Sunday, March 27, 2016

Opiates And Moral Dilemmas For Physicians








I became aware of an article from Reason magazine written by a physician Jeffrey A. Singer titled Physicians Face A Moral Dilemma In Conscription on War on Drugs (1). In keeping with the main theme, the subtitle was “In the government’s new war on opiates, physicians and their patients find themselves caught in a crossfire.”  Physicians are generally in the crossfire of any number of government healthcare reforms. The opening lines of this essay should not surprise any physician.  We have been in the crosshairs for thirty years.  There is a tangible difference in the War on Drugs.  In the 1990s, I can recall a vague threat about incarceration for not doing my notes properly.  That wasn’t a threat to me specifically but an entire clinic of physicians than I belonged to at the time.  In retrospect it sounds absurd, but that the was pre-911 days when the FBI spent a lot of time reading physician notes and deciding whether or not they had committed health care fraud by not doing enough documentation.  These days physicians can be prosecuted and incarcerated for the way that they prescribe opiates. The threat is much more real.

Dr. Singer’s introductory paragraph points out that when any health crisis occurs politicians are eager to step up and offer their solutions and throw a lot of money at the problem.  In this case President Obama is building new drug addiction centers and “training” government physicians on opioids to the tune of $100 million.  Hillary Clinton is promising $10 billion as a criminal justice initiative as grant for drug treatment centers and training for first responders to administer opiate antidotes.  I have never seen a single politician or government bureaucrat acknowledge that the reason why the opiate epidemic exists has to do with policy initiatives that occurred right around the year 2000.  At that point, physicians were encouraged to treat pain more aggressively and with fewer checks and balances than they had in the past.  The cumulative effect of these policy changes was a lower threshold for prescribing opiates for chronic noncancer pain and a removal of some of the gatekeeper mechanisms – like getting second opinions from pain specialists on this practice.

The First War on Drugs was described as the initial prohibition of opiates and cocaine by the Harrison Act in 1914.  Singer describes a scenario where a physician who would prescribe an opiate to help a patient “cope with their addiction” as being in conflict with the law.  The Harrison Act prohibited physicians from prescribing opiates to maintain an addiction.  He cites this example as being the first moral dilemma.  It is more complicated than depicted.  There have always been a number of physicians who consciously or unconsciously maintained large numbers of patients in addiction and that was their medical practice.  That practice does not pass current conflict of interest considerations much less the ethical obligation of physicians to do no harm.  It is a given that legal interventions are generally blunt instruments for protecting people from their problematic decision-making and that a complete picture of all of the data (the number of people addicted by medical treatment versus non-medical sources) is never clear.  Is there a problem with suggesting that physician themselves should not be a primary source for creating and maintaining addiction?  The main problem is that even the most well-informed and well-intentioned physician can end up with a patient who is addicted to a medication.  There is currently no known way to prevent that.  Are those physicians criminals in any way?  I don’t think so.  At the same time, should there be a prohibition against physicians setting up a practice that maintains high number of patients in addiction, does nothing to facilitate their recovery from addiction, and has no other purpose – of course there should be such a prohibition. 

The next argument in the essay has to do with the safety of opiates versus alcohol.  This is a common argument by people who see nothing wrong with the legalization of drugs.  I am not suggesting that Singer is making this argument; he is trying to point out that opiates are relatively safer than alcohol and alcohol is a legal drug.  I think that he is wrong on several counts in this argument.  The first point has to do with the overall toxicity of alcohol.  He cites a number of diseases that have to do with the long-term toxicity of alcohol.  Alcoholic cirrhosis for example is typically the fifth or sixth leading cause of death in middle-aged men.  The estimated dose required in most cases is 15-pint years or drinking one pint of whiskey per day for 15 years (2).  Doing a quick calculation shows that this is about 143.26 grams of ethyl alcohol per day.  The progression to cirrhosis will vary based on sex, genetic factors, and rates of metabolism.  The overriding point is that alcohol consumption at this rate is limited to a small percentage of drinkers and the population exposure to alcohol is relatively stable based on current legal and cultural factors.  A related issue is that if you are alcohol dependent tolerance and withdrawal phenomena may lead to a marked increase in consumption – up to 750-1,500 ml/day in order to maintain blood levels high enough throughout the day to prevent withdrawal.  The exposure of multiple tissues over time causes the damage.

The primary mechanism of injury and death from opiates is respiratory ataxia and arrest by the direct action of the drug on small clusters of cells in the midbrain and medulla.  Opiates have a direct effect on the center that determines respiratory rhythm and the center that responds to chemical changes due to oxygen deficiency and carbon dioxide accumulation.  Benzodiazepines, alcohol and sleep medications are often involved in these situations and have a combined effect.  Alcohol in high enough doses can have a similar effect in depending on the individual and their state of tolerance.

