After the ritualized complaints about Trump, the editors of the Washington Post get down to brass tacks about the “opioid epidemic”:
Data show wide geographic discrepancies in rates of opioid prescribing (poor, rural counties have higher rates than urban ones), which suggests that objective medical considerations are not the only reason for heavy usage where it occurs. Indeed, the latest research shows that opioids are not the most effective treatment for common forms of non-cancer pain. Quite often, they have been dispensed precisely because more effective alternatives — physical therapy, for example — were not available.
Even after recent reductions, doctors in the United States still prescribe legal opioids at three times the 1999 rate. If doctors met the goal Mr. Trump set in his speech — a one-third reduction in opioid prescriptions by 2021 — they would still be prescribing at double the 1999 rate. And the United States would still be administering legal opioids far more frequently than its peer nations in the industrialized world. This country prescribes opioid pain medicines twice as frequently as Germany does, but as bitter experience has taught, that doesn’t make us twice as good at treating pain.
Ignoring the possibility that Americans actually have more pain than Germans do or that Americans are just whingers, what explains the change? I think it can only be explained by incentives—all of physicians’ incentives point to prescribing more painkillers, especially the desire to do something. However, I’m open to other explanations. Why do American physicians prescribe opioids pain medications at such a high rate?
Steve, no doubt, will have insight. But my two cents, I think patients will simply doc shop until they get what they want. That doesn’t make them whiners, it just makes them impatient consumers with options. And it means some patients where opioids are not indicated will in fact receive them.
That said, as a veteran of nerve compression pain due to herniated discs, a pain I can only compare to putting a hand on a hot skillet, I think it would be malpractice to not provide some form of relief.
As I’ve mentioned before I have chronic pain. On any given day I have widespread pain somewhere around 6-7 with twinges that go up to 9.
I prevailed on the medical profession for a number of years to help me and they did their best. Ultimately, I decided that it was better to live my life than shuffle around giving the appearance of living my life while actually being absent. So I thanked my health care team for their efforts and began managing my pain completely on my own with a combination of meditation, exercise, just toughing it out, and, ultimately, this blog. That was my choice and I wouldn’t deny others their own choices.
And I’ve always had a soft spot for your condition, as I, too, still have other types of chronic pain. As you say, sometimes you just tough it out and are thankful for the better days. And I reach for the Advil bottle. Its not fun.
We have some current and former professional athletes here in the community. Quite an array of scars, hobbled gates, funny looking elbows etc. No one knows what happens behind closed doors, but I’m not aware of opioid abuse, just some tough minded people.
I don’t even know if separating the whiners from the tough minded is all that useful. There simply seems to be a portion of the population who get a buzz from these drugs. That’s what they are really after. That’s a different phenomenon altogether – both abusers and prescribers should be filed under people behaving badly.
If you have health insurance, doctor shopping may not be easy.
Not only doctor shopping is difficult, insurers are reluctant to pay for physical therapy, work hardening, spinal simulators, psychotherapy, etc that reduce the need for analgesia.
Incentives matter and when patient satisfaction scores are on the line, scripts get written.
Wonder if anyone has pondered whether the slower paced German work environment and higher alcohol consumption (including beer in the company cafeteria) has any impact on opioid use.
Pain is a difficult subject for any number of reasons. One of them is that we don’t yet have good, cheap, easy, empirical ways of measuring it. How do you determine whether someone actually has pain or is a whinger? Typically the physician relies on self-reported measures.
There’s a gender issue here, too. I believe that docs tend to treat men’s complaints about pain more seriously than they do women’s. I don’t know if that’s because the majority of docs are men, women seek care more, or what but I do believe that it’s true.
Returning to the point, given the limitations of our knowledge about pain, how would we determine whether the Germans have more, less, or the same amount of pain than we do? How do you distinguish between complaining more and having more pain?
I think there’s a big cultural element – opioids are part of poor white America in a similar way to what crack used to be for urban black communities. Europeans, being more homogenous, don’t see this as much.
But I also think it’s partly doctors. Just in my own experience, I’ve always been prescribed powerful painkillers whenever there was some potential for severe pain – probably a half-dozen times over the last couple of decades. They ended up sitting on a shelf.
Pain meds’ the dr. ,and the dentist offer them freely to me. I don’t take them because to me, they are ineffective. I fill the scripts because my wife likes them, they just seem to make her sleep.
As to “whiners”, I doubt that. I think pain varies among individuals.
Why would you fake pain when you wanted to go do something else?
This would take pages to cover. Briefly, I hope, in the 80s and early 90s we clearly undertreated pain. Then it became a topic of interest, then the drug companies pushed narcotics they said would not get people addicted. Pain meds blossomed. Now that we know that they are addictive, we are still stuck with knowing that pain is an issue. People don’t especially want to go back to the 80s. We know that if we don’t treat acute pain adequately, it is more likely to become chronic pain. Plus, we now have “empowered patients” who will doctor shop if they don’t get treated.
Now throw in the fact that in these poorer areas, often more rural, they don’t have good medical resources. Heck, even in places with good resources insurers just don’t pay for alternative care for pain. It is probably (we are trying to get a study going on this) cheaper in the long run to use the more expensive modalities like physical therapy, but insurers, like many American businesses, are all about the short run. So, docs in these areas don’t have the resources and most don’t have the know how. (I hire pain specialists. It really is its own specialty now.) So, docs just order opioids.
Which sounds kind of awful, and it is in some ways, but then I am not sure what we can really expect the docs in these areas to do. We pulled the stats on the PCPs and opioid prescribing for our city area and for our rural areas. The ones in the rural areas order 2-3 times as many opioids. Granted, it is a bit of a different population, but that is a lot. Most of these are otherwise decent docs. So, our approach is to try to give them help. We are lucky in that our network is willing to bear the costs. (I actually just wrote up a proposal last week for the second stage of our plan.) Even then, while I like to think we are enlightened and like to put pt needs first, I suspect a lot of that willingness is because we now have our own insurance product and are taking on risk. Divorces us just enough from payors that we can make these kinds of decisions.
Steve