Make doctors precisely explain why they are prescribing opioids and why they decided on the pill count and refill allowance for each patient.
Recently, a friend’s teenage daughter underwent a procedure common for young adults: she had her wisdom teeth extracted. I had the same procedure performed in the late 1990s, at age 20. Back then, I was given a bottle of ibuprofen for the pain and, for the bleeding, told to apply tea bags. My friend’s daughter was given something just a tad stronger:
A teenager was given a strong opioid painkiller to numb the pain of a routine tooth extraction. It’s absurd that this is the accepted medication for this procedure when there are no complications, nothing that would indicate breakthrough pain on a level of requiring a narcotic that is given to cancer patients.
However, the fight against opioid abuse is finally gaining promising victories by wielding an effective weapon: lawsuits.
Holding Big Pharma Accountable
As the epidemic grew, many – myself included – called for state and local authorities to take drug companies to court for knowingly encouraging large-scale consumer usage of highly addictive prescription painkillers such as OxyContin, Vicodin and Percocet. Thousands of lawsuits have now been filed and in August, the $572 million decision won by Oklahoma against Johnson & Johnson became the first large-scale trial ruling concerning Big Pharma’s role in creating the opioid crisis. The state argued that J&J, which had supplied 60% of the opioids drug makers used for painkillers, aggressively marketed the drug to doctors and patients as safe.
They lied, we died, and now they have to pay up. Hopefully these are just the first few drips in an oncoming flood of restitution owed Americans by companies responsible for an unprecedented addiction crisis. They deserve whatever fates come their way – criminal, civil, or, as the 800-pound spoon left at Johnson & Johnson’s headquarters intended, shame-filled.
Now, as the overdose death rate shows signs of ebbing but has by no means abated – 68,000 Americans died in 2018 compared with 72,000 in 2017, hardly cause for celebration – it’s time to ask what’s next.
For years, drug companies pushed opioids as a panacea for all things pain-related. The result was an absolute avalanche of prescriptions: 191 million in 2017 alone, which averages to 58 opioid prescriptions for every 100 Americans. And despite guidelines intended to discourage opioid painkillers as a first-step approach to easing pain, primary care clinicians – most patients’ initial gateways to healthcare – wrote 45% of all opioid prescriptions.
Surgeons also have been implicated in widespread overprescribing. One study of nearly 20,000 surgeons, led by Johns Hopkins School of Public Health researchers, noted the common practice of prescribing dozens of opioid medications even for low-pain operations. Some prescribed over 100 opioid pills for the week following a surgery, along with usage instructions far exceeding guidelines from several academic medical centers. No wonder some six percent of all patients prescribed opioids post-surgery become dependent.
The diagnosis is simple: Doctors have proven incapable of, or unwilling to, exercise responsible discretion in determining which conditions and medical procedures necessitate painkillers notoriously linked to addiction, misuse, and overdose.
A Painful Backlash
Complicating matters, the opioid crisis has become a two-way street.
In response to the backlash to the initial opioid free-for-all, many doctors have become so wary of prescribing opioids that those who truly need them are unjustly suffering. Much of this hesitancy is a reaction to guidelines issued by the Centers for Disease Control in 2016 that, according to Richard Lawhern, founder of the Alliance for the Treatment of Intractable Pain, has subjected patients with legitimate chronic pain to a “draconian reduction” in doctors willing to meet their needs with opioid-based medication.
The problem with the CDC’s directive was vagueness of language. The guidelines state that opioids are appropriate for pain caused by cancer, end-of-life care, and “palliative care.” But “palliative” is a subjective term, and therefore confusing for doctors who, understandably, now have their guards up against malpractice suits in addition to opioid addiction and abuse. In a February 2019 reiteration of its guidelines, the CDC clarified that opioids are reasonable for chronic pain but, unfortunately, repeated its ambiguous wording concerning specific conditions.
However unintended, the result is patients who rely on opioids for legitimate medical reasons suffering for the sins of Big Pharma and, subsequently, the incompetence of government officials and the inadequacies – including cowardice – of doctors.
The scale of the crisis and forcefulness of the backlash also has resulted in patients who, through no fault of their own, became dependent on opioids and, at the drop of a guideline, found themselves completely cut off from a highly addictive drug and dropped into a hellish withdrawal. The unsurprising consequence of this overreaction by doctors is patients turning to the streets for unregulated, often fentanyl-tainted heroin. Any laws written to specify opioid painkiller administration must include reasonable ways of relieving already-addicted patients through treatment centers and weaning agents like methadone and buprenorphine (suboxone).
However, the conviction permeating the chronic pain community – that doctors rather than laws should be the primary determinant of opioid prescriptions – simply doesn’t hold water. It’s become clear that doctors don’t necessarily know best. We need rules that hamstring the parasitic overprescribers while unhandcuffing the paranoid underprescribers.
Guidelines Aren’t Enough
It’s time for legislators to take the mystery out of this branch of medicine. If doctors can’t stop writing opioid prescriptions to those who don’t need them, or refusing to write prescriptions for those who do, then we must enact laws with clear prescribing instructions.
We’re all familiar with mandatory sentencing guidelines; we need mandatory dispensing guidelines – laws that bring harsh punishment for overprescribing pain medication when it’s not indicated, while reassuring doctors that they will not be unfairly punished for providing chronic pain patients with the relief they require.
The time has come for customized ailment and procedure-related opioid painkiller dosing laws, complete with extensive medical rationale requirements. Make doctors precisely explain why they are prescribing opioids and why they decided on the pill count and refill allowance for each patient.
We also need to look at something else: ourselves. Especially in post-surgery settings, the opioid overprescribing epidemic was exacerbated by the naïve, altogether modern notion that patients should never feel discomfort or pain.
If alternatives to opioids don’t kill 100% of post-procedure pain, the new one-word answer should be “tough.” The idea that we can go through life without ever experiencing pain is not only delusional but, as we’re seeing, destructive. Things heal. Patients will need more, well, patience.
Numbing people literally to death is not the answer. It is irresponsible and dangerous to prescribe opioids for an ingrown toenail. Or for carpal tunnel syndrome. Or to a child following a tonsillectomy or, of course, a teenager after a tooth extraction.
On the flip side, it is cruel and flat-out stupid to deny patients with serious chronic pain access to a now-demonized family of medicines that for many has meant the difference between functioning and debilitation.
The time for general guidelines is behind us. We need strict, specific statutes that greatly diminish doctors’ discretion while placing transparency and responsibility squarely on their shoulders.