OPIOID/NARCOTICS Epidemic 2017

I have written this piece in various forms for at least 15 years now. What I mean is this: I have written/ spoken to CO County and State Medical societies, to Boulder Community Hospital administrators/”patient representative”/ Physician and Nurse colleagues. to the main Physician malpractice insurer in CO (COPIC), to columnists at the NYT and the Boston Globe newspapers,  as letters of response to news pieces in NYT, Boston Globe, Denver Post, 9 News, as a very occ. response to  Physician/Nurse/PA/EMS friends and colleagues who would post on Social Media sites, and MANY MANY personal conversations w/ work colleagues, friends and family.

I started saying, in 2005, the following: This is going to be the absolute worst public health disaster of my career in Medicine, and likely of the century, in this country. This is already killing people at an alarming rate ( this in 2005!), and it is going to get much worse. I am shocked, dismayed, and cannot believe what I (  actually “we”, meaning all of my work colleagues) are seeing here. This is medically, ethically, statistically, and morally completely bankrupt.  I said to friends ( and sugg. to several prominent Journalists) that this will go down in history as an iatrogenic atrocity – I said that it would surpass the AIDS crisis that I witnessed in my earlier medical career in the 1980s in Cambridge and Boston, MA. I urged the Journalists to start a study of what is going on, told them that someday a definitive history of what actually happened here would be written ( as it has been about mgmt. of the HIV epidemic in this country). I even considered starting the book myself ( yes, in 2006)! However, it seemed an overwhelming project, US Federal and State agencies and the  Patient Pain advocacy lobby  were just too powerful in their encouragement and exacerbation of this situation.                                                                        Here are my observations and comments from being in the epicenter of the Opioid/Narcotics Epidemic in this country for > 15 yrs., as a Health Care Provider:

