Opioids: The Poster Child for Corruption in Health

The sudden death of the King of Pop, Michael Jackson, and the recent judgment against his  physician, Conrad Murray, holding him responsible for his death, illustrates how corruption in healthcare can turn “do no harm” into a jail sentence. The field of pain management has been the target of similar corruption; “Pill Mills” and “the Oxycontin Express” have been highly publicized as phenomena related to the poorly regulated controlled substance practices in Florida.   This corruption has unfortunately hindered the proper management of chronic pain patients in some cases, as doctors have become hesitant to quickly prescribe.

Chronic pain is a significant disease category, in terms of its incidence and cost.  The Institute of Medicine of The National Academies estimates that approximately 116 million Americans suffer from chronic pain and direct health care costs and indirect costs including lost productivity, totals approximately $560 to $635 billion annually[1].  Effective treatment of chronic pain is essential to lower the burden of this disease.   However, effective treatment often requires the use of opioid medications, controlled substances that can be abused and diverted. The nature of these medications, coupled with regulatory loopholes in the state of Florida, has allowed “Pill Mills” and the “Oxycontin Express” to emerge.  In addition,  recent alarming trends in deaths due to prescription drug overdose, opioid medications have caused them to become highly stigmatized[2].  In effect, and to the detriment of patients opioid medications are under-prescribed by doctors who fear feeding “the monster”[3].

The past 15 years has seen an increase in regulatory policy development in an attempt to prevent the abuse of prescribed opiates, yet their focus on criminal investigations and prosecutions of physicians has unfortunately escalated their reluctance to prescribe[4]. Policies that demonize healthcare providers effectually compounds the problem of the under treatment of chronic pain. The Risk Evaluation and Mitigation Strategies (REMS) program is a recent major initiative by the Food and Drug Administration (FDA), that shifts the focus from demonizing individuals to informing them, by requiring the education of practitioners and patients prior to the prescription of opioid medications in an attempt to promote appropriate and effective prescribing practices.  Research has shown that despite the REMS program, the unwillingness of a substantial proportion of physicians to prescribe opiates will persist9. Therefore, despite the scale of this policy initiative (REMS), its impact on the burden of chronic pain may fall short.

The question remains, is there a policy initiative that can help to rectify the losses the field of pain management has suffered as a result of the corruption opioid drugs has been involved with?  I say, yes.  Education, healthcare, and government are meant to work systematically to produce positive health outcomes, yet for chronic pain and opioid use, this system has failed.  The number of primary healthcare providers far exceeds the number of board certified Pain Management Specialists, who are well versed in appropriate opioid administration[5].  With limited availability of these specialists, physicians who are undertrained in the field are treating, and prescribing opiates for many chronic pain patients.  This practice was compounded when the Joint Commission on Accreditation of Health Organizations set as an initiative the endorsement of the effective treatment of pain in the 1990’s[6].  Due to this strong initiative an influx in the prescription of opioids for the treatment of pain occurred and created an artificial confidence in prescribers of opioids. Therefore one problem is matching the supply of Pain Management Specialists with the demand for opioid therapy, possible via increased fellowship opportunities at academic institutions.

Furthermore, currently the Drug Enforcement Agency requires the licensure of controlled substance (including opiates) prescribers.  However, this licensure is granted to any medical doctor, who applies, that has passed all three steps of the United States Medical Licensing Exam[7].  As discussed earlier, Pain Management Specialists are specifically trained in the appropriate administration of opioids, yet they carry the same licensure as those without this specialization.  Since the abuse of prescribed opioid medications is a persistent and serious problem, inefficiency of controlled substance licensing practices may be considered problematic.

The persistent under treatment of chronic pain and prescription opioid abuse signifies that it is urgent that significant policy reform be implemented.  Corruption related to opioid pain medications has certainly created a catch-22:  arguably the most effective tool to improve the outcomes and burden related to chronic pain is the effective prescription of opioid medications, which is the very tool that healthcare providers are hesitant to prescribe due to the potential for abuse and misuse.  Physicians who think, “You’re damned if you do, and you’re damned if you don’t”, are not too far off from reality when it comes to effective pain management.

[1] Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.

[2] Goldberger, B.  (2011).  Drug Overdose Deaths-Florida 2003-2009.  JAMA; 306(12): 1318-1320

[3] Dews, T., Mekhail, N.  (2004).  Safe use of opioids in chronic noncancer pain.  Cleveland Clinic Journal of Medicine; 71(11): 897-904.

[4] Gilson, A., Mauer, M., Joranson, D.  (2007).  State Medical Board Members’ Beliefs About Pain, Addiction, ad Diversion and Abuse: A Changing Regulatory Environment.  The Journal of Pain; 8(9): 682-691.

[5] Breuer, B., Pappagallo, M., Tai, Y.,  Portenoy, R.  (2007).  U.S. Board-Certified Pain Physician Practices: Uniformity and Census Data of Their Locations. The Journal of Pain; 8(3): 244-250

[6] Dahl J, Pasero C, Patterson C.(2000). Institutionalizing effective pain management practices: the implications of the new JCAHO pain assessment and management standards. Program and Abstracts of the 19th Annual Scientific Meeting of the American Pain Society.

[7] US Department of Justice. Drug Enforcement Administration. Office of Diversion Control. Registration Procedures. Accessed on Oct 29, 2011 from: http://www.deadiversion.usdoj.gov/drugreg/process.htm


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