Looking at the acute mortality related to alcohol and opiates, I don’t think that there should be any doubt that opiates are probably more lethal than alcohol.  The CDC states that about 2,200 people die every year from acute alcohol poisoning (3).  The population at risk appears top be 38 million binge drinkers.  Men ages 35-64 are at highest risk.  In 2014, there were 18,893 overdose deaths from prescription painkillers and 10,574 deaths from heroin overdose (4).  In this case the estimated populations at risk include 1.9 million people with a prescription painkiller problem and 586,000 heroin users.  Furthermore the death rate from prescription painkiller and heroin use parallels the availability.  I am puzzled by the author’s suggestion that opiates are “much safer” and that there is “honest disagreement among health care practitioners over just how harmful long term opiate use can be…”.

I guess that I am one of those disagreeable health care practitioners.  Anyone can fact check the above argument for acute toxicity and I would encourage a close look at the trendlines over the past 15 years.  If you look at this lines, you will find that the rate of deaths due to heroin overdose was relatively stable for at least a decade before a sizable number of prescription painkiller users decided to start using heroin.  The decision is a strictly economic one.  The most commonly abused prescription painkiller costs a dollar per milligram on the street.  Addicts are typically using $120-240 mg per day.  The equivalent amount of heroin can be purchased for about ¼ as much.  The end result is that stable rate of heroin overdose deaths has quadrupled in the last 5 years.  It is stark to contemplate that the total opiate death rate is based on a population at risk that is about 10% the size of the drinking population at risk.

Dr. Singer describes the movement that led to increased opiate prescribing at the beginning of the 21st century as “enlightened” and “compassionate.”  He uses the term opiophobia as the irrational fear that doctors and patients have about these medications.  I think it is very clear that these advocacy groups and bureaucrats had no clue that increased access would lead to an epidemic of addiction and overdose deaths.  The moral dilemma for physicians is not colluding with law enforcement in the War on Drugs and “cutting patients off.”  The moral dilemma is practicing sound medicine in a system that blames them for not prescribing enough opioids and then ten years later blames them for prescribing too many.  All of this occurs against the backdrop of a culture that has an insatiable appetite for intoxicants in a country that has one of the highest per capita opiate consumption rates in the world.  The moral dilemma for physicians is recognizing that they can’t predict who will or not become addicted to an opiate and that many physicians do not have the skills necessary to not prescribe to patients who either really don’t need the drug or are probably addicted to it.

There is more than one moral dilemma in the opiate epidemic.  On the patient side should you let your doctor know if you have an addiction before the opiate prescription is written?  Should you let your doctor know that the first pill from the prescription left you feeling euphoric, energetic, confident and like you have never felt before in your life?  Should you let your doctor know that you are continuing to take prescription painkillers even though they don’t work for the pain or because the pain is gone?  Should you tell your doctor or pharmacist that you suddenly have access to all of the opiates from a deceased family member who was in hospice care and ask how to keep them off the street?

There are many moral dilemmas associated with opiates for everyone and very little moral guidance.

      
George Dawson, MD, DLFAPA


Supplementary:

To calculate the mg alcohol in a pint of whiskey:

1 pint = 473.18 ml

473.18 ml x 0.4 (percent alcohol) x 0.757 g/ml (specific gravity of alcohol) = 143.26 g ethyl alcohol



References:

1:  Singer JA.  Physicians Face Moral Dilemma In Conscription on War on Drugs.  Reason.com  March 23, 2016.  Accessed on March 25, 2016.

2:  Lefton HB, Rosa A, Cohen M. Diagnosis and epidemiology of cirrhosis.  Med Clin  North Am. 2009 Jul;93(4):787-99, vii. doi: 10.1016/j.mcna.2009.03.002. Review. PubMed PMID: 19577114.

3:  Centers for Disease Control and Prevention.  Alcohol Poisoning Deaths.  CDC Vital Signs, January 2015.

4:  American Society of Addiction Medicine.  Opioid Addiction 2016 Facts and Figures.  ASAM web site accessed on March 26, 2016.   

       

9 comments:

  1. It is typical of all kinds of bureaucracies for there to be a pendulum that swings from one extreme to the other. Someone sees a problem (e.g. dying cancer patients on death's door being refused opiates because "they're addictive"). So then everyone overcorrects and starts handing them out right and left. And then people start OD'ing and the pendulum starts up again. "When will they ever learn?" to quote an old folk song.

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    1. Agree David.

      The other issue at the outset here was the "pain as a fifth vital sign" and 10-point pain scale as a "quantitative measure". People were essentially recruited into treating pain that they were not even complaining about. At one point the VA said that anyone who screened at a 4/10 on the pain scale needed a "comprehensive pain evaluation." During some of my lectures I ask about who in the room should be in the most pain. The correct answer is the old man or me. We discuss the effects of aging and pain and why that natural process doesn't necessarily require a prescription for opioids.

      The other issue is that people are being given opioids at this point for injuries they would have never received them for in the past like a sprained ankle. At the start of the epidemic there was also the notion that if opiates were "properly prescribed" the rate of addiction is low. I don't see it that way at all. I think there is a vulnerable population out there, we don't know how many there are, and they will be at risk with any exposure.

