By Ed Coghlan
1.1 Billion dollars has been set aside by the Obama administration for the purpose of addressing the abuse of heroin and prescription drugs which have contributed to an ‘epidemic of overdoses and deaths. Data from the Centers for Disease Control and Prevention (CDC) indicates that opioids — a class of drugs which include prescription pain medications and heroin — were involved in 28,648 deaths in 2014, an increase from 2013. Drugs of abuse include heroin, synthetic opioids such as fentanyl, and prescription drugs that have flooded streets through illicit and aftermarket sales. These statistics are muddied by CDCs acknowledgment that counts in some cases are duplicated, and that sources of supplies are not always attributable to prescriptions written by physicians.
The President’s FY 2017 budget takes a multi-pronged approach to address this epidemic. First, it includes new mandatory funding over two years to expand access to treatment for prescription drug abuse and heroin use. This will be used for expansion of state programs designed to address opioid use disorders which have a specific diagnostic code in DSM-V-TR that excludes persons receiving treatment for chronic pain from this definition; expansion of the National Health Services Corp to support persons with substance abuse disorders; funds to reduce barriers to entry into services, and, funds for analysis of program effectiveness.
What is missing from this approach? Funds to address the distinct need for research into effective continuation of treatment protocols for persons who suffer from the more than 200 readily identifiable health conditions that generate chronic pain syndromes are strikingly omitted from this budget. While a mention of CDC’s effort to implement guidelines for primary care support to persons with chronic pain is given a nod, in fact there is no mention of funding for the need for medical education of health care professionals, continuing education for practitioners currently in place, and no mention of the fact that skilled treating providers with broad skills across disciplines are needed particularly in rural areas where integrated services are largely absent. CDC’s proposed guidelines offer no force of regulation to mobilize funding for the expansion of alternative approaches to include technology, telemedicine or integrated alternative medicine. Counseling and complementary approaches to care remain unaddressed despite their potential complementary effectiveness for persons who are disabled by chronic pain syndromes, the elderly, or those who lack transportation to care. This is a serious oversight of the needs of this population which the addiction and diversion model fails to support.
According to the National Institutes of Health (NIH), one in five adults over the age of 45 sustains a diagnosis of 2 or more serious health conditions, and after the age of 55, the number of health related conditions increases to an average of 5 or more. ‘Safe communities’ means not only removal of illicit drugs from the streets – it also means health prevention services, and assurance of the appropriate patient selection and treatment of patients who require a continuum of integrated care supports. These supports include the medication management of chronic pain, which may be co-morbid with other health conditions. While this population may be ‘at risk’ for substance abuse disorders, they are far more vulnerable to the effects of polypharmacy, drug-drug interactions, predatory pain management practices, and poorly designed medical interventions in communities that lack providers. Placing the focus entirely on opiates ignores the forest for the trees and misses a large opportunity to understand the nature of the problem we can readily observe – which is not limited to opiates, but is rooted in a reaction approach to health care.
There is no evidence that the proposed guidelines under development will improve the way opioids are prescribed or help providers offer safer, more effective chronic pain treatment, while reducing opioid misuse, abuse and overdose. We seem to have fallen victim to the notion that doing something, anything, is better than nothing. But, given the current state of advancing state legislation which incorporates these proposed guidelines, we may well continue to see a large treatment gap continue to grow. Without federally directed intervention in the training and support of primary care and specialty physicians and oversight through evaluation of outcomes, we may be hard pressed to understand how effective these guidelines actually are.
Persons with chronic pain are generally responsible users of medications. All of the statistics available indicate that fewer than 3% of the more than 100 million persons who rely on opiates graduate to abuse of their medications. The majority of physicians strive to be responsible in their conduct – there is no reliable indication that physicians are abusing their obligations for stewardship. Throwing all of the nation’s resources into expanding a model that emphasizes addiction reduction fails to account for one very simple fact – that addiction is largely rooted in conditions associated with culture and the social indicators of health care. The 2017 budgeted interventions attack personal behavior, not the root causes of addiction or the injury and disease processes that install chronic pain disorders. Regulating personal behavior is unlikely to result in cultural change – it never has, and it is unlikely that it ever will.
Santayana said, “those who fail to learn from history are doomed to repeat it.” Are we really still so incapable of learning that we are engaging in the same conduct and logic over and over again – expecting a different outcome? Isn’t that a form of “magical thinking”?
I guess it’s an election year.