The End of Narcotic Pain Medication?

First posted 11/15/2012
The LA Times ran a very interesting story a few days ago about deaths from overdose of narcotic pain medications.  I strongly encourage readers of this blog to read the story, which discusses the issue from the perspectives of doctors, patients, and family members.
The story reports that a small number of Southern-California doctors wrote prescriptions that have killed a large number of patients. Over the past five years, 17% of the deaths related to prescription-drug overdose–298 people—were linked to only 0.1% of the area’s doctors.  I was not surprised by the findings in the article, as I have read stories from other parts of the US reporting similar statistics.
There is a simple reason for the skewed numbers.  Prescribing opioids for chronic pain is associated with risk of death by overdose.  More and more doctors are avoiding that risk by refusing to treat chronic pain with opioid pain medication.  That means that the few doctors who are willing to prescribe such medications are linked to a higher number of deaths from those medications.
Are the doctors who prescribe narcotic pain medications ‘bad doctors?’  Some doctors would claim that they are.  I have described the doctors in a group called PROP, or Physicians for Responsible Opioid Prescribing, who take the position that almost all opioid treatment of chronic pain is inappropriate.  I understand the point made by those physicians.  Treating chronic pain using opioids carries significant risks.  Complications, including death, are common.  But I have met a number of patients who suffer from severe pain who take issue with doctors who tell them that they are better off without opioid pain medications.  And I’ve noticed myself, from my own rare occasional injury, that it is one thing to talk about the proper treatment for someone else’s pain, and another thing when one’s self, or one’s loved one, suffers from pain.
The skewed numbers also demonstrate the problem with online doctor rating systems that report on the complication rate for one doctor vs. another.   Across the spectrum of patients in need of surgery, for example, are healthier patients with relatively low risk of complications, and sicker patients with higher risk of complications.  If a doctor restricts his/her practice to treating only the healthier (often younger) patients, is he/she a better doctor than the doctor treating the sicker, older patients?  The numbers for the first doctor will surely look better than the numbers for the second doctor!
Some people worry that the efforts to ‘score’ doctors based on outcomes will lead doctors to avoid treating the neediest, highest-risk patients.  As evidence that those concerns are valid, one only need look at the trends in opioid prescribing. If treating certain conditions increases the risk of being called a bad doctor, many doctors will focus their efforts elsewhere.  Doctors are, after all, only human.
Perhaps because of years of academic competition, doctors are less likely to support colleagues under fire than to pile on, like sharks sensing blood in the water.  As a result, the risk of treating chronic pain using opioids goes beyond being called a bad doctor, and can include loss of license and even criminal prosecution.  As much as any doctor wants to relieve a patient’s pain and suffering, watching colleagues go to prison doesn’t do much to incentivize narcotic pain management!
Some healthcare regulators and even some physicians try to make this issue appear simple, by painting patients with chronic pain as drug-seekers at worst, or as ignorant healthcare consumers at best.  But as someone who has worked in the trenches, I know that the issue is not that simple.  Right now, across the US, a number of doctors are listening to patients who are tearfully describing their misery and pleading for help.  As these doctors consider the options for their patients, they think about the comments by President Obama’s President Obama’s drug czar, R. Gil Kerlikowske, about the LA Times findings: “Do I think this has the potential to change the game in the way it’s being looked at and being addressed, both at the state and federal level? Yes, I do.”
If you were a doctor, what would YOU do?