Senators Claim Doctors Pressured by Medicare Survey to Prescribe Painkillers

Senators Claim Doctors Pressured by Medicare Survey to Prescribe Painkillers

Patient satisfaction surveys used by Medicare to help identify good hospitals could be contributing to the “growing epidemic” of abuse of prescription opioid drugs, according to two U.S. senators.

In a letter to the head of the Centers for Medicare and Medicaid Services (CMS), Sen. Chuck Grassley of Iowa and Sen. Dianne Feinstein of California claim “there is growing anecdotal evidence that these surveys may be having the unintended effect of encouraging practitioners to prescribe (opioid pain relievers) unnecessarily and improperly.”

bigstock-Caduceus-Medical-Symbol-Chrome-7762432Under the 2010 Affordable Care Act, a Hospital Value-Based Purchasing program was established to reward acute-care hospitals with incentive payments when they are ranked highly by patients for their quality of care.

Medicare patients are asked to complete surveys asking them whether they needed pain medication, whether their pain was well controlled, and how often hospital staff helped with their pain.

Linking pay with performance was the goal, but according to Sens. Grassley and Feinstein, some doctors have prescribed opioids to improve their scores on the patient satisfaction survey.

“A doctor in South Carolina reportedly cited low patient satisfaction scores as the reason why he prescribed Dilaudid (hydromorphone), a powerful painkiller commonly used to treat cancer pain, to treat a patient’s toothache,” they wrote to CMS Administrator Marilyn Tavenner.

“Indeed, almost half the members of the South Carolina Medical Association have admitted to prescribing opioids in response to patient survey scores. One hospital with low satisfaction scores even went so far as to offer Vicodin ‘goody bags’ to patients discharged from its emergency room in an effort to improve its scores.”

Grassley and Feinstein also cited an emergency room doctor in the Midwest who “quit the profession altogether” because he felt pressured to prescribe opioids to drug seeking patients.

The senators asked Tavenner to explain in writing what is being done to address the impact of patient surveys on the prescribing of opioid pain relievers. Grassley and Feinstein are co-chairs of the Senate Caucus on International Narcotics Control.

A large study recently published in the Journal of Hospital Medicine found that U.S. hospitals were already prescribing opioids at high rates to patients in 2009 and 2010 – before the Medicare satisfaction surveys were even used. Over half of all nonsurgical patients were given painkillers during their hospitalization, often at high doses.

Authored by: Pat Anson, Editor

There are 27 comments for this article
  1. Paul Kepper at 11:43 am

    After reading this and several of the comments, I think it is important that we become very fluid in all aspects of our health care. I have found several recent reads that have convinced me that we are not always taken care of by our docs. For instance in Tom Schneider’s book, A Physician’s Apology he talks about myths in the medical field. He was also a patient so to hear is take on it coming from both sides is very convincing. I recommend it, his site is ihealthspan.com, just his site have some great info. We need to take care of ourselves as much as possible!

  2. BL at 8:51 pm

    Fitch, I appreciate the time and effort you’ve put into clarifying what you’ve said. I also want to apologize for comments that I made that were directed to you and your loved ones.

  3. Fitch at 5:59 pm

    SMF,

    Please read my latest post to RS after it passes the internal review process. These new comments will bring clarity to what I was attempting to explain in previous posts.

    I often write with built-in assumptions, expecting that the reader may have an excellent grasp of the subject matter. I have learned from my mistakes in that respect.

    However, if you wish to take issue with the published figures illustrating opioid consumption worldwide, please direct your objection to the individuals responsible for disseminating what you allege to be faulty data. I am only interpreting what is in the public domain. This information is readily available and published in multiple sources inside and beyond the borders of the United States.

    Thus, if you have different information please illustrate this to the group in a separate comment. Please provide acceptable and valid sources if you wish to challenge this easily accessible and broadly disseminated data.

    Again, I have to leave now (permanently), and I am crossing my fingers that this is the last criticism that I will have to acknowledge. If I address this subject matter again, then, I will do a much better job explaining myself and my position in a single comment.

  4. Fitch at 5:18 pm

    RS,

    I do have experience in managing chronic pain. Each individual interprets pain from his or her own perceptive reality. If you study the theory of Symbolic Interactionism, then, you would learn that everyone navigates his or her word a little differently from person to person. For example, you may see the color green differently than your spouse or me and so on. I do not want to take you through the entire theory, but I recognize what my spouse or me can tolerate (associated to chronic pain) should not equate to what someone else may be able to tolerate.

