I need some help from my colleagues. I have been studying what I will refer to as the opiate panic that started in 2016 with the CDC’s decision to provide “guidelines” to general practice physicians treating pain. I must say, at the time, I did not object to these. I always like hearing the opinions of others, and that’s exactly what this advice was… opinion, not evidence-based fact. Opinions are like religions; they hurt no one and may help many unless enforced by law, at which point they do tremendous harm.
Please understand that while I have continued my scientific studies, I would be much happier designing and building biomedical devices than crunching numbers. Since we should always exercise our weakest aspects of body and mind, I tackled opioid prescribing vs overdose deaths from 2006 to 2022. First, I wanted to see about the increased prescribing of opioid medications after medical societies and learned healthcare professionals convinced us that it was not good to let people die screaming in their beds.
I lived through this paradigm shift and remember it well. I had just transitioned from needing to know all about nuclear-armed rockets for US Space Command, just in case, of course… I need to learn all the technical specifications and maintenance requirements of human beings so I could be a doctor. I can tell you right now: I will take Tsiolkovsky’s elegant equation over Kreb’s cycle any day. So there I was in 1993, all bright and shiny, with hair, ready to understand my chosen profession that I had fought to achieve since I was about ten years old.
My alma mater was Mayo Medical School, now the Mayo Clinic Alix School of Medicine. Named for Jay Alix, who was kind enough to part with a $200 million dollar donation. I’m sure they have a staple with my initials on it somewhere in honor of the tuition I paid. Mayo has the lowest acceptance rate of any medical school in the country, around 2%, they say, but the year I applied, there were over 6000 applicants, with only 40 selected, and two of those were dentists. Maybe it was a clerical error or perhaps the uniform, but I got in.
Perusing my transcripts, I see that 1) I should have taken the digestive system much more seriously, and 2) we did not get a lot of training in pain, and nothing on addiction. Year one involved a lot of basic science, but at Mayo, we also met patients right away. When learning about phenylketonuria, a patient with the disorder was kind enough to chat with us. This was a wonderful way to learn as we remember individuals and their stories much more than we do dry statistics and textbooks. But we met no severe chronic pain patients… or addicts.
Years one and two had no class dedicated to either pain or addiction, while year three had a palliative medicine course. Palliative medicine is often associated with end-of-life care, but it is not limited to this domain; at least, it should not be. All severe chronic pain treatment is palliative in nature. Year four had another palliative course, and that was it. As I cycled through each branch of medicine, I found they all had developed their own habits when it came to pain treatment. And they did not always agree.
The first of these and the ones with the least compassion for pain were surgeons. As a necessity of their profession, surgeons must look at the most horrendous injuries and conditions and say, “I should cut right there.” This detachment requires an almost superhuman ability to suppress usual human reactions. It is a well-known fact that those with psychopathic tendencies are drawn to a few professions. Surgeons, lawyers, and CEOs are the top three.
There is a good reason for this. Psychopaths are not an evolutionary error. People with this variant of normal human behavior can be very productive, handling stress and life-or-death decisions better than the rest of us usually. I’m not saying in any way that all or even most surgeons are psychopaths. However, I do think this profession has adopted that behavior pattern as a model.
They are actually less likely to kill someone, as emotions like jealousy and rage are most associated with this crime. But psychopaths are like Marines. When they go bad, the body count is high, and people remember that. I am not suggesting that all surgeons are psychopaths, or even that most of them are. Non-psychopaths in medicine must learn to adopt the emotional blunting that is necessary to function in the critical care environment. I can tell you that as an ER doctor, I saw much more carnage than I did in the Marines, and while I learned to tolerate it, some patients still haunt me. Decades later.
Surgeons will treat you while you are in the hospital, but they will not compromise their ability to assess your medical status for your comfort. That can be taken to an extreme, and the nudge to at least lower the volume of those crying out from pain was reasonably well received. This was not least because, after doctors had been targeted in the ’70s and ’80s for treating “addiction,” a word synonymous with dependence at that time, they appreciated a little cover to be humane. Surgeons adjusted in-hospital treatment but not much else.
The ER doctor sees more and a greater variety of acute, subacute, and chronic pain patients on a regular basis than any other medical specialty. Much more than the anesthesiologists who now dominate the pain treatment sector, I would argue. And we were trained to be adept at rapidly getting pain under control without compromising patient safety. Woah, unto the ER resident that gets a neurosurgical patient comfortable enough to sleep before the surgeon has seen them, but overall, we have quite a bit of latitude and discretion, or at least we used to.
ER, doctors must now worry that treating a child with a terrible burn with a few milligrams of morphine will see them sued eighteen years later if that person develops an addiction, as some attorney “proves” to a medically naïve jury that the first dose of opiates set them on a clear course of destruction. I dare you to argue otherwise. Emotions will stomp your logic and data any day. But the real problem with ER doctors is what we were taught about addiction. Or, more accurately, what we were mistakenly taught.
The diagnosis of addiction seems simple at first glance. If you can’t live without something and might kill to get it, then you are addicted. But, of course, most of you feel that way about oxygen. You want it, you need it, and when I try to take it away from you, you get violent. So, while we need to be a little more precise, the ER is still where we must save lives with limited time and information. But just the same as I won’t diagnose you with Ehler’s Danlos in the ER, I shouldn’t diagnose you with addiction, but leave that to those with more time on their hands.
