Did doctors who cared too much lead to the opioid epidemic?

Sometimes medicine offers us wonderful, almost unimaginable gifts. Heart attacks that were devastating, life-altering events a few decades ago are now treated with expediency and skill that our grandparents couldn’t imagine. A couple of days pass, and the victim is home with stents in occluded arteries and directions to modify activity and diet. Pneumonia, once the “old person’s

friend” (so called because it took the aged to eternity), is far less terrifying, thanks to both antibiotics and the pneumonia vaccine.

However, some of the things we do give benefits that are less clear. Although it could be an entire column in itself, the “stroke center” movement, with the promise of miracles from “clot-busting drugs,” is a thing full of as many questions as answers. And what about depression and antidepressants? When I looked up the side-effect profile of an antidepressant a friend was taking, I was reminded that all of them have the potential side effect of increasing suicidal behavior.

But what about pain management? Thanks to improved understanding of the physiology of pain, the persistence of medical providers and the investment and research of pharmaceutical companies, we have a wide array of pharmaceuticals available for the treatment of pain. Some are over-the-counter, like acetaminophen and ibuprofen. And others, those we refer to as narcotics or opioids (because in previous times they were derived from opium), are useful, potent and (as is increasingly evident) fraught with danger unless used very cautiously.

Of course, for a very long time, physicians were taught to be judicious in prescribing narcotics. Our venerable teachers warned young doctors in training to be frightened of the side effects. We were especially aware of the very immediate danger that patients would stop breathing and die due to excess sedation. We were also aware that over time, patients on narcotics might develop problems with addiction.

About 20-to-25 years ago, that whole paradigm shifted, and physicians were suddenly accused of callous disregard of suffering by prescribing too few narcotics. I remember this because I was in my emergency medicine residency at that time. We were constantly reminded to give more narcotics and be sensitive to pain. We were taught to use the “pain scale,” in which a patient-reported score of zero meant no pain and a score of 10 meant “the worst pain of your life.” Nevermind that it was entirely subjective and that there was no objective standard, no “painometer” against which to measure it. We were instructed to see pain as the “fifth vital sign” after blood pressure, pulse, respiratory rate and temperature. Of concern to many, these initiatives coincided with the development and aggressive marketing of ever more powerful, addictive medications like Oxycontin tablets and Fentanyl patches and lozenges.

Patient-satisfaction surveys included the question: “Was your pain adequately treated?” Physicians were castigated when those satisfaction survey scores fell. Physicians were instructed, by non-clinician administrators, to give more pain medication to make patients more satisfied. (A satisfied customer/patient is one that may come back!) Physicians who resisted, in the name of science or safety, were too often met with threats of reduced income or job loss if patient satisfaction scores fell. In some instances, physicians were (and still are) reported to state medical boards for alleged inadequate treatment of pain.

I sincerely believe that most of those encouraging us to write more narcotics prescriptions did so out of genuine concern and compassion. People are in pain, so why not treat the pain? In medicine, where science meets suffering humanity, it’s so easy for us to say, “Well, it just makes sense, doesn’t it?” We assume that our compassion will be supported by science. It happens with infections: Sure, it’s probably a head cold, but what’s the harm in an antibiotic to keep the patient happy? The child bumped her head pretty hard, so what’s the problem with a CT scan, even though she looks good? The parents are customers, after all, and want a scan!

With tragic consequences, our compassion sometimes causes harm as the Law of Unintended Consequences rears its ugly head. For instance, those antibiotics for colds? They can cause dangerous allergic reactions and life-changing intestinal infections requiring hospitalization or surgery or result in death. Those CT scans everyone wants? Physicians are trying to reduce the number of scans, as many of us are concerned that they may induce malignant tumors later. And those pain medications? The evidence looks pretty damning.

Addiction to prescription narcotics is growing at a terrifying rate in the U.S. Likewise, death rates from narcotic overdoses have soared. The U.S. has seen 165,000 deaths from opioid overdose between 1999 and 2014. In fact, opioid-related deaths have now surpassed deaths from firearms in the United States. Admittedly, some of those deaths are not due to prescription opioids but rather to injected heroin. However, many heroin addicts began their addiction issues when taking legitimately prescribed pain medication.

Sadly, seniors are not immune. Physicians don’t want to see seniors suffer, so they often give narcotics even for pain that in decades past would not have been treated with those drugs. We give them for back pain, headache, arthritis, or other less serious conditions. And we use them extensively in the treatment of chronic, intractable pain. In fact, in 2015, one-third of Medicare recipients received a prescription for an opioid analgesic; some 40 million prescriptions.

Furthermore, seniors not only develop addiction, not only die from accidental overdoses, their narcotic analgesics have a host of side-effects, including (but not limited to) the following: excessive sleep, impaired thinking, increased pain sensitivity, nausea, constipation and cardiac arrhythmia. Also, opioid drugs contribute to weakness and loss of balance and thus to falls, resulting in head and spine injury, various fractures and other trauma. Their already impaired reflexes are dampened by their medication so that for those who still drive, it becomes an even more dangerous activity than before.

No one is immune from this devastating epidemic, not rich nor poor, not young nor old. The medical profession, the mental health community, law-enforcement, social services, churches, families and friends all have to come together and find ways to roll back the rising tide of death and addiction, which came as an unforeseen outcome of attempting to ease suffering with compassion and science.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan.  

Image credit: Shutterstock.com

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