Is the United State’s opioid epidemic partially a result of the structure of its healthcare system? (Final Version)

By Alex Seibel

Washington- When Travis Rieder got into a motorcycle accident nearly two years ago, there were two concerns on the minds of his doctors: saving his foot with emergency surgeries, and treating his debilitating pain with the opioid drugs at their disposal.

The doctors were professionally obligated to prescribe him oxycodone to ensure that Rieder did not suffer unnecessarily. Unfortunately, the same sense of obligation was not there for ensuring that Rieder would know when and how to reduce and stop his dosage, with the only advice he was given resulting in what he described as his month in withdrawal hell that was worse than the accident and surgeries.

Rieder, assistant director for education initiatives and research fellow at the Johns Hopkins Berman Institute of Bioethics, recounted his harrowing brush with opioid dependence in the January issue of Health Affairs, and how at least ten doctors failed to advise him in how to quit taking the drugs in a way that would help him avoid suffering the effects of withdrawal. Rieder, through his experience and in his research since, has come to recognize his doctor’s inability to help him get off opioids after prescribing them as an ethical failing.

“This can be seen simply as a specification of the Hippocratic dictum to ‘first, do no harm.’ By prescribing a drug that has predictable harmful effects without a plan for dealing with them, a physician is at least partially responsible for causing those harms,” Rieder wrote in the Health Affairs article.

The role of drug manufacturers in helping to cause the opioid epidemic has been a frequent subject of headlines. There was Purdue Pharma’s 2007 prosecution in federal court over misbranding their opioid drug OxyContin as being less addictive than it really is, resulting in a fine of $600 million. More recently, McKesson Corporation and Cardinal Health were respectively fined  $150 million and $44 million for failure to adequately monitor and report suspicious orders of their opioid drugs made through pharmacies. The Center for Public Integrity reported late last year that drug companies have used lobbyists and funded seemingly independent advocacy groups in order to fight prescription limits of their drugs in statehouses throughout the U.S., and that D.C. lawmakers and regulators have also been subjected to heavy lobbying in favor of the use of opioid drugs in treating pain.

Rieder says that, while “pharmaceutical companies certainly didn’t have their hands clean” concerning the cause of the crisis and that their direct marketing to doctors helped influence the prescription of opioids, that the view that some activists have of the companies being a sole cause is somewhat misguided. Expectations placed upon doctors to treat pain by the consensus of the medical field in the 90s onward have also played a large role, according to Rieder. A 1997 article in the American Journal of Nursing identified pain as “the fifth vital sign”, due to the fact that pain can get so severe in some patients that quality of life is severely reduced, sometimes to the point of causing suicidal thoughts and actions.

“Right at the same time that we have this influx of heavily marketed really powerful sustained release opioids you also have a medical field that is now telling its doctors ‘you’ve been undertreating pain for decades and you have been torturing your patients”, Rieder said, and that this “pushed doctors into a situation where they weren’t trained to prescribe these opioids or to manage them with any kind of care.”

Rieder wrote in his Health Affairs article that the two pain management teams that handled his case were only prepared to prescribe medication, not help patients withdraw off of them, and cited the finding of Judy Foreman that there is little to no formal training in U.S. medical schools for pain management.

This appears to be changing thanks to the CDC issued “Guideline for Prescribing Opioids for Chronic Pain” that provides doctors and other medical professionals with guidance on how to prescribe these medications to patients and how to determine when to help them get weaned off. The Association of American Medical Colleges and the American Association of Colleges of Nursing have both written pledges signed by medical and nursing schools throughout the country to improve education and training of students in utilizing opioid drugs in patient treatment.

Dr. Peter Liepmann, a family physician who wrote a Health Affairs article in response to Rieder’s account, is skeptical that such measures are enough to address the sort of issue that Rieder faced in his treatment. Liepmann wrote that the problem is primary care doctors, who assess a patient’s medical issues as a whole as opposed to the other specialists that focus on certain aspects of a patient’s care, do not spend enough time with patients due to how insurance payment policy makes longer primary care visits expensive for medical facilities and favors sending patients to specialists instead. This lack of time with a patient’s primary care doctor means it is easier to miss a problem with a patient’s opioid drug use, according to Liepmann.

“Insurance companies set prices and make health care payment policy, based on what’s good for insurance companies, not what’s good for the nation. Hospitals and health systems provide services based on what’s profitable,” Liepmann wrote.

“Primary care is the basis of functional health systems, the U.S. is built on hospitals and specialty care (instead), so that is why costs are high,” Liepmann said.

Like Rieder, Liepmann is hesitant to place all the blame on pharmaceutical companies for the opioid epidemic, though he does say that the various medical industries in the U.S. have a lot of influence on healthcare policy to their own benefit rather than that of patients. One of the problems with trying to address the opioid crisis is that drugs which can help alleviate symptoms of opioid addiction and withdrawal in individuals are expensive in part because of the ability of drug companies to influence policy regarding pricing. A month’s worth of Suboxone treatment can cost $1,100 dollars, according to Liepmann.

“It’s ungodly expensive, and you know there is this battle going on between drug companies and the insurance companies… you’ve got the big health systems, you’ve got the big health insurance companies and big pharma; you’ve got Godzilla, Gargantua and King Kong duking it out in New York City knocking big buildings over, and you know we are running around in the streets trying not to get stepped on,” Liepmann said.

The relationship between opioid and heroin addicts that get started on an addiction or dependence from a legitimate doctor’s prescription is unclear, according to Rieder, but there has been clear correlation between use of opioid medications and later use of heroin. Rieder cited one study which found that non-medical use of opioid medications preceded future heroin use at a rate of 89 percent, and the source of said medications was either through family, friends, or personal prescriptions.

It wasn’t until three months after Rieder’s accident and surgeries that one of his surgeons noticed he was still taking the drugs and advised him to start getting off them, according to Rieder’s Health Affairs article. Rieder said that one study found that 6 percent of patients that go to a doctor for a minor to moderate procedure and are prescribed opioids are still taking those medications three to six months later.

“That’s a really kind of shocking statistic because we don’t expect most people to be on regular opioid use three months after a minor procedure, I mean I was getting weaned off three months after a basically catastrophic set of procedures, so that was really striking,” Rieder said.

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