• America’s growing opioid problem

    Analyzing nationally representative data on ambulatory visits, Joseph Frank, John Ayanian, and Jeffrey Linder (Archives of Internal Medicine, 2012) illustrated the recent growth in opioid use, in both absolute terms and as a proportion of those with diagnosed substance use disorders (SUDs). A large minority (36%) of SUD patients go untreated by either pharmacological or psychosocial therapeutic means.

    Opioid use growth is facilitated by the health system. In NEJM last week, Anna Lembke wrote,

    Sixty percent of the opioids that are abused are obtained directly or indirectly through a physician’s prescription. In many instances, doctors are fully aware that their patients are abusing these medications or diverting them to others for nonmedical use, but they prescribe them anyway. Why?

    Among the reasons she provided are: “[t]he ‘all suffering is avoidable’ ethos” and that “it is faster and pays better to diagnose pain and prescribe an opioid than to diagnose and treat addiction.” She concluded,

    [T]he problem of doctors prescribing addictive analgesics to patients with known or suspected addiction will be solved only when the threat of public and legal censure for not treating addiction is equal to that for not treating pain and when treating addiction is financially compensated on a par with care for other illnesses. The former will occur only when addiction is considered a disease by medicine and society, for only then will it be treated as a legitimate object of clinical attention. The latter will occur only when time spent with patients is valued as much as prescriptions and procedures.


    • While the article in NEJM is very interesting, and presents data that although shocking, are probably only the “tip of the iceberg,” so to speak. However, the proposals for curbing the problem — viewing the prescribing physician as the culpable party (which in some cases is true) –demonstrates the profound ignorance of the authors of the environment in which those physicians practice, and the consequences the suffer for questioning the pain diagnosis and attempting to NOT prescribe the opiods.

    • It is very easy for ivory tower research doctors who havent treated patients in years to angrily wag their finger at the physicians down in the trenches and shout SHAME ON YOU from their thrones.

      Even though they have a good point that doctors overprescribe narcotics, angry rants from on high dont fix the problem. I’d like to see what these academics do if their job was determined by the “patient satisfaction rating” that the docs in the real world have to deal with.

      Get rid of ridiculous “patient satisfaction” ratings will certainly help.

      I’m also amused when everybody yells about doctors overscripting narcs, yet on the other hand we allow NURSES with one quarter the training of physicians to write for any narcotic they want with zero oversight or supervision from a doctor. The number of people writing narc scripts should be decreased, not loosened up for anyone with a nursing degree to do.

    • I have to say that I completely disagree with the sentiment of the post. Obtaining opioids for legitimate purposes is much harder in the USA. Physicians don’t prescribe enough opioids. Too many physicians in the USA seem to have a ‘tough guy’ puritanical attitude.

      From a recent nyt article:
      Researchers who surveyed more than 3,000 cancer patients found that nearly two-thirds said they were in pain or receiving pain medications. Roughly a third felt they needed more painkillers to fully treat their symptoms.A month after the patients saw their oncologists, the researchers again asked the patients about their pain. Instead of showing improvement, the percentage of patients who continued to be in pain remained unchanged.Their pain, in other words, had not been treated.

      The findings are a sobering echo of research from nearly two decades ago that revealed that more than 40 percent of cancer patients did not receive adequate treatment for their pain. While patients were reluctant to ask for relief or to take prescribed pain medications, the researchers found that physicians were just as unwilling to prescribe the needed medications. Nearly a third of cancer specialists waited until the patient was only months away from death before offering maximum pain control.

      The fact that opioids are the flavor of the month in terms of drug abuse should not engender a society where we punish the sick for the drug abuse of others.

      And if we are so concerned about drug abuse and its ill effects on health – the net effect of the war on drugs is a net health negative. Prison, gang shootings and the criminalization of large segments of society all significantly reduce life expectancy.

      And there has been recent evidence if damage to hippocampal damage due to persistent chronic pain.


      • Overuse alongside underuse is a hallmark of our health system. That they may coexist for opioids comes as no surprise. (It’s always helpful if you provide links, e.g., to the NYT article you mention, if not prior research.)

      • Robert
        There is a distinction between chronic cancer pain, and chronic pain syndromes. The latter is the focus of most inquiries and generates the greatest cynicism amongst practitioners treating pain.

        This is a short 2012 commentary describing state of affairs, and is as good as any:

        In my own practice, individuals with cancer pain get what they require, often high dose narcotics. Its ethical and decent, and encompasses a different practice approach than folks with (+) prognoses.

        Hope this helps

      • For every 1 patient with cancer, there are 100 patients who have non-descript “chronic pain” who go around from doc to doc seeking narcotics.

        I’ve seen at least 1000 patients with “chronic pain” and guess how many of them had a diagnosis of cancer? Two.

        Lets stop pretending that cancer patient numbers make up a large portion of people who have “untreated” pain. Certainly there are cancer patients who need better pain control — they do NOT make up significant numbers in the overall population of people with “pain”

    • Below is a link to the nyt article I mentioned above concerning the lack of pain relief offered by physicians.


    • “Overuse alongside underuse is a hallmark of our health system.”

      Even if you accept that this is true in general, this particular “crisis” has much less to do with the attributes of our health care system than it does with our policy of drug prohibition. Drug addicts get pain meds from doctors when they want them for the same reason that Willie Sutton got held up banks when he wanted cash. That’s where the money was, and doctor’s offices are where you get your Oxycontin.

      None of this will change until we give our fellow citizens with a chemical dependency problem a safe, legal mechanism for obtaining whatever substance they happen to be addicted to without them having to waste their time, and an immense amount of valuable medical resources by pretending to be sick in order to obtain them.