Friday, February 15, 2019
Opioid Hysteria: Rampant Reductionism and Industrialization
Even before my recent encounter with severe post-surgical pain, I considered the “opioid epidemic” a form of cultural hysteria. The remarkable over-reaction highlights the problem of reductionism. It also illuminates the personal cost of the industrialization of medicine.
Reductionism occurs when people condense extremely complex processes into one or two simple categories. Considering climate change the result of automobiles, for example, inaccurately reduces the multiple, complicated causes of the global problem to one.
The causes of people becoming addicted to opiates, or any other substance, are extremely complex. (Opioids, ancient pain-relieving or analgesic medications, refer to any opium-like substance).
Instead of addressing the complicated nature of the problem, contemporary culture has become highly focused on one, small angle—physicians’ prescribing habits. As a result, only one, minor perspective is addressed while much more significant ones are ignored.
What’s complex about dependency or addiction?
Before answering the question, consider the definitions used by substance abuse experts. Misuse refers to using a drug for an unintended reason, like taking an opiate for mood elevation rather than pain relief. Abuse means a regular pattern of misuse is occurring. Dependency, or addiction, refers to a physiological state in which people develop increasing tolerance to substances, like opioids, and become sick if they stop using them.
Some individuals prone to addiction have a genetic propensity towards it; others use alcohol or drugs to cope with sociocultural problems like poverty, racism, social isolation, or homelessness; still others use drugs to deal with loneliness, multiple personal losses, or serious illnesses; some become dependent on substances because they feel trapped in unhappy relationships or unsatisfying jobs.
Endless other reasons exist.
It is a sad truth that opioid addiction problems have increased substantially over the last ten years.
And yet, again, society has reacted in an amazingly simplistic way.
By monitoring doctors more carefully, setting highly restrictive guidelines on how they prescribe opioids, and reducing the production and distribution of these medications.
Meanwhile, the myriad other causes just described—social, cultural, economic, genetic and more—persist unchallenged and unchanged.
No one talks much about them.
They cannot be reduced to one or two categories.
Governmental regulations—save a massive change in political and social structure—do not address these other, more significant causes of addiction. Reducing income inequality, eliminating poverty, increasing access to social services, building community rapport, addressing the isolation leading to gang formation, funding mental health services, and similar interventions would help in much more significant ways.
Again, none of these more relevant solutions receive much attention.
Instead, headlines regularly proclaim how evil physicians prescribe to excess. In reaction, the Centers for Disease Control and Prevention (CDC) issued new guidelines in 2016, seeking to reduce opioid misuse. The CDC urged physicians to exert care in prescribing these medications and avoid doing so if possible.
Intended as guidelines, many physicians interpreted these regulations as mandatory.
These CDC guidelines, in turn, led to close scrutiny of physicians by medical boards and even by the Drug Enforcement Administration (DEA). The Boston Globe, according to a survey they published in 2017, found that nearly 70 percent of primary care physicians reduced their opioid prescriptions as a result. Ten percent stopped issuing them entirely.
This despite the fact that less than only 8 percent of chronic pain patients become addicted to opiates, and that physicians professional behaviors are a minor part of the problem.
According to a story in last Sunday’s New York Times, 18 million patients rely on opioids to treat intractable long term pain. Many chronic pain patients have had their opioid dosages reduced or eliminated since the new CDC guidelines. A Veterans Health Administration (VA) study cited in the same article found “alarming” rates of suicide following discontinuation of opioid therapy.
As the New York Times article, and myriad other sources of information validate, many patients who legitimately utilize opiates now suffer from severe pain, and some commit suicide, now that prescribers are overly cautious. Ironically, the problem of suicide now emerges as these patients are precipitously, and often without careful evaluation, denied access to pain-relief they desperately need.
If you’re interested in the problem, do a google search of the controversy over opioids. That same New York Times featured a story of a woman with severe bladder pain. When scanned, her bladder looks like “an open sore.” She has trouble getting the pain medications she needs. Disturbingly, she hopes for a cancer diagnosis which would then legitimize her need for opiates. They are her only form of pain relief.
You’ll also find myriad stories documenting how some emergency rooms across the country have run out of these extremely effective analgesic medications, leaving trauma victims to suffer extremely and unnecessarily.
Recently, I was personally affected by the hysteria, but not nearly as badly as literally millions of other patients in the US.
Admittedly, my stories pale in comparison with these other patients’ suffering or committing suicide when legitimately-prescribed pain medications are discontinued.
Here are my two tales:
Just last December, I had my second open-heart surgery in a decade. It again involved replacement of an infected aortic valve. Typical of these procedures, surgeons literally sawed through my sternum to gain access to the heart.
The only physically painful part of the recovery, both times, was from cutting the sternum. Unlike any other bone, it cannot be set. Staples are used to re-unite the surgically-fractured sternum, but it remains highly painful for around two months. Every post-surgical breath brought significant pain; a cough, a sneeze, or even a yawn elicited severe, almost unbearable pain.