    Moreover, I am very sorry that the person you are describing is having such a difficult time. Chronic pain wears on even the strongest mind, this kind of pain contributes to high blood pressure, rapid heart rate, and from there the list of affects is debilitating and endless.

    What I was not trying to do is lump every individual and his or her pain together into one basket as being similar. Please accept my heartfelt apology if this is how I came across to you or anyone else. I am very sorry for not explaining myself correctly and the last thing that I would want to exhibit is cruelty toward any living being.

    Symbolic Interactionism suggests that change in one’s self-construct will take place quickly or slowly based on their intellect. Each individual’s (Self) has an historical narrative, which is our validated set of experiences from birth to present. I believe one solution is to affect one’s historical narrative to understand pain as it exists for them. However, regardless of one’s level of intellect, any change that one would hope to achieve occurs at the micro-level. Moreover, other components within the theory supersede one’s historical narrative.

    Having said this, I believe it is possible to train one’s mind to understand and tolerate pain (to some degree), but the theory tells us this is not going to happen overnight. Additionally, it may never happen for some. The issue that I have been trying to explain is that opioids are imperfect (harmful), thus, one should incorporate multiple strategies when dealing with chronic pain. This is the point that I was attempting to highlight. Additionally, I pointed to the fact that society in the United States tends to abuse opioids. Many individuals with far less serious problems and mild pain (opposite from what you, your woman friend, and others have described), can easily obtain opioids. This is what I find troubling. Moreover, those others are affecting your women friends access to opioids, and to those others that really need them. Thus, I hope this explains why this post and the comments are important, and to bring focus back to the individual who is unable to survive without them. Opioids exist to benefit your friend and others like her who live with chronic pain. For instance, I am certain that you are incensed when you go to the doctor and you or your women friend leaves feeling as though they have been unjustly accused of being a drug abuser. This is both a humbling and humiliating experience.

    I am sorry, but I do not have time to post again, so this is my final, final, post. I felt it was important to respond to your comment, so I made this a priority over any of my other obligations.

    Fitch

  5. SMF at 2:58 pm

    As you have directed others to do I suggest you do some research of your own.As stated the statistics are flawed. The US is NOT the largest consumer of Opiates. Other countries use different Opiates than the US for the same conditions they are prescribed here. Check, Canada, the UK, Germany, Australia among others.

    Most Chronic Pain patients have taken every path possible to AVOID taking Opiates before they do so. I know I did. I’m thankful for them and that I can function today because of the compassionate set of health care professionals available to me.

    To suggest we can all treat our pain with Tylenol is an abomination!

  6. RS at 12:40 pm

    Fitch
    I see that you have some very strong opinions about treating conditions that you have obviously never experienced first hand. May I suggest you read some of the chronic pain sites so you can hear first hand the struggles the sufferers endure each and every day. I watch a chronic pain sufferer with multiple incurable diagnoses struggle just to have the slightest quality of life. The pain is obviously so unbearable for her and there is no hope for relief. Her only moments of relief are during the 2-3 hours each day when she can take 1 pain pill in the morning and take the other one when she goes to bed so she can ret some sleep. Mind you, it is never more than 3-4 hours a night. You can’t lump all pain patients into a box and treat them the same way.

  7. Fitch at 10:42 am

    BL,

    I think you make a very good and logical point. I agree with everything that you state in your last comment.

    Fitch

  8. BL at 9:16 am

    Fitch, what about patients whos insurance doesn’t cover any other treatments but meds ? When appealing the insurance decision is to no avail ? I have no problem with combining meds and other forms of pain management. But, only when the other forms are helpful and don’t make things worse. I should also add, that I do not agree with constantly increasing the dosages to higher levels and to stronger pain meds. My concern is when a person is not able to do activities of daily living, showering, dressing properly, fixing a small meal, etc due to chronic severe pain. A person can adjust their lifestyle in many ways. But, there isn’t much room when it comes to the basics. Not to mention that we aren’t taling about any quality of life in these situations.

  9. Fitch at 7:24 am

    Kimberly,

    I am not discounting that you are in pain; I am simply suggesting there are other options that you might want to explore. For instance, I previously referred to a drug that did not make it to final FDA approval (Moxduo). I believe this drug is available in Australia. You might want to take a few moments to learn about the benefits derived from this drug and ask your doctor’s advice. Essentially, this drug is a low-dose opioid combo. I believe low dose is the way to go in pain management.