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    2. A lot of the KOL thinking in this area was based on flawed surveys like the NEJM Porter and Jick article in 1980. In refill followups, few patients reported functional impairment...duh...news flash, you're not going to report functional impairment if you're getting a refill.

      Functional impairment from prescription drugs is like bipolar disorder...the way you get to the diagnosis is through collaterals. But that isn't going to happen in the age of the 15 minute med check and HIPAA.

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    3. Self report and survey data are responsible for extremely low complication rates of opioids. I recall a VA study: "Some evidence suggests that the risk of addiction from legally prescribed opioids is low – 2% of 15,000 veterans (Edlund,et al) and 6% of another sample (Pletcher, at al) – all abuse rather than addiction."

      Anyone who knows the incredible bureaucracy of the VA system, can imagine getting realistic responses on a survey like that. And can you really split hairs between addiction and abuse on a survey instrument that is going to be completed in some cases by addicts? The unfortunate truth is that good data in this area is hard to get to.

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    4. To top it off, the most unctuous and self-deluded KOLs of the nineties (including Dr. Portenoy, yes I am naming names, since PROP already exposed this) would top off the argument by claiming physicians who were concerned about addiction were cruel and ignorant who needed to get up to speed with his ideas. Classic enabling of the splitting dynamic in already fragile patients and manipulation for personal gain.

      http://www.medpagetoday.com/PainManagement/PainManagement/47855

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  2. My attempt to explain cognitive dissonance to a pain management clinic owner who happens to be a doctor after he was whining about regulations and blaming overdose on 'opioid abusers':

    "Ah, I'm glad you asked. The tension that is causing your altered perception, exonerating you from any wrong doing, exists between your wallet and your oath - between your education and your wristwatch. Bear with me. I believe that you believe that you're not intentionally harming people. You're a doctor. Of course you don't want to harm people. See where I'm going with this?

    However, as the owner of a pain clinic, the fiscal impact of truly embracing non-maleficence as a guiding principle has created a defensive wall around your conscience. So, when something does go wrong (addiction, overdose, destroyed families), you shift the blame to 'opioid abusers' as you've called them. Your very terminology implies these patients - your patients - have a self-inflicted disorder characterized by low morals and weak wills. Maybe even they deserve to die. Ok, that was too much.

    Then, we venture into the next layer of your cognitive dissonance. For, as a doctor, you must know that your very own AMA declared alcoholism an 'illness' in 1956. Nearly 50 years later, another of your associations, ASAM, defined addiction as a brain disorder after a 4 year 80 expert study. If you believed that, you'd have to do something about it. You're a doctor after all. Healing people is what you do! See what I did there? Yet another defensive wall is erected around your conscience. One protects your money, the other your time. I hope you get the help you need.

    You're a dying breed, Doc. The Surgeon General and the CDC are on our side. The AMA and ASAM are on our side. The President is on our side. Hell, Steven Tyler in on our side. There's room for you. Come get you some."

    I didn't charge him for the insight. It was complementary. #DropsMic like a badass #SocialWorker on the right side of history. #NationalRecoveryMovement

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    1. Like most things in medicine - financial conflict of interest is only cover a fraction of the problem. Physicians on straight salary who don't own a clinic and have no additional financial interest are no less likely to have patients with addiction problems than pain clinic owners. There is also a clear selection process, many more patients who develop an addiction in primary care settings are likely to end up referred to pain clinics.

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  3. Stigma is the reason why one man's money and time are of greater value than another man's life. I can see no other reason why primary care docs are reluctant to register for or diligently utilize Prescription Drug Monitoring Programs in states where participation is "encouraged." Stigma is the reason persons with substance use disorders are disposable as evidenced by policy, practice, and legislation. "Stigma is a degrading and debasing attitude of the society that discredits a person or a group because of an attribute… (2015 International Conference on Stigma
    Howard University, Washington, DC)." Not for long. We are entering into an era where best practice is no longer "encouraged." Public health policy and practice will be legislated. Time's up. Too many white kids died this time.

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    1. I think that you are wrong. If there was ever any evidence of physicians being ordered around by an ineffective bureaucracy - it is the opiate epidemic as outlined in the above post. Physicians don't trust bureaucrats and they should not. Health care systems in general have decades of history of discriminating against people with addiction and mental illness. Politics and business are looking for people with no political clout so they can move money to more favored sectors. Stigma may be a small part of that, but it does not account for health plans telling me in the 1980s that I could no longer treat patients with addiction in a hospital. They all had to go to county detox units with no medical coverage instead. That is a huge savings for the insurance company.

      Pharmacovigilance/pharmacosurveillance will be the order of the day soon:

      http://real-psychiatry.blogspot.com/2014/02/dangerous-medications-part-one.html

      The top 10% of prescribers currently writes 50-60% of all opioid prescriptions according to the current pharmacosurveillance database:

      http://real-psychiatry.blogspot.com/2015/12/the-beginnings-of-true.html

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