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August 14, 2019

When a Vital Sign Leads a Country Astray—The Opioid Epidemic

Author Affiliations
  • 1Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill
  • 2Department of Surgery, University of North Carolina School of Medicine, Chapel Hill
JAMA Surg. Published online August 14, 2019. doi:10.1001/jamasurg.2019.2104

The New York Times published a statistic: “Of all the nations of the world, the United States consumes the most habit-forming drugs per capita.”1 Similar statements have been published before, but one may be surprised that this one was published in 1911, quoting the US Opium Commissioner, Hamilton Wright, MD CM. He went on to call opium the “most pernicious drug known to humanity.”1 Despite this warning, more than 100 years later, the United States is reeling with more than 70 000 deaths from drug overdose per year, with more than 67% of these attributable to opioids.2

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    4 Comments for this article
    FINALLY! The truth.
    Mark Baucom, MD | Private practice derm surgeon
    I have been stating this for years! Yet the bureaucracy demands that we document pain AT EVERY VISIT- and if it is “greater than zero” Document a plan of action! This is not appropriate, relevant, necessary or helpful. Yet it is critical to our “MIPS” score and, if not all documented, we get penalized in reimbursement for failure to comply. As noted in the article, the same is true for hospitals. How has this not been front and center of the discussion from day one? No doctor wants to over prescribe, but no one wants a JHACO inspector or CMS citing for failure to “meet the standards.”
    You Could See This Coming from a Thousand Miles Away
    Michael Maffett |
    I'm retired. I'm double boarded, IM and anesthesiology. In my career, I did part time pediatrics in the Army, ran an ER, ran a general practice, and practiced anesthesiology for 25 years. I worked part time in our pain clinic from 1986 to about 2000, or when I could not stand it anymore. As a resident, I took an interest in pain because it was such a primary complaint. However, pain therapy was in its infancy. We did mostly blocks and did limited prescribing. Along the way, these "letters" appeared and suddenly pain, the treatment of a daily human condition, became the fifth vital sign. The Joint Commission championed it. The macro problem here, usually overlooked by academia, as opposed to clinicians, is the problem of malingering, feigning a medical condition for secondary gain. You find out about this quickly in the military; it's snowing outside and maneuvers are starting. Then there is disability, a bad job, a big test tomorrow, a bad marriage, or emotional needs. When I was new in practice, the first few months I saw a steady stream of people wanting diet pills, benzodiazepines, or quaaludes. Meanwhile victimization became an industry (i.e. currently 49 million Americans are on some form of disability).

    When the long acting opiates appeared, it opened the floodgates. Our on call doctors were harassed 24/7 by out of hospital calls for pain prescriptions. We quickly cut that off with "Call during office hours." We came out with contracts to be signed by pain patients with on chronic meds. Violate the terms and you are not longer a patient. Meanwhile, in anesthesia we use fentanyl by the barrel full. It's a very useful medicine, but it's very dangerous. I thought 20 years ago, in my science fiction brain, that someday the bad guys are going to start synthesizing this, and thousands would die. Tragically, my speculations came true. However, I could never have predicted the duplicity of the pharmaceutical industry or the weakness of the FDA in protecting our patients. It is science fiction becoming a tragic reality.
    Steven King, M.D., M.S. | Pain Medicine Physician
    The article skirts over some very important issue.

    Since at least 1987, when the Institute of Medicine published a report on pain management, we have known about the inadequacy of physician education on the subject in both med school and post grad programs yet we have done little to remedy this. That doctors could believe the false claims of Purdue and other opioid manufacturers and not know what the Porter and Jick letter actually said demonstrates the complete failing of our educational system.

    And another thing the author, apparently an anesthesiologist, ignores is the whole question of
    why the management of chronic pain is considered to be a part of anesthesiology as it is in virtually every medical center in this country. Perhaps one of the reasons for the misprescription of opioids and the abuse and addiction epidemic is that those who are given the task of teaching about pain know little about these subjects nor about the whole issue of the psychological aspects of chronic pain. As far as anyone can determine anesthesiology premier place is based on finances and not science.

    Unless we revise our whole educational system with regard to the teaching of pain management, we will continue to have ignorant physicians who can't tell what's right or wrong.
    Daniel Frank, MD | MedNorthwest
    This article perfectly states the problem. The most galling aspect of the opioid crisis from a physician's perspective is the failure of JCAHO and other medical organizations to take responsibility for causing this nightmare. They created a bogeyman of the insensitive doctor who was letting patients suffer and placed enormous pressure on us to over-prescribe these addictive drugs.