    Our society is in trouble, unlike the rest of the world, we are often consuming opioids unnecessarily, and this is not only sad, it is unhealthy and it is very expensive. The reality is that only a tiny percentage of the population benefits from doctors writing opioid prescriptions with both hands. The effect of this practice contributes to government spending and certainly negatively effects overall spending. Thus, when the financial tentacles are untangled it is contributing to the already unmanageable deficit we as Americans own and share responsibility to manage. When other options exist, that may be better, cheaper, and safer to implement and safer to US society, then, why do we in society appear to have tunnel vision in this regard? However, Kimberly you have a genuine concern that needs to be addressed properly by a trusted expert.

    Therefore, I wish you nothing but the best and I hope you find a solution that does not contribute to the issues that you find yourself battling.

    Moreover, I apologize if my comments were taken out of context. I wrote in stream of consciousness, which often serves to hide useful information, by poor sentence structure.

    I will mention one last thing. Zohydro should not have been approved in its present form and without an associated antagonist of some kind incorporated into its structure. The fact that it was approved speaks volumes. The lure of riches is just too much for some people to handle. Having been wealthy, I can say it is not worth selling one’s soul to attain wealth. Often the families that have the financial resources to “get buy” see the best in everything that they do, say, and see. However, nothing comes without challenge whether one is wealthy, in poverty or their finances lie somewhere in between. I am not preaching, but simply talking from experience and my perception.

    I wish you all the best,

    Fitch

  10. BL at 9:29 pm

    Fitch, I must admit that it is nice to see someone who doesn’t mind paying higher so the poor can have access to other forms of pain management and also for nursing home care in the situations where other methods are of no avail. It is a shame the majority of Americans are against higher taxes. Maybe you could show others where paying higher taxes is the thing to do.

  11. Kimberly Kay Miller at 5:31 pm

    FITCH,

    I have several diseases for which TYLENOL would be absolutely useless in treating. I am not sure what to tell you except I hope you or any members of your “holier than thou club” never, ever have to experience the nightmares I have had to endure to obtain a very small amount of opioids. It certainly has NOT been my pleasure, nor did I ask for any of these diseases.

    Hope as hard as you can that you are NEVER acquainted with the likes of Interstitial Cystitis, just one of my lovely companions for which there is no cure, one drug approved by the FDA and it is useless and I have not even named any of the others, NONE of which acetaminophen would benefit and, in fact would be contraindicated in usage as a treatment.

    Don’t assume all pain patients are the same and certainly don’t assume we are drug addicts. I did not ask for ANY of these diseases and surely would love to stop having to take ALL medications if I could.

    See Link for the following page:
    “Opposition to Kentucky HB 1-Reform HB 217 aka “Pill Mill Bill”
    https://www.facebook.com/pages/Opposition-to-Kentucky-HB-1-Reform-HB-217-aka-Pill-Mill-Bill/595049517218134

  12. Fitch at 2:29 pm

    One’s mind can control MOST pain, not all, and I am not suggesting that this should be the only “go-to” that one should train to combat pain. Some individuals have strong minds, and some are unable easily to train their mind to cope with pain.

    We are all different, thus, what may work for one may not work for another without considerable influence and training. Again, opioids are not the answer to treat long-term pain, and as soon as you figure this out you will take your first step in the right direction.

    However, before spewing out inaccuracies please spend a few months (if necessary) researching the subject. One learns by keeping an open mind and looking at all the options, and not by discarding everything but your own view, which is obfuscated by self-interest and corporate propaganda. I wish you well and hope you figure this out sooner before its too late.

  13. Fitch at 2:01 pm

    If you think that that opioids work to nullify pain beyond a few weeks then you are hooked on opioids. I am sorry, but this is the truth. Again, why do you think that other countries can manage pain without focusing on opioids, but for some reason we are unable to do the same? I am very sorry; to bring reality into play, but do you consider longevity, quality of life, and health to be important? Please do your research, then, you may wish to try to incorporate additional strategies to mitigate pain along with opioid options. Moreover, low dosages work better that high dosages with respect to opioids, thus, I am at a loss as to why the FDA rejected Moxduo. However, the way they have defended their approval of Zohydro, should bring awareness to the fact that something is amiss inside the FDA. Please read everything that I have posted everywhere before making comments that have absolutely no basis in reality and are harmful to you and US society.

  14. brenda myers at 9:30 pm

    ridiculous-stay out of MD’S business !!!!

