My first job out of college in the late 80’s was as a research tech at a biotech firm where my naïve ideas about developing cures to improve health quickly gave way to an appreciation for the actual mission of drug manufacturers: making money by bringing patentable products to market. The process is rife with ethical conflicts of interests because pharmaceutical companies are in the business of selling drugs rather than prudently parsing how and when they should be used. The latter responsibility falls primarily to doctors and, in hospitals, nurses, who have significant influence over when they are given. Logically, those companies market to doctors prescribing controlled substances, and increasingly in those years, directly to patients who were guided to lobby their caretakers for medications. Not surprising that opiate manufacturers also capitalized on policies designed to eliminate pain by funding regulatory bodies charged with accreditation of healthcare organizations (see below). A major factor in the creation of opioid crisis has been the promotion, and lack of regulation of pharmaceutical drug companies’ promotion and sales.
By the late 90’s, as a young doctor just out of residency in emergency medicine, I took my idealism into my little corner of the medical world where I set out to practice with integrity. I was sure my lifelong affinity to fringe artsy friends, a few of whom got into drugs and died of overdoses, had equipped me to understand how exceptional the use of narcotic analgesics had to be. It came naturally to look for alternatives to narcotics whenever possible. Enter the next phase of greed vs. good intent. Hospital profit margins were increasingly tied to patient satisfaction scores and the healthcare industry became transformed to service for customers rather than healing and the preservation of health for patients. The total elimination of pain was correlated with higher satisfaction scores and hospital policies were designed to encourage caretakers to use narcotics more liberally. Some of my colleagues joined in resisting that push at some risk to jobs others gave in taking the path of least resistance. A major factor in the creation of the opioid crisis has been the market driven operation of hospitals for competitive advantage over health outcomes.
Our healthcare regulatory agencies often attribute challenging trends in medical care, as caused by a failure of education and training. Enter the 5th Vital sign, pain level, as part of a campaign to teach its fundamental critical value. In the mid 90’s an organization known as the American Pain Society, advocating against the under-treatment of pain, proposed evaluating pain as a vital sign. The idea caught on nationally like wildfire, spurred by early adoption by the Veteran’s Health Administration (VHA) and The Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Pharmaceutical companies actually sponsored JCAHO to promote the movement. Soon after that, the aggressive treatment of pain with opioids was given greater potential for abuse by the Centers for Medicare and Medicaid Services (CMS) through the governmental implementation of a patient satisfaction survey called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Patients were asked to rate their care including the complete relief of pain as part of the survey which creates an incentive to over-treat if as many organizations have done, tied practice ratings to financial reward. These parameters are hard wired into our current national health care system. No amount of medical education and training is going to speak louder than suggesting to clinicians they can expect higher salaries if they avoid disagreements with patients demanding narcotic analgesics. A major factor in the creation of the opioid crisis is the unintended consequences of federal legislation.
Finally, there were the pain management specialist clinics or “Pill Mills.” There is no doubt some physicians were irresponsibly prescribing opioid narcotics for financial gain and were greed-driven and irresponsible. I was living and working in Florida Emergency Rooms redirecting patients to pain management clinics and the newly minted “pain management specialists” during the first decade of the 21st Century which ultimately culminated in the DEA sweeping in to shut down over 250 such practices. It is ironic that I was a relative under-prescriber in the midst of treating some of the most acutely injured (emergency physicians prescribe about 5% of all opioids). Many of those arrested, convicted and serving sentences currently were the business owners who recruited corruptible physicians into dubious practices and Florida was full of such characters in those years. My standard response when one of these enterprising entrepreneurs approached me at the gym with creative easy-money propositions of this sort was “I already have a job, I’m an emergency physician.” I’ve always been suspicious of businessmen that made or make their fortunes running lucrative healthcare organizations. Yes, some physicians played a role in creating the opioid crisis, but why did the Governor of the state veto a “Pill Mill Bill” designed to attack illicit and legal narcotics sales in a state devastated by opioid addiction. Could some legislators have a hand in creating and perpetuating the opioid crisis?