Thursday, May 19, 2016

The NY Times Opinion On Congress and the Opioid Epidemic

The NY Times came out with an opinion piece of the opioid epidemic on May 16 (1).  In their opinion it was a good thing that Congress had finally decided to "get involved."  They emphasize the need to fund treatment and prevention programs.  But wait a minute, didn't Congress already approve the The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) That act was supposed to provide equal treatment for mental disorders and addictive disorders.  Here it is a few years later and we are supposed to be still trying to fund treatment despite a specific piece of legislation was was already supposed to provide funding?  In fact, this same editorial board came out with a very rosy assessment of the MHPAEA three years ago and they were wrong back then as well.  In that link, I posted reasons why the parity act would fail and of course - it did.  That failure is the only reason the editorial board is now calling for funding for treatment and prevention programs,  I criticized their original post because they lacked anyone with medical expertise on their panel and they did not seem to know how health care works or why Congressional intervention does not work. It looks like the same mistake has been repeated.  At some point we need to recognize that the opinions and legislation about health care aren't worth the paper they are printed on.  At least from the perspective of the prospective patient or the physicians who are trying to treat them.

This piece does reflect a dim grasp of the health care system in this country that is set up by Congress in the first place.  Some of the suggestions made me want to laugh out loud.

"The federal government can make the biggest difference by expanding high-quality treatment programs. States, which have more sway over doctors and hospitals, need to do more on the prevention side by placing limits on opioid prescriptions. States can encourage doctors to order alternative pain treatments, like physical therapy, and require insurers to cover those services." (1)

This seems to assume that the federal government is somehow interested in quality while they are setting up managed care organizations that really have nothing to do with quality.  Everything is set up to be cost-effective (translation = cheap).  There is nothing cheaper in the way of mental health care and treatment for addictions than refusing to fund it and that is a routine occurrence in spite of the MHPAEA, the bill that was supposed to put the care of mental illnesses and addictions on par with other medical conditions.  The second error in this paragraph is the idea of a bureaucrat somewhere placing limits on opioid prescriptions.  That will immediately alienate the majority of the physician workforce that currently prescribes opioids appropriately and of course the patients of these physicians.  And finally the idea that alternate treatments will be covered misses the cultural contributions to the opioid epidemic and the fact that Congress doesn't seem to be able to mandate insurance companies to do much of anything.  If they can't mandate equal coverage for mental illness and addiction, why would physical therapy be any different?

On the question of how much legislation must be written and how much money appropriated, the money figures quoted range from $600 million to $1.1 billion to address the treatment needs of 435,000 regular heroin users, 1.9 million people who are regular prescription opioid users, and 4.3 million people engaged in non-medical use of prescription painkillers each month.  Considering only the prescription of buprenorphine for medication assisted treatment of opioid use disorder and the $1.1 billion dollar figure, at about $1,000/month for buprenorphine, that figure would result in the treatment of 92,000 individuals and that is not including the cost of medical evaluation and administration of the drug.  That is less than a quarter of the heroin users and less than 10% of the painkiller users.  It also does not fund any of the additional treatment services including addiction counseling and a continuum of sober support and housing.

In situations like this, seeming to address the problem by political one upmanship is always tempting.  A Governor is quoted in the article giving her opinion that the cause of the current epidemic is the prescribing practices of physicians.  I am sure that many legislators take the same concrete approach to problems but this is a much more nuanced problem.  Technically speaking - all physicians leave medical school knowing how to prescribe opioids.  Not all of them are good at managing the relationship with the patient or telling patients what they might not want to hear.  The commonest errors I see in prescribing addictive drugs to people has nothing to do with technical expertise of the physician.  It has to do with the idea that the patient is in distress and that it is the physician's job to do something about it.  Many of these physicians have a difficult time balancing the decision to prescribe an addictive drug versus the potential harm of addiction or the harm of not treating a pain syndrome that does not respond well to opioids.  Many of these same physicians lack an understanding of addiction and the fact that it is possible to continue to take an addictive medication even though it is providing no symptomatic relief from pain.   The third problem is the patient's lack of insight.  There a lot of biases when it comes to addiction and assigning responsibility.  There are numerous arguments about whether addiction is a disease or not and these are generally arguments about who is responsible for the addiction and its treatment.  I don't think that there is any doubt that a person who is addicted to opioids will behave in a predictable manner to keep the addiction going.  They will not tell their physicians that they have an addiction and in some cases try to get extensions on prescriptions, escalate the dose of a prescription, get more opioids from non-medical sources (dealers or acquaintances) or use the opioid for a reason that it was not intended - usually insomnia, anxiety, or depression.  How do legislators address this complex problem?  Basically by blaming physicians and passing legislation that doesn't make any sense.

It is important to remember that this epidemic did not start in a vacuum.  There was an activist movement among some professional societies and regulatory bodies to treat pain more aggressively.  Looking at past  New York Times editorials, some of this was recorded and in at least one case, the opinion came down on the side of aggressive pain treatment.   Congress and the media seems to have come full circle on the issue of opioids and is ready to head back in the other direction.  The news can be a powerful source of influence in encouraging people to use public health measures to stop this epidemic.  That can be as basic an idea as not hoarding leftover opioid painkillers and discarding them.

Hoping that Congress will solve the problem, when they were supposed to 7 and 22 years ago, does not seem like the best idea.  If they went back to sleep - nobody would notice the difference.

George Dawson, MD, DFAPA

1:  The Editorial Board.  Congress Wakes Up To The Opioid Epidemic.  New York Times May 16. 2016.

2:  The Editorial Board.  Making the Pain Go Away.  New York Times.  March 4, 1994:

"The new guidelines, issued in detail for physicians and in brief for patients, call for treating pain early and aggressively, starting with the simplest options, like aspirin and acetaminophen, and progressing through mild opiates to more potent drugs like morphine."


"But there are scant data from scientific studies to document whether or not marijuana is as effective as or better than other anti-nausea drugs. The same outdated attitudes that inhibit the use of narcotics for pain relief should not be allowed to suppress clinical investigations into the therapeutic uses of pot."

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