  15. BL at 5:24 pm

    Fitchm are you suggesting those with chronic severe pain onlu use tylenol every day with the max being 4,000 in a 24 hr period ? That does seem to be just the opposite of what has been said about the dangers of tylenol recently. I know someone who is doing this just so they can lay in bed and be in a little less pain. Their impairments are documented and they are on disability. I have read their medical records and I have gone with them to their dr.Due to them being on Medicaid and Louisiana Medicaid not covering chronic pain management, there is no alternative. Unless you have had to live days, weeks, months, years without being able to step into a shower due to chronic severe pain, or bend over and pick up trash that falls on the floor or take your garbage out. You have no business telling others what they must endure. Since you think chronic severe pain is no big deal, I wish you and your loved ones nothing but that. After all it’s no big deal, right ? Train your mind to ignore the pain that is so severe it makes you fall. And if you fall and can’t get up, you can lay there until somneone finds you . I’m sure you can use your mind to help you control everything.

  16. Fitch at 2:47 pm

    In complement to my comments, I am not resorting to scare tactics. I am simply discussing options that one could consider before running to opioids to manage every kind of perceived pain imaginable. It is true that some individuals perceive pain in different ways, and for these persons it may be more difficult to get past the pain while training one’s mind to manage pain without opioids. The circumstances that exist for each person are complex from case to case. The mind is a powerful thing, but if one’s mind is sidetracked by worry, or other significant issues, then, several layers of problems might need peeling and repair prior to reaching the best and safest solution.

    Please respect that opioids are abused for a reason and this is not the fault of the patient. The opioid’s effect contributes to abuse and future abuse. However, opioids offer limited benefits; thus, this fact must be recognized if one desires to manage their pain both safely and effectively over the longer term. This is your life!

    Fitch

  17. Fitch at 2:23 pm

    Hi Kimberly,

    Some in the medical community believe that opioids are the “be all / end all” for dealing with pain. Opioids are sometimes necessary for dealing with post-operative pain and useful options with respect to end of life situations; however, they are counterproductive to patient pain in MOST cases and in most instances.

    Why are other countries able to manage pain effectively without going straight to opioids? For instance, I am familiar with many patients who have opted to take acetaminophen in lieu of opioids directly after major surgery and have managed perfectly well (their choice BTW). Thus, similar to most of the population, I think you have been brainwashed. The mind can handle pain, one must know how to train their mind in this regard, but this is the healthiest option. For instance, laser surgery might require a single 3 hour effective dose of opioids to nullify one’s perception of pain altogether.

    The real issue is that opioids affect the pleasure center of the brain and trick he or she into thinking they want more when this is unnecessary. I agree there are specific situations like pain associated to CERTAIN kinds of cancer, or multiple, multiple, lower disc issues contributing to pinched nerves that may require longer than what would be considered normal treatment. However, with respect to lower back damage, it is often treatable and in relatively short order. Nevertheless, there are other options available versus opioids that may present themselves as safer alternatives.

    Again, why is the United States using a disproportionate amount of opioids compared to the rest of the world? Can you answer this question based on what I have discussed?

    Do not discount the power of the mind to be able to manage MOST pain if properly trained. For instance, I can use my mind to drop pain associated high blood pressure from 220 to 130; therefore, this should be possible for everyone to accomplish. I want to add that the excuses that the FDA used to justify Zohydro’s approval were troubling to say the very least. I hope any investigation has the creativity to uncover all the factors that may have contributed to the drug’s approval. It appears the investigators are unable to “think beyond” in a complex business reality and options to manipulate assets that exist today and figure out potential cookie jar related persuasion.

    Before you argue, please remember that opioids are opioids, so please do not contrast toleration between different opioids as they are all opioids and essentially function the same way. I have already stated that patients who are unwilling to destroy their bodies with opioids are finding relief from acetaminophen after surgery and they only need to take the FDA recommended dosage for a maximum for twenty-four hours. It is also interesting that most of the post operative pain is headache pain and not associated to the actual surgical event. Additionally, check out the goings on at Stanford University in this regard, I believe their research will shed additional light upon these comments. Remain open that other options exist aside from opioids with regard to pain management. Know that opioids are working on the pleasure center of the brain to divert one’s attention from pain, thus, with this in mind maybe there is a better way.

    I wish you well and good luck! Yet, look for other alternatives to manage your pain that will not affect your quality of life in the future.