    • In the very early 2000s, Federal and State agencies started an aggressive campaign to “encourage” Doctors and Nurses to prescribe previously unheard-of doses of narcotics to patients w/ any type of pain.
    • This campaign involved the usual techniques of marketing. Huge colorful signs were placed all over the Hospitals, which stated: “PAIN is the 5th VITAL SIGN! If you or your family member are having pain, tell the Nurse immediately”.  Nurses were made to ask many times of patients: ” Are you having pain? What is the level of your pain on a Scale of 1 to 10?” They were then instructed to call the Doctor on-call to get narcotics prescribed in whatever doses the patient reported they needed.
    • We were required to attend ( mandatory!) “Educational conferences” by the Hospital/Clinic administrators and by our medical malpractice insurers. This is what occurred at these conferences:
      • A “Physician”, Hospital administrator, and/or  Medical malpractice insurer executive would stand at the podium and deliver the same speech again and again
      • We were told that we Doctors, Nurses and Pharmacists were significantly undertreating patients’ pain. We were told that our prescribing rates for narcotics/opioids were very low, and that it had been determined ( by these organizations) that we were inappropriately fearful of prescribing these drugs. We were told that when we did prescribe them, the doses and durations of treatment were very inadequate.
      • We were shown slides that stated the following ( supposedly w/ “scientific data” supporting these claims): that there were 3 types of patient response to narcotics: Group 1 – pts who exhibited relief of their chronic pain when the narcotics doses were escalated to “appropriate” levels ( invariably massive doses, and often in lethal dose range) w/out any signs of addiction; Group 2 – pts who exhibited relief of their chronic pain w/ doses as described above, but/and had signs of “physiological dependence” w/out addiction; Group 3 – pts who exhibited relief of their chronic pain w/ doses as described above, but/and had signs of addiction..  We were told that Group 3 was very rare, thus our fears of prescribing these drugs were unfounded.  I distinctly recall being mystified by what I was hearing, and watching the other doctors in the audience expressing varying degrees of same. When a Doctor, Nurse, or Pharmacist would ask the lecturer for data, references, critical discussion, the answers would be vague, lacking the usual well-controlled and peer-reviewed studies. We would be chastised and told that we were not being compassionate. We would be looking at each other in the audience and shaking our heads… My teaching in Medical School, and my experience w/ seeing patients, was that these were, in fact, high-risk drugs. That sparing, cautious use was appropriate. I couldn’t accept that what we were being told was accurate.  We were also showed examples of malpractice awards made by juries to patients, against their Physician who refused to prescribe massive doses of narcotics. I specifically remember them citing a case in California.
    • The next phase of the campaign to get Physicians, Nurses, and Pharmacists to prescribe these massive doses of narcotics was promulgated by the Joint Commission on Accreditation of Hospitals. The Commission began to aggressively assess “patient satisfaction” scores as a critical part of their process of accrediting hospitals. Hospitals, fearful of receiving temporary/contingent accreditation. or losing accreditation altogether, increased their “education” of Physicians, Nurses, and Pharmacists. At my local hospital, we were required to attend periodic meetings w/ the Hospital-employed Patient Representative. She would always say the same things: “The most common patient complaint I get is that  pain is not adequately treated”; graphs would be presented w/ the Nurses and Physicians who had the most patient complaints around refusing narcotics dose escalations – they were reprimanded, disciplined, and in some cases “terminated” . We were all disheartened, became cynical. A huge body of “Black humor” jokes became prevalent amongst staff in the ED, the Hospital floors, etc.. We all knew, quite clearly, that these policies were killing people.
    • As the epidemic progressed over these > 15 years, I noticed the following:
      • We became used to admitting  “pain” patients on huge doses of prescribed narcotics over and over again w/ the following: recurrent, complicated, and increasingly antibiotic-resistant aspiration pneumonias ( d/t their decreased consciousness, and inability to clear their airway normally); recurrent fractures ( skull, spine, long-bone) d/t recurrent falls caused by their narcotics doses; recurrent life-threatening blood clots d/t immobility and hypercoagulability caused by their narcotics doses.
      • We had to start placing all of these patients on continuous oxygen monitoring while hospitalized, d/t their frequent episodes of hypoxemia and decr. consciousness from their narcotics doses ( we would ask each other: What is happening to them when they are at home and not continuously monitored by Nursing staff?!)
      • At the time of discharge, there would be frequent heated arguments between the pt. and the Nurse handling the discharge: How many Oxycontin, Percocet, etc.. would the pt. receive to “tide them over” until they saw their out-patient prescribing Doctor?
      • The EDs of course, were (are) the frontlines of the frequent fatal and non-fatal narcotics overdoses
    • As the death toll dramatically escalated, I noticed a curious phenomenon. Public Health authorities ( and thus the Press) would list the casualties based on numbers of Overdoses. Nowhere do I see an accounting of the deaths due to skull fractures/brain injuries from  falls, deaths due to pneumonia or severe skin and heart infections, deaths due to fatal pulmonary emboli from DVTs of extremities, deaths due to Motor vehicle crashes, etc. etc..
    • Who is keeping track of the many patients who survive the above-mentioned events, but need to be transferred from our acute Hospital care to a SNF because of their catastrophic, hypoxemic permanent brain injury ( many of these people are previously healthy adolescents and young adults)

We are currently ( 2017, early 2018) in the following phase of this epidemic: Various organizations (the Press, people in communities nationwide, et al) constantly report the following: Doctors and Nurses are to blame for this situation – “they administer inappropriately high/lethal doses of narcotics to any patient who asks for them”, and “This was all an organized plan/plot by “Big Pharma” to increase profits by marketing and “pushing” use of these narcotics”. I do not see anyone, anywhere discussing the following:
– The role of the Patient Pain Mgmt Advocacy Lobby in convincing Governmental organizations to force “education” of doctors, Nurses, Pharmacists, Hospital Administrators, to prescribe these massive doses of narcotics to “everyone”
– The role of the Joint Commission on Accreditation of Hospitals in aggressively marketing this strategy in hospitals, financially and professionally administering severe punishment to individuals/organizations who protested
– The role of the above organizations in requesting ( pressuring?) Pharmaceutical Corporations to rapidly and massively escalate production of these drugs ( to ensure a constant and huge supply of them to Hospital Pharmacies)

(This issue incites emotions of outrage, sadness, etc. in me! Therefore, this piece continues to be a work in progress, and not definitively edited!!)