During my first cardiac mis-adventure, opiates were a non-issue. The reductionist, absurd intervention had not yet happened; the industrialization of medicine had not yet metastasized. The surgeon, cardiologist, and internist following me liberally prescribed opioids during the two-month recovery period.
I did not misuse, abuse, or become addicted to them.
Most physicians are not trained addiction medicine. I am not either. Therefore, most health care providers have little understanding of the nuances of substance abuse problems. They do not know how to assess for the risk of misuse, abuse, or addiction.
Ten years ago, in my case, it mattered naught.
Because opioid hysteria gripped the nation since then, the weeks following my most recent surgery, in December 2018, were remarkably different. The surgeon recommended a pre-surgical course of non-narcotic medications to reduce post-surgical pain. Almost certainly influenced by the CDC guidelines, he hoped to prevent the need for opiates.
In the days following the surgery, one type of opioid, oxycodone, was thankfully provided for me. The freshly-sawed sternum-pain was severe. I was given one refill of oxycodone upon discharge from the hospital. Two weeks later, I practically had to beg my surgeon for a final, third additional refill.
As a result, I endured significant sternum pain for the last month it took the sternum to (mostly) heal.
There was no reason for me to suffer with extreme pain that last month. It’s not good for the mind/body to suffer pain. It slows healing; it also raises levels of cortisol, the stress hormone.
I became the victim of the opioid hysteria.
Here’s my second example:
I have consulted the same internist for 27 years. I have suffered from migraine headaches since age 18, well before I met her. The migraines average around once a week, typically beginning with the stereotypical scotoma. (A scotoma is a visual disturbance like an aura before a seizure).
Around an hour after the scotoma, a severe headache descends upon me. I have tried various anti-migraine medications. None of them work. Therefore, I simply take a small dosage of an opioid right after the scotoma. The resultant headache pain is numbed, and I am able to function.
For literally a quarter of a century, my lovely, kind internist prescribed around 50 hydrocodone, a milder form of oxycodone, per year. Some weeks, when the headaches occur more frequently, I take them more often. Sometimes I go a month without taking a single one.
Again, I never misuse or abuse them. I never have become dependent on them. Like the vast majority of medical patients, I am not prone to addiction.
After the surgeon reluctantly refilled that final prescription of oxycodone, I asked my internist for some hydrocodone for the residual sternum pain and the migraines. She reluctantly prescribed 20 of them, informing me she wanted to discuss non-narcotic ways to cope with both types of pain.
I thought to myself,
“Oh, bummer, she has become oppressed, and now I have too.”
When we discussed it in person, she, like the surgeon, encouraged me to use over-the-counter analgesics, like tylenol or ibuprofen. These are ineffective on severe, migraine headache pain.
Also during our discussion, she told me people often will take an opioid “just because they are there.”
Not true, and another example of propaganda-like indoctrination.
That’s the end of my story.
Like I said, it’s a paltry one compared to so many others.
How does the opioid hysteria relate to the industrialization of medicine?
Before the days of massive HMOs, increased governmental regulation of medical practice, and influential pharmaceutical companies, patients tended to develop personal relationships with physicians. Ideally, they utilized them, as occurs in the United Kingdom, as “consultants.”
In other words, doctors came to know their patients, their patients got to know them, and physician-patient dyads developed ongoing, even intimate (but naturally bounded) relationships. Their physicians became acquainted with patients’ family members, understood the unique psychosocial stressors affecting them, and closely tracked their vulnerability to medical problems, i.e. family histories of diabetes or hypertension.
These days, most physicians must have more “encounters” (previously known as doctors visits or appointments), and must have them progress quickly. Because insurance companies have cut reimbursement rates, they must do so to cover their overhead and make a living. Further, they fear their professional behaviors will be monitored by some variation of Big Brother, oppressing them and adversely affecting the old-fashioned personal touch of the medical profession.
Unfortunately, and as many patients have experienced, neither reductionism nor the industrialization of medicine will change any time soon.
I consider myself lucky, even blessed, to have a personal relationship with my physician—oppressed or not.
She’s an awesome person.
She displays that rare combination of human kindness combined with excellent medical training, knowledge, and experience.
And yet she too has become influenced, arguably oppressed, by these impersonal, over-reactive societal forces.
We can only hope that, in accordance with the progression of thesis, antithesis, and synthesis attributed to the philosopher Hegel, society will swing back to a more reasonable approach towards the opiates. Let’s hope it occurs before trauma victims enter emergency rooms lacking opiates, chronic pain patients suffer unnecessarily, and others kill themselves. Meanwhile, our quick-fix, social media, app-oriented age tends to reduce, or even ignore, the real causes of complex problems like the rise in opioid addiction rates.
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Alan Karbelnig, PhD, ABPP