Monday, November 17, 2014

Pain management dogma and the opiate prescription epidemic

A recent post at Academic Life in Emergency Medicine talked about an epidemic of opiate prescriptions and the associated spike in mortality. The post and a related article in the Annals of Emergency Medicine focused primarily on the concerns of emergency medicine providers but it has more general applicability.

The article deals with multiple dimensions of the problem including the need for educational and even regulatory guidance. One point that particularly interested me has been the focus of many of my older posts this topic over the years which is that this epidemic got started with the “pain the fifth vital sign” initiative that began about a decade and a half ago. It's hardly coincidental that the opiate related fatalities started rising in 1999. The Institute of Medicine, the pharmaceutical industry and our own professional societies were among the many accomplices.

The “educational” piece of the campaign obfuscated the medical lexicon and elevated dogma over science. Worse, it was illogical. How, for example, could something so culturally driven and subjective as the symptom of pain be a vital sign? Nevertheless the campaign was so powerfully leveraged that administrators and physicians were wowed and cowed. Finally some are taking a more critical view of things. I recently posted this retrospective on some of the original tenets of the movement. A decade ago no one dared challenge them. Looking back now it would be humorous had the effects not been so devastating. From that post:

What still baffles me is why so many doctors accepted the biggest and most obvious load of nonsense, the idea that pain, long established in clinical medicine as a symptom, could suddenly become a sign. Even The Joint Commission and my own professional organization, the Society of Hospital Medicine (then known as NAIP) were serving the Kool-aid.

Other nutty ideas were promulgated:

Opiates are safe.
Uh huh. How's that working these days?

Doctors' concerns about opiate addiction are overstated; true opiate addiction is in fact rare.
Ten years or so ago if you pointed out narcotic seeking behavior you would be told, dismissively, that this was not addiction but pseudoaddiction. Pseudoaddiction, they said, was merely behavior exhibited by a patient whose pain was uncontrolled. Put another way, if your patient engaged in seeking behavior it meant you were not doing your job.

Pain can be measured.
Translate: pain is not subjective. Pain does not have emotional components. How many people knew that was a crock but were too intimidated to call it out?

No one should have to experience pain. Pain can be made to disappear from the planet.
Really? How about all those patients on chronic narcotics who have had their doses increased, time and time again, to ridiculously high levels, and are still suffering?

It's great to see that some people are finally saying enough is enough.

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