should have access to a minimum level of insurance benefits and, for some patients and some pain conditions, that includes opioids.
To safely treat the largest health care problem in America, chronic pain, our society must not react by limiting access to medications. A system that intimidates doctors and refuses to fill prescriptions, which is happening at some corporate pharmacies, ultimately leads to patients suffering from debilitating pain, isolated and desperate. Paradoxically, patients for whom medical options are limited are being abandoned, forcing them into hopeless circumstances. Along with a commitment to find better therapies and better access to them, we need to change our attitudes, by providing these patients — and their doctors — with the dignity of care equal to that accorded other chronic illnesses.
Lynn Webster is medical director, CRI Lifetree and immediate past president, American Academy of Pain Medicine.