Now, I could diagnose you with substance use disorder, but even that requires a bit of history that the ER may not have time for. Sticking to drug use or abuse, naming the specific drug would be a lot smarter. But many ER physicians take it upon themselves to throw the diagnosis of addiction or “drug seeking” into a chart. Guaranteeing that almost no physician can ever treat your pain again. Even though the Department of Health and Human Services says it is legitimate to treat pain in those suffering from addiction, Dr. DEA says “No.”
Once the paradigm had shifted to symptom-based pain treatment, the whole fifth vital sign thing, using the 0 to 10 metric, prescribing loosened up quite a bit, and prescriptions for opiates increased slowly until 2010, when it peaked. What happened in 2010? Nothing really. Over the intervening decade and a half, data showed that we had perhaps loosened up a bit too much, and the medical scientists and associated societies updated our training and the rate of prescribing started to drop.
Between 2010, when reasonable physician-led autocorrection started, and 2016, when the CDC issued its “guidelines,” the total prescribing rate had dropped by 13%. But wait! The DEA charts show that prescriptions kept going up! Indeed, they did—in total, but not per capita. While doctors were being more circumspect, we still had an ever-increasing elderly population. Something not known to reduce pain incidence. While prescriptions increased by 12,002 over that period, the US population went from 311,182,645 to 324,607,776, an increase of 13,414,931. It’s the little things that almost trip us up.
Now we come to 2016 and the issuance of the CDC guidelines. I have seen recorded videos of federal officials saying how much they really needed a prescribing “speed limit” so they could more easily prosecute doctors, as if patients were as regulated as cars and pain was a nice smooth highway. The CDC obliged and came up with its recommendations. These were quickly instituted into health insurance mandates to physicians because, let’s be real, fewer medications prescribed equals more money in their pockets. They don’t care about our pain unless it affects their bottom line or stock price.
From 2016 to 2022, I show the prescription rate dropping from 0.657 to 0.390 per capita. That’s a drop of 41%. And since opiate prescribing was the cause of the opiate epidemic, according to the DEA, that should have corresponded with a drop in opiate overdose deaths from its 2016 level of 42,249 to 25,061. That’s great, and we can give them an award, right? Sadly, the death toll climbed to 79,770 instead. But where could they have gone wrong? They stomped every pain doctor near the opinion-based speed limit. Why didn’t that work?
What went wrong is that rather than review the evidence, form a hypothesis, test the hypothesis, and institute a policy, the federal government jumped straight from opinion to enforcement. This might be okay if we were talking about video games or TikTok, but we aren’t. We are talking about flesh and blood human beings suffering from the most terrible conditions known to science. Spinal and vertebral injuries, neuralgias including complex regional pain syndrome, ankylosing spondylitis, and genetic pain syndromes. Humans don’t tolerate agony well.
For every diagnosis, there is a unique human being suffering and deciding whether or not to live another day. For many of these people, opioids are the only thing that gives them some quality of life. Now granted, these medications can be dangerous if abused or misused, but what prescription medication is not? Antibiotics killed about 3,800 per year in the US, and NSAIDs 16,500. That’s right. More people died from NSAID-related GI bleeds than heroin in 2021. But what is everyone telling us to use instead of opioids? NSAIDs and antidepressants.
Starting someone on an antidepressant is associated with an increased risk of suicide for the next couple of months; it’s right there on the box. Taking someone off opiates is associated with an increased risk of suicide, too. In fact. A study conducted in 2020 found that of 2,887 overdose and other suicide-related deaths evaluated, 57.4% were related to opioid treatment being stopped. Those figures didn’t count pain-related alcohol deaths. And the doctors can’t win no matter what they do.
A physician in Kentucky was successfully sued after a veteran, Brent Slone, had his pain medications stopped and texted his wife, saying he could not tolerate the agonizing pain before taking his life. Other studies have shown that stopping benzodiazepines if someone is on opiates, something many physicians have been prosecuted for, is associated with a 1.6 increase in death rate compared to just leaving them on. And as I’ve said. No one wants to experience horrible pain day after day. Now, I am no dedicated number cruncher, just a sometimes-humble rocket scientist and physician.
But it looks to me, from my analysis, like the US federal government could be responsible for a lot of dead people. This won’t come as a surprise for those of native American or foreign extraction, I suppose, but in those times, it was on purpose. This time, it was just ignorance… wasn’t it? I would hate to think they were doing it on purpose… Again. Like Tuskegee. The 2023 DEA budget request is $3.1 billion, and the BOP has requested another $8.2 billion, so they can continue doing exactly what has NOT worked over the last half-century.
We need to demand that at least $1B per year be made available to evidence-based medicine practitioners for the study, treatment, and rehabilitation of those who suffer from addiction and the education of physicians treating them. No more elevating a few extreme opinions as THE standard by which all physicians and medical providers are judged. And let’s also stop denying that the federal government is dictating the practice of medicine and start enforcing the law that forbids them from doing so, before we lose another hundred thousand to overdose and millions more to incarceration.