    Fitch

  18. Kimberly Kay Miller at 4:37 pm

    Here we go again with typical scare tactics of fear monger reporting. The use of overdose numbers from ten years ago, when any legitimate pain patient (or drug addict) will tell you that these days prescription pain medication is next to impossible to get, especially in some states. If you’re a chronic pain patient, you have the misfortune of suffering unrelenting pain on a daily basis, and you are really in a world of hurt. Since “pill mill bill”, laws that were created to keep controlled substances out of the hands of drug abusers are keeping pain patients from getting adequate pain treatment. While these laws have managed to keep the much-needed pain medications from chronically ill pain patients, drug addicts have long since moved on to heroin. Heroin is much cheaper and more plentiful, leaving the sacrificial lambs, chronic pain patients, suffering with no end to their misery.

    Every time one of these stories runs, you can count on a few things, 1) Outdated, longer accurate overdose rates, 2) Pain Patients portrayed as addicts 3) No coverage of the effects these new laws have had on pain patients. and 4) little or no obvious connection made between the action of the DEA and politicians, who created the pill mill laws, and the rise in the use of heroin.

    These types of articles, besides just being “old news” are detrimental to chronic pain patients and serve no purpose other than to rile up the public against those “drug-seeking”, pharmacy-shopping”, drug addicted pain patients, which couldn’t be further from the truth. Let’s do some actual investigative research and interview some pain patients whose lives have been turned upside down as a result of this type of careless reporting.

    See Link for the following page:
    “Opposition to Kentucky HB 1-Reform HB 217 aka “Pill Mill Bill”
    https://www.facebook.com/pages/Opposition-to-Kentucky-HB-1-Reform-HB-217-aka-Pill-Mill-Bill/595049517218134
    Kim Miller

  19. BL at 10:47 am

    As always, the details are missing. If you have someone with chronic severe pain who is barely managing their pain and now they have a severe tooth ache that can’t be taken care of for several days, a strong pain med might be in order. Details like what were the patients other health problems, was their bp and heart rate raised to a serious level due to the additional pain, was the pain making them unable to eat any food, things like that are missing. It is a shame that what is missing isn’t looked at as seriously as what is there. I’m aware that these patient surverys don’t have these medical details. That should make everyone, especially the medical community and politicians question when this info is used in this manner.

  20. Marian Medvec at 9:16 am

    Sorry about the Dilaudid – toothache remark. I am sure some toothaches can be excruciating.

  21. Marian Medvec at 9:15 am

    Well, I have been on pain medication for almost four years. I do not abuse it and cannot abuse it because it is doled out by the doctor and the pharmacist to the last pill and the last minute. But it is still effective. My rx has not increased in number or dosage, and even though there is some tolerance, I find that this medication does help with the pain from my chronic severe degenerative disk disease. Can chronic patients live without it. Maybe. But if you have any life or any activity in life, it certainly helps.

  22. Marian Medvec at 9:05 am

    As the population ages, there are more and more discomforts experienced. At any age, but even starting in middle age, many people have chronic pain problems. These cannot be ignored. Pain Management doctors are required to treat pain, even if they cannot determine the cause of it. Regarding giving out powerful narcotics for a toothache, and giving goody bags containing Vicodin, that is just irresponsible on the part of the doctors and I do not believe that would increase the rating of the hospital. Not providing pain medicine after surgery in a timely manner and for chronic conditions will affect the hospital rating, in my opinion.

  23. BL at 10:21 pm

    This is nothing but an attempt to cut costs by the politicians. I do find it interesting, that again, detailed info isn’t there. For example, what was the condition the pain meds were prescribed for. I certainly hope Senators Grassley and Feinstein are never prescribed pain meds for anything. It won’t be until the politicians have to suffer like regular Americans that they will understand. Although, I know they nor their families will ever have to suffer like this.

  24. penny at 8:30 pm

    Is this country that we as us citizens going to be in pain the rest of our living days. People you need to wake up I’m serious leave this crap alone and get the real drug dealers. I as well as my mother and father are dying I’m still young 43 but I have a lot of issues including heartattack Lung disease i can go on But YOU NEED TO LET THE PEOPLE IN PAIN AND SICK AND SUFFER DAILY ALONE. I WONDER IF YOU GUYS ARE THE CAUSE OF DRUG DEALS BECAUSE OF STUPID LAWS I WILL BE DAMN IF I WATCH MY MOM OR DAD OR LOVED ONE SUFFER IN PAIN AS THEY LIVE IN THIS MESSED UP WORLD. ..IM SO SICK OF HEARING THIS. .. An I don’t get anything from the hospital emergency unless it’s the same as what my doctor gives me. I want peace especially when people die in pain

  25. Steve M at 8:21 pm

    This is ridiculous, if doctors are finding out that legitimate pain patients are being under tests, they rigidly should prescribe more pain medications (opioids, NSAIDs, etcetera). However, any doctor prescribing opioids when they know that opioids aren’t necessarily is violating the law and they are the problem, not the surveys.

