By Scott McKinney Ph.D.
Imagine if, as a society, we had the inability to be good parents. The resulting context would be one where a greater need existed for individuals and groups that provided a solution to the problem. One could imagine that the childcare industry would grow proportionate to the need for quality care, schools would likely adapt to meet demands, and society would debate about what we need to do to be better parents. The problem is that none of this replaces the power of good parenting and the solution was never really directed at the problem. That may sound absurd, but something very similar–a product of regulation–is fueling the opioid epidemic. That something is neglect.
The opioid epidemic is in the news on just about every television and radio show. The U.S. Department of Health and Human Services declared a public health crisis in 2017. It is such a significant topic that our President has probably tweeted about it. The administration’s new policy emphasizes being tough on crime with vague promises for harm-reduction and treatment. Our regulators debate, campaign, and vote on issues around controlling borders and over-regulating Physicians, yet no one is talking about the typical mom, dad, husband, or wife that deals with chronic pain issues. As the regulatory broom sweeps our nation, normal and functioning, people are being brushed away by a straying bristle. The, now common story, of a person dealing with chronic pain goes something like this.
They have an unfortunate accident or diagnosis. They seek medical care for the pain and the path typically leads to opioid prescriptions. Years go by, everything is managed. Of course, their tolerance to the medication being prescribed has increased, and so too, their dose. One day, they go to what seems a typical follow-up appointment with their provider. The provider, with increasingly higher “regulatory-induced-anxiety”, informs the person that they will no longer be able to write their prescription and need to refer them to another provider. This seems simple enough in the individual’s mind. Unfortunately, they soon learn that this was more than an anomaly; it is a growing trend. After countless calls and Google searches they find other physicians unwilling to take over their care or indicted by the Federal Government. There problem just became critical. The clock has now started for a person who will run out of the medication that enabled them to function normally. Their managed pain will start to ravage the ability to function and the overall quality of their life. And, of course, let us not forget the withdrawal they will soon endure. Unknown to them at the time, they have joined the unnamed.
Patients are being put in this exact scenario each day around us. They are forced to look for non-opioid solutions to their chronic pain issues, which may not provide the same level of functioning they once had or seek the only treatment available for those dependent on mood-altering chemicals. They are told they either don’t need opioids or they need addiction treatment.
This is becoming a regular story in the substance abuse treatment sector. Patients dependent on opioids, without providers willing to address their needs, seek solace in a sector that will provide them care. The problem with this is that addiction treatment centers are ill-equipped to care for these patients. Many do not meet the diagnostic criteria for substance abuse and have a primary diagnosis of chronic pain. Between dealing with chronic pain and being able to properly diagnosis the problem, many providers are having to create “pain-management for addiction” programs specific to this population or are only treating the resulting dependence from a more significant problem. Like the bad parenting problem, we are not addressing the problem’s source.
If we want to begin correcting this problem we first need to recognize the population discussed. Yes, we need to hold physicians accountable when prescribing opioids for pain. But, there is also a lack of differentiation between substance abuse disorder and substance dependence. So, who are we talking about in the first place? The updated Diagnostic and Statistical Manual of Mental Disorders (DSM-V)’s additional criteria of substance use disorder results in a series of diagnostic codes that neglects compliant, chemically dependent chronic pain patients; they have no diagnostic identifier unless they are classified as substance abusers.
How can we begin to help a population that doesn’t even have a name? This is problematic in two ways. One it leaves pain and addiction professionals without the proper diagnostic label for this population. Secondly, medications and services without proper diagnoses are not covered by health insurers. So, they are either misdiagnosed or are simply thrown aside in some direction. An amendment to the DSM-V needs to be made to accommodate the criteria needed to justify chemical dependency or an additional set of ICD-10 codes for those chemically dependent that do not meet substance abuse criteria. As we continue to have discussion around the opioid problem the patients dependent but not abusing opioid prescriptions are as much of a priority as those abusing medications or using illicit substances. They are all our neighbors, friends, and family.
Dr. Scott McKinney is the president of the Midwest Institute for Addiction. He has served in the United States Marine Corps as a Recon Marine and combat veteran. His passions have taken him from the world of Physical therapy and human performance to those with substance use and dependence. He continues to find opportunities to work for the betterment of others.