Editor’s Note: Chris Johnson is an emergency medicine physician who practices in the Twin Cities, Minnesota. He is chair of the Minnesota Department of Human Services Opioid Prescribing Work Group and serves on the Board of Physicians for Responsible Opioid Prescribing, as well as the Board of the Steve Rummler Hope Foundation. The opinions expressed in this commentary are solely those of the author.
Story highlights
Chris Johnson says opioid addiction is rampant in U.S. Why?
He says to grow market, pharmaceutical companies began pressing doctors to prescribe opioids for chronic pain
Johnson: Doctors, medical industry needs to focus more on 'patient outcome,' not 'patient experience'
So the recent report from the Midwest Medical Examiner’s Office made it official – Prince Rogers Nelson died in his residence April 21, 2016, from an accidental overdose of the prescribed opioid, fentanyl. He was 57.
In the aftermath of the death of such an iconic figure we are experiencing a flurry of political activity as our elected leaders, both Republican and Democrat, hurry to pass some form of legislation that will help stem the tide of opioid-related death that claimed the lives of some 165,000 Americans from 2000-2014.
Most of the proposals debated last week in Washington – including the compromise package the House approved Friday – aim at improving access to treatment for those who are already addicted.
Medications such as Suboxone (buprenorphine) are proven effective in helping those who are addicted to opioids avoid relapse. Narcan, the opiate reversal agent, can save the life of someone who is acutely overdosing and needs to be in the hands of first responders everywhere.
Improving affordability and access to these and other proven treatments is a must and I am in full support of those measures.
But that alone will not stop this epidemic nor turn back this tide of misery.
Opioids: Addictive painkillers
Because missing in these conversations is an even more necessary and urgent discussion – one that takes a long hard look at the medical industry itself. Where has the “healing” profession been in all this? It is very important to understand how and why this epidemic happened so that meaningful change can occur.
To convey that understanding, I am forced to paint an unflattering picture of the industry that I have been a part of for the last 15 years. I wish I could tell you that this epidemic was due to an honest mistake. That the science was unclear or had mixed results that only later became evident. But I can’t.
There was never good science that these medicines worked effectively in the long term. I also wish I could tell you that the only reason the problem persists is a “lack of physician awareness.” But I won’t. The reason this opioid problem started and the reason it continues is sadly for the most American reason there is – business.
Prior to the 1990s, doctors in the United States had prescribed opioids, such as Percocet or Vicodin, for pretty much the same reasons that doctors in most countries did – for pain resulting from acute injuries such as fractures, and for pain from the tissue damage caused by cancer.
But that all changed in 1996 when Purdue Pharma introduced its new, extended release oxycodone preparation – OxyContin. Instead of just focusing on patients with chronic pain from cancer, Purdue Pharma sought a much bigger market – patients who suffered chronic pain from everyday conditions, such as back and joint pain.
To do this, they recruited and paid experts in the field of pain medicine to spread the message that these medicines were not as addictive as previously thought. This effort was enormously successful and thus was born campaigns such as “Pain as the 5th Vital Sign.” As a physician in training, I remember being told that the risk of addiction for patients taking opioids for pain was “less than one percent.”
What I was not told was that there was no good science to suggest rates of addiction were really that low. That “less than one percent” statistic came from a five-sentence paragraph in the New England Journal of Medicine in 1980. It has come to be known as the Porter and Jick study. However, it was not really a study. It was a letter to the editor; more like a tweet. You can read the whole thing in 90 seconds.
All the authors said was that among the many hospitalized patients who were given a dose of opioid for their acute injury, very few developed addiction. That is all it said. It said nothing about what happens to patients who take these medicines indefinitely.
Yet those few sentences got transformed by relentless marketing into “opiates are not addictive.” Which was as crazy as saying “tobacco is not addictive,” if someone smoked four cigarettes and did not become a chain-smoker. It was blatantly irresponsible medicine. But it worked. Prescriptions soared.
By now, you know that the U.S. consumes 80% of the world’s opioid painkillers while comprising just 5% of the world’s population. And as the sales have increased, so, too, have the overdose deaths and the rates of admission to addiction treatment centers. In 1999, 4,030 Americans lost their lives to accidental opiate overdose. In 2014, that number had increased to 18,893. That is more than six World Trade Centers.
Some of you no doubt are asking: Where have the good doctors been in all this? Aren’t they supposed to be watching out for our safety? The answer to that question is very discouraging, but I can reach no other conclusion after studying and fighting this problem for the last 10 years. The answer is we are right where we have always been – minding the register.
The values currently prioritized by medicine were made explicit to me several years ago. During my annual performance review, my medical director told me: “You know, we are so proud of you for all the work you are doing fighting the opiate prescription problem. But it is such a fine line between increasing the risk of addiction and HCAHPS scores.”
Wow. Every health care professional reading this knows exactly what I am talking about. HCAHPS stands for Hospital Consumer Assessment of Healthcare Providers and Systems. These are “patient satisfaction” surveys and they talk about pain management specifically. Hospitals are required to participate in these surveys and reimbursement is tied to how well they do. Hence, every hospital administrator and department chair is acutely aware of their “score.”
The buzzword in the industry right now is the “patient experience.” This is simply the notion of “customer experience” as applied to health care. Notice that the focus is not on “patient outcome.” Physicians are under enormous pressure to move quickly and generate that positive experience, often with just 12 to 15 minutes to complete a visit.
In such a system, it is no wonder that the prescription pad is used as the solution. There is no time to do anything else.
To solve the opiate crisis therefore requires more than telling doctors to simply “stop prescribing.” The prescription is just the final “output” of a care delivery system that has multiple inputs at multiple levels. These inputs must be addressed if we are going to solve this.
We must change the system that creates the pressures that result in such bad medicine. Time with the patient should actually be valued. And the long-term health of the patient should matter more than “throughput” and “relative value units per hour.”
If this sounds too fuzzy and “Kumbaya” for you, I would point out that this exact sentiment is expressed in the Hippocratic oath. The 1964 version (which I recited in medical school) admonishes us to remember “that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug.”
In America, we are far too heavy on the knives and drugs, and far too light on the warmth and sympathy.
I realize that making these fundamental changes to our health care delivery system will be very difficult. There are a lot of powerful interests with very little to gain by changing the current system. But change must happen. Because the yearly body count due to the opiate epidemic is simply not acceptable.
I believe we can do better. For the memory of Prince and the thousands of others whom we have lost too soon.