    How many drug seekers actually fill those surveys out?

    CMS should change nothing.

    Also, Dilaudid is not limited to cancer pain, it is STANDARD PRACTICE too use it for non-cancer pain, including toothache, which can be excruciating.

  26. Fitch at 7:19 pm

    From my perception, what I see is positive is that all the press surrounding this drug’s FDA approval brought out some very good bits of information. From my experience, I already knew what others are sharing today in rejecting that opioids are the best and only answer to pain relief to be true.

    I think the most important of these bits exist in three comments. 1). “All opioids are essentially similar, they are opioids, thus, one is going to be similar to another, regardless, of the argument put forth that some are hitting different receptors in the brain.” 2). The argument put forth that one opioid may be tolerated better than another may, could be stated another way. One opioid may offer its users a better high compared to another. For instance, Kadian does not offer the high that other opioid meds do unlike OxyContin, codone, oxymorphone, so users often reject Kadian in favor of other opioids for its pain relieving properties. However, Kadian regulates the delivery of the opioid; therefore, the drug is constantly working, but it does not peak, unlike other opioid options. 3). You can expect an opioid to manage pain for 10 days, possibly less if one attempts to chase the “high” by self-medicating at higher dosages than the prescribed. In response to the medicines perceived effectiveness from patient perspective. The doctor may decide to increase the dosage at the next visit. However, it is believed that the only way for a patient to realize effective pain management, would be for him or her to stop and start 2 weeks – 2 weeks. Unfortunately, even this strategy has limits to its usefulness as the medication has a cumulative effect in one’s system (it remains in one’s physical body forever, and the changes to one’s brain on how it perceives pain and opioids is also believed permanent). Therefore, if you have been on the medicine for a long time (six months), if you are to take opioids in two years’ time then you may receive only a week of effectiveness and so on. Thus, the multiple, multiple, articles that have been published recently, have pointed out that not only does the United States population abuse opioids unlike any other country, yet other countries outside the United States appear to be able to manage patient pain very well. Hmmm I say.

    How in the world can we find justification for how we approach pain management? I will answer this question. Whether we are a pharmaceutical manufacturer, company (with single or multiple products), pain doctor or GP, or patient, this occurs (in part) by cognitive dissonance. We learned that these parties are using faulty data to make their case for approval and to validate the approval process. They have justified their responses by the faulty data and through the parties that they believe (some through dissonance, some though greed combined with dissonance). They believe what they are doing is helping pain patients and society (even if this help is limited to only for a brief moment in one’s life). The doctor is fed numbers in the form of marketing material, of which they assume is accurate. The patient population may use the medicines affects, or the perceived benefits as dissonance. The opioid may be contributing to a false believe that he/or she is suffering from pain, thus, the cycle of abuse continues for this patient unless he or she has the willpower to say “enough is enough.”

    Anyway, this should give one a little cause to pause, yet it does nothing, and why is this possible? Ultimately, profit is the other part of the equation. Profit is spilled down from the drug companies to bring opioids to the general population (the users) by a variety of real world business viability necessities. These necessities exist as part of the pharmaceutical company’s marketing and distribution channels. Thus, profit is spilled down to several politicians in the form of campaign financing. It is spilled down to the FDA (in the form of power, future pharmaceutical or biotech employment, and very possibly by the promise of other incentives, which may be a little harder to identify, but not impossible if one has investigative talents). It is spilled down to United States universities in the form of grants and research funding. It is spilled down to the media in the form of advertising purchases. Additionally, it is spilled down to the pain doctors (the dealers). It is true that some of the more prominent pain management doctors (essentially the dealers) are “paid to play” in the form of direct employment or indirect employment. Indirect payment is the fees paid to local, regional, or national speakers (pain doctors who over-prescribe pain medicine) by the pharmaceutical companies they have so aligned.

    This sad reality exists for the residents of the United States, and with it, there also exists consequences. The obvious cause and effect consequences that accompany opioid consumption is its contribution to abuse, crime in the form of illicit distribution and consumption, addiction, the move to cheaper drugs (like heroin), death, and a huge monetary cost is tied to these effects, which is obvious. We need to move to the reality that is good for the country and society and away